Purpura rhumatoïde de l’adulte

Navigating Adult-Onset IgA Vasculitis-Associated Nephritis

PURPOSE OF REVIEW

IgA vasculitis (IgAV), formerly Henoch-Schonlein purpura, is the most common systemic vasculitis in childhood. In adults, however, this condition is poorly understood, yet associated with more severe disease and poorer outcomes. This necessitates the need for early diagnosis and management.

SCOPE OF REVIEW

We describe the pathophysiology, clinical manifestations, and diagnosis of IgAV in adults. Poor outcomes are often due to the high frequency of glomerulonephritis in IgAV-IgA vasculitis-associated nephritis (IgAVN). We hence also aim to summarize the latest clinical data regarding treatment strategies in IgAVN. The diagnosis and differentiation in histology between IgAVN and IgA nephropathy (IgAN) remain a challenge. Review of treatment therapies: Pathological mechanisms between IgAVN and IgAN appear to be consistent between the two, and data from IgAN are often extrapolated to IgAVN. The role of various immunosuppression therapies remains controversial, and in this review, we will discuss immunosuppression use and highlight evidence surrounding emerging and promising novel therapies in IgAVN/IgAN. Our aim for this review is to guide future treatment strategies and direct future studies.

A Rare Case of Henoch-Schönlein Purpura Following a COVID-19 Vaccine-Case Report

In the COVID-19 pandemic era, anti-SARS-CoV-2 vaccination is considered to be the most efficient way to overtake the COVID-19 scourge. Like all medicines, vaccines are not devoid of risks and can in rare cases cause some various side effects. The objective of this case report is to highlight this unusual presentation of Henoch-Schönlein purpura following an anti-COVID-19 vaccination in a 62-year-old adult. The 62-year-old patient admitted to the emergency room for a petechial purpuric rash, sloping, occurring within hours, involving both legs and ascending. The clinical signs also included polyarthralgia and hematuria. Reported in the history the notion of an anti-COVID-19 vaccination 8 days prior to the onset of symptomatology. In the case of our patient, we retain the diagnosis of rheumatoid purpura based on the EULAR/PRINTO/PReS diagnostic criteria. Corticosteroid therapy (prednisone) was started, resulting to a rapid regression of clinical and laboratory symptoms, few days after the treatment. Patient was asymptomatic on subsequent visits. The low number of published cases of post-vaccine vasculitis does not question the safety of vaccines, but knowledge of such complications deserves to be known in order to avoid new immunizations that could have more serious consequences, and to avoid aggravating or reactivating a pre-existing vasculitis.

IgA Vasculitis in Patients with Inflammatory Bowel Disease: new insights into the role of TNF-α blockers

OBJECTIVE

Association of IgA vasculitis (IgAV) and inflammatory bowel diseases (IBD) is rarely described, mainly during anti-TNF-α therapy. We aimed to describe the association of IgAV and IBD.

METHODS

We retrospectively analyzed the association of IgAV and IBD through the implication of the GETAID and FVSG networks. Characteristics of IBD and IgAV were collected using a standardized case report form.

RESULTS

Forty-three cases were included. IBD (mainly Crohn's disease (CD) in 58%) preceded IgAV in 38 (88%), with median interval of 9.2 (IQR 5.4-15.4) years. In these 38 patients, at IgAV diagnosis, 5 (13%) had active IBD and 28 (74%) were treated with anti-TNF-α for a median duration of 31.5 (IQR 19-56) months. Main IgAV manifestations were purpura all patients (100%), joints in 20/35 (57%), renal in 15/35 (43%) and gastrointestinal in 11/35 (31%) involvement. IgAV was treated with glucocorticoids in 25 (66%), colchicine in 6 (16%), cyclophosphamide in 6 (16%), and anti-TNF-α were discontinued in 15/28 (54%). No IgAV relapse occurred when TNF-α blockers were stopped, vs 23% in patients pursuing it. Conversely, 5 (33%) had IBD flare or complication after anti-TNF-α cessation vs 1 (8%) in those continuing biologics. Anti-TNF-α were resumed in 6 (40%), with subsequent IgAV relapse in 4 (67%).

CONCLUSIONS

This large cohort suggests that TNF-α blockers may promote the onset of IgAV in IBD. Discontinuation of anti-TNF-α was associated with vasculitis remission but increased risk of IBD relapses, whereas continuation of anti-TNF-α was associated with IBD remission but vasculitis relapse.

[Henoch-Shonlein purpura in adults in South Tunisia: a series of 14 cases]

Henoch-Schonlein purpura (HSP) is a small-vessel vasculitis secondary to IgA deposits. We conducted a retrospective study of 14 cases of HSP in adults based on EULAR/PRINTO/PRES classification criteria for HSP over a period of 18 years (1996 to 2014) in Department of Internal Medicine at the Hedi Chaker University Hospital, Sfax, South Tunisia. The purpose of our study was to highlight the epidemiological, clinical, therapeutic and evolutionary features of HSP in our adult patients. The average age of patients was 33 years (ranging from 17-64 years) with male predominance (sex ratio of 1.8). Vascular purpura with petechiae was constant. Articular manifestations (arthralgia and/or arthritis) were reported in 9 patients (64.2%). Gastrointestinal involvement was reported in 13 patients (92.8%). Renal failure was found in 11 patients (78.5%) revealed by nephrotic proteinuria in 7 cases, microscopic haematuria in 9 cases, high blood pressure in 4 cases and renal impairment in 1 case. The most common histological type was diffuse proliferative endocapillary glomerulonephritis (36.3%). High dose corticotherapy was initiated in 7 patients with proliferative renal impairment, bolus of Solu-Medrol in 4 cases, associated with cyclophosphamide in one case. Two patients with severe gastrointestinal involvement received corticotherapy. After a mean follow-up period of 18.5 months (4-36 months), outcome was favorable in all cases without relapse and chronic renal failure was reported only in one case.

Recruitment of CXCR3+ T cells into injured tissues in adult IgA vasculitis patients correlates with disease activity

OBJECTIVES

Adult immunoglobulin A vasculitis (IgAV) is an immune complex small vessel vasculitis. So far, the involvement of T cells in this pathology has been poorly studied. The aim of this study was to analyze T-cell homeostasis as well as cytokine and chemokine concentrations in the blood and tissues of IgAV patients.

METHODS

T cells, cytokine and chemokine concentrations were analyzed in peripheral blood using flow cytometry and multiplex assays. T-cell infiltrates in the kidney and the skin were characterized by immunohistochemistry. This study prospectively included 44 adult patients with biopsy-proven IgAV and 24 age- and sex-matched healthy controls.

RESULTS

We observed reduced proportions of circulating CXCR5-and CXCR3-expressing memory CD4 T cells at diagnosis but normal values at remission. The plasma levels of Th1-related cytokines (IL-12, IL-27 and IFNγ) and of the TFH-related cytokine, IL-21, were paradoxically not reduced in patients. We observed increased plasma concentrations of the CXCR5 ligand, CXCL13, and of the CXCR3 ligands, CXCL10/11, suggesting a potential relocation of the corresponding T cells into inflamed tissues. We then confirmed the recruitment of CXCR3-expressing T cells into the skin and kidneys. In the skin, T-cell infiltrates mainly co-localized with damaged dermal small vessels. Finally, patients with the largest kidney T-cell infiltrates were also those with the highest proteinuria.

CONCLUSION

Altogether, our results strongly suggest that, in IgAV patients, CXCL10/11 orchestrate the recruitment of CXCR3-expressing T cells in injured tissues, contributing to tissue damage and disease activity.

IgA vasculitis (Henoch-Shönlein purpura) in adults: Diagnostic and therapeutic aspects

Immunoglobulin A (IgA) vasculitis, formerly called Henoch-Schönlein purpura, is an immune complex vasculitis affecting small vessels with dominant IgA deposits. Clinical manifestations mainly involve cutaneous purpura, arthralgias and/or arthritis, acute enteritis and glomerulonephritis. IgA vasculitis is more common among children than adults, with more severe disease in adults. Gastrointestinal and renal involvements represent the principal causes of morbidity and mortality in adults. Factors associated with long-term end-stage renal disease (ESRD) include baseline renal function impairment and baseline proteinuria >1 or 1.5 g/day, and on renal biopsy degree of interstitial fibrosis, sclerotic glomeruli and fibrinoid necrosis. Management of IgA vasculitis in adults is rendered difficult for clinicians because of the absence of correlation between initial presentation and long-term renal outcome, and the possible occurrence of spontaneous remission in patients with severe presentation or, in contrast, possible evolution to ESRD in patients with mild symptoms. Treatment is often symptomatic because disease course is usually benign. Treatment of severe involvement, including severe gastrointestinal complications or proliferative glomerulonephritis, remains controversial, with no evidence that corticosteroids or immunosuppressive agents improved long-term outcome. Prospective, randomized, controlled trials are thus needed to analyze the benefit-risk ratio of such treatments.