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Solans-Laqué R, Rúa-Figueroa I, Blanco Aparicio M, García Moguel I, Blanco R, Pérez Grimaldi F, Noblejas Mozo A, Labrador Horrillo M, Álvaro-Gracia JM, Domingo Ribas C, Espigol-Frigolé G, Sánchez-Toril López F, Ortiz Sanjuán FM, Arismendi E, Cid MC. Red flags for clinical suspicion of eosinophilic granulomatosis with polyangiitis (EGPA). Eur J Intern Med 2024; 128:45-52. [PMID: 38880725 DOI: 10.1016/j.ejim.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/31/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), is a rare ANCA-associated systemic vasculitis. Its overlapping features with other vasculitic or eosinophilic diseases, and the wide and heterogeneous range of clinical manifestations, often result in a delay to diagnosis. OBJECTIVE To identify red flags that raise a suspicion of EGPA to prompt diagnostic testing and to present an evidence-based clinical checklist tool for use in routine clinical practice. METHODS Systematic literature review and expert consensus to identify a list of red flags based on clinical judgement. GRADE applied to generate a strength of recommendation for each red flag and to develop a checklist tool. RESULTS 86 studies were included. 40 red flags were identified as relevant to raise a suspicion of EGPA and assessed by the experts as being clinically significant. Experts agreed that a diagnosis of EGPA should be considered in a patient aged ≥6 years with a blood eosinophil level >1000 cells/µL if untreated and >500 cells/µL if previously treated with any medication likely to have altered the blood eosinophil count. The presence of asthma and/or nasal polyposis should reinforce a suspicion of EGPA. Red flags of asthma, lung infiltrates, pericarditis, cardiomyopathy, polyneuropathy, biopsy with inflammatory eosinophilic infiltrates, palpable purpura, digital ischaemia and ANCA positivity, usually anti-myeloperoxidase, among others, were identified. CONCLUSION The identification of a comprehensive set of red flags could be used to raise a suspicion of EGPA in patients with eosinophilia, providing clinicians with an evidence-based checklist tool that can be integrated into their practice.
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Affiliation(s)
- R Solans-Laqué
- Internal Medicine Department, H. Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - I Rúa-Figueroa
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - I García Moguel
- Allergy Department, Hospital Universitario 12 de Octubre; Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - R Blanco
- Rheumatology Department, Hospital Universitario Marqués Valdecilla, IDIVAL, Immunopathology group, Santander, Spain
| | | | - A Noblejas Mozo
- Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain
| | - M Labrador Horrillo
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - J M Álvaro-Gracia
- Rheumatology Department, Hospital Universitario Gregorio Marañón, IisGM, Madrid, Spain
| | - C Domingo Ribas
- Pneumology Department, Corporació Sanitaria Parc Taulí, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - G Espigol-Frigolé
- Autoimmune Diseases Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - F M Ortiz Sanjuán
- Rheumatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - E Arismendi
- Pneumology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain and CIBERES, Barcelona, Spain
| | - M C Cid
- Autoimmune Diseases Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain.
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2
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Treccani M, Veschetti L, Patuzzo C, Malerba G, Vaglio A, Martorana D. Genetic and Non-Genetic Contributions to Eosinophilic Granulomatosis with Polyangiitis: Current Knowledge and Future Perspectives. Curr Issues Mol Biol 2024; 46:7516-7529. [PMID: 39057087 PMCID: PMC11275403 DOI: 10.3390/cimb46070446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/12/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
In this work, we present a comprehensive overview of the genetic and non-genetic complexity of eosinophilic granulomatosis with polyangiitis (EGPA). EGPA is a rare complex systemic disease that occurs in people presenting with severe asthma and high eosinophilia. After briefly introducing EGPA and its relationship with the anti-neutrophil cytoplasmic autoantibodies (ANCA)-associated vasculitis (AAVs), we delve into the complexity of this disease. At first, the two main biological actors, ANCA and eosinophils, are presented. Biological and clinical phenotypes related to ANCA positivity or negativity are explained, as well as the role of eosinophils and their pathological subtypes, pointing out their intricate relations with EGPA. Then, the genetics of EGPA are described, providing an overview of the research effort to unravel them. Candidate gene studies have investigated biologically relevant candidate genes; the more recent genome-wide association studies and meta-analyses, able to analyze the whole genome, have confirmed previous associations and discovered novel risk loci; in the end, family-based studies have dissected the contribution of rare variants and the heritability of EGPA. Then, we briefly present the environmental contribution to EGPA, reporting seasonal events and pollutants as triggering factors. In the end, the latest omic research is discussed and the most recent epigenomic, transcriptomic and microbiome studies are presented, highlighting the current challenges, open questions and suggesting approaches to unraveling this complex disease.
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Affiliation(s)
- Mirko Treccani
- GM Lab, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, 37134 Verona, Italy;
| | - Laura Veschetti
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milano, Italy;
- Vita-Salute San Raffaele University, 20132 Milano, Italy
| | - Cristina Patuzzo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy;
| | - Giovanni Malerba
- GM Lab, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, 37134 Verona, Italy;
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy;
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Davide Martorana
- Medical Genetics Unit, Department of Onco-Hematology, University Hospital of Parma, 43126 Parma, Italy;
- CoreLab Unit, Research Center, University Hospital of Parma, 43126 Parma, Italy
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3
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Nakamura Y, Kikumoto N, Takeuchi H, Kimura T, Nakamori M, Fujiwara K. Combination Biologic Therapy with Mepolizumab and Dupilumab for Severe Eosinophilic Granulomatosis with Polyangiitis and Chronic Rhinosinusitis with Nasal Polyp. Yonago Acta Med 2024; 67:157-162. [PMID: 38803595 PMCID: PMC11128079 DOI: 10.33160/yam.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 05/29/2024]
Abstract
We report the case of a 55-year-old female with eosinophilic granulomatosis with polyangiitis and chronic rhinosinusitis with nasal polyp. Rhinosinusitis recurred 6 months after full-house endoscopic sinus surgery. Although conventional treatment with azathioprine and mepolizumab with steroids was given, it was difficult to simultaneously control both rhinosinusitis and eosinophilic granulomatosis with polyangiitis. Clinical examinations showed polyps in the olfactory cleft, and the patient's anosmia gradually became persistent. Even after administering mepolizumab for a certain period of time, symptoms did not improve, but when the biologic agent was switched to dupilumab, an improvement in recalcitrant chronic rhinosinusitis with nasal polyp was observed. While dupilumab was administered intermittently for refractory chronic rhinosinusitis with nasal polyp, the rhinosinusitis improved and symptoms such as worsening of eosinophilic granulomatosis with polyangiitis paresthesia were observed. Both symptoms gradually subsided 19 months after starting intermittent administration, leading to the discontinuation of dupilumab administration. Rhinosinusitis in the setting of eosinophilic granulomatosis with polyangiitis may be refractory in some cases, and this case provides findings demonstrating the strong effect of dupilumab on eosinophilic inflammation.
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Affiliation(s)
- Yosuke Nakamura
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Naoki Kikumoto
- Division of Respiratory Medicine, Tottori Seikyo Hospital, Tottori 680-0833, Japan
| | - Hiromi Takeuchi
- Division of Otolaryngology, Tottori Red Cross Hospital, Tottori 680-0017, Japan
| | - Toru Kimura
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Motoki Nakamori
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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4
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Hariharan P, Nemchenok L, Hadi M, Williams V, Caliendo A. Young Female With Hypereosinophilia, Rash, and Gait Disturbance: A Case Report. Cureus 2024; 16:e56498. [PMID: 38638789 PMCID: PMC11026124 DOI: 10.7759/cureus.56498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/20/2024] Open
Abstract
Eosinophilia is known to be associated with a multitude of co-morbidities. However, unexplained eosinophilia poses a diagnostic challenge, and the methods used to investigate unexplained eosinophilia vary from region to region. In this case report, we describe a unique case of a young female presenting with marked eosinophilia to a tertiary hospital in the northeastern United States. Our patient presented with a few weeks of lower extremity rash, gait instability, and new onset marked eosinophilia. We further report the investigations undertaken during the hospitalization to highlight the broad differential diagnoses. Later, we provide a consolidated diagnosis of eosinophilic granulomatosis with polyangiitis (EPGA) based on the clinical context. Our patient was eventually started on a high-dose steroid taper. In the following weeks, while we noted gait improvement, we observed biomarker (eosinophilia) relapse after steroid taper. Depending on symptom progression, we planned for future remission induction with immunomodulatory agents. The report further discusses the pleomorphic presentation of EPGA cases, the natural course of disease, and currently available prognostic indices.
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5
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Bloom JL, Langford CA, Wechsler ME. Therapeutic Advances in Eosinophilic Granulomatosis with Polyangiitis. Rheum Dis Clin North Am 2023; 49:563-584. [PMID: 37331733 DOI: 10.1016/j.rdc.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis that affects a variety of organ systems. Historically, glucocorticoids and a variety of other immunosuppressants were used to abrogate the inflammation and tissue injury associated with EGPA. The management of EGPA has evolved greatly during the last decade with the development of novel targeted therapeutics that have resulted in significantly improved outcomes for these patients, with many more novel targeted therapies emerging.
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Affiliation(s)
- Jessica L Bloom
- Section of Rheumatology, Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue B-311, Aurora, CO 80045, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44195, USA
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, J215, 1400 Jackson Street, Denver, CO 80206, USA.
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6
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Seth N, Tran PP. Cholecystitis: A Rare Presentation for Diffuse Eosinophilic Granulomatosis With Polyangiitis. ACG Case Rep J 2023; 10:e01023. [PMID: 37073381 PMCID: PMC10106219 DOI: 10.14309/crj.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/06/2023] [Indexed: 04/20/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis is a rare disorder of small- to medium-sized vessel vasculitis that can affect a multitude of organ systems. It typically presents as asthma, with 50% of cases having some gastrointestinal involvement, but involvement of the gallbladder is very rare. We present a unique case report of a patient who presented for nonspecific symptoms, ultimately leading to a cholecystectomy, which officially histologically diagnosed them with eosinophilic granulomatosis with polyangiitis.
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Affiliation(s)
- Nikhil Seth
- Baylor Scott and White Internal Medicine, Temple, TX
| | - Phi P. Tran
- Baylor Scott and White Internal Medicine, Temple, TX
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7
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Sato M, Yatomi M, Wakamatsu I, Uno S, Hanazato C, Masuda T, Yamaguchi K, Aoki-Saito H, Kasahara N, Miura Y, Tsurumaki H, Hara K, Koga Y, Sunaga N, Okada T, Ikota H, Hisada T, Maeno T. Effective treatment with mepolizumab in a patient with severe eosinophilic granulomatosis with polyangiitis complicated with small intestine perforation. Respir Med Case Rep 2023; 43:101818. [PMID: 36950026 PMCID: PMC10025129 DOI: 10.1016/j.rmcr.2023.101818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/27/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is systemic vasculitis caused by eosinophilia affecting small to medium-sized blood vessels, which damages the organs. Antineutrophil cytoplasmic antibody-associated vasculitis EGPA treatment guidelines added anti-interleukin-5 antibody mepolizumab to the standard treatment protocol for active-non-severe EGPA based on the MIRRA study. Nevertheless, the role of mepolizumab in treating patients with active severe EGPA has not been established. We treated a patient with EGPA complicated with small intestine perforation using steroid pulse intravenous, high-dose glucocorticoids, intravenous high-dose immunoglobulin therapy, and mepolizumab without immunosuppression agents; the patient went into remission, suggesting that mepolizumab is an effective therapeutic agent that could lead to remission in severe EGPA.
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Affiliation(s)
- Mari Sato
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Masakiyo Yatomi
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
- Corresponding author.
| | - Ikuo Wakamatsu
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Shogo Uno
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Chiharu Hanazato
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Tomomi Masuda
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Koichi Yamaguchi
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Haruka Aoki-Saito
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Norimitsu Kasahara
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Yosuke Miura
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Hiroaki Tsurumaki
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Kenichiro Hara
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Yasuhiko Koga
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Noriaki Sunaga
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Takuhisa Okada
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, 3-39-22, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
| | - Hayato Ikota
- Department of Diagnostic Pathology, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8514, Japan
| | - Toshitaka Maeno
- Division of Allergy and Respiratory Medicine, Integrative Center of Internal Medicine, Gunma University Hospital, 3-39-15, Showa-machi, Maebashi, Gunma, 371- 8511, Japan
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8
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Tsioulos G, Kounatidis D, Vallianou NG, Koufopoulos N, Katsimbri P, Antoniadou A. Severe eosinophilic granulomatosis with polyangiitis responding to a combination of rituximab and mepolizumab. Am J Med Sci 2023; 365:93-98. [PMID: 35970248 DOI: 10.1016/j.amjms.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 01/04/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss Syndrome, is a multisystem antineutrophil cytoplasmic antibody (ANCA) positive vasculitis, characterized by the presence of chronic rhinosinusitis, asthma and prominent peripheral blood eosinophilia. Although the most commonly involved organ is the lung, followed by the skin, EGPA can affect any organ system. Herein, we present the complicated case of an 18-year-old male patient with severe life-threatening EGPA, with central nervous system, cardiac and gasterointestinal involvement, which was resistant to initial treatment with glucocorticoids and cyclophosphamide. The patient responded well, achieving complete remission after the addition of rituximab and mepolizumab to glucocorticoids and cyclophosphamide.
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Affiliation(s)
- Georgios Tsioulos
- Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Dimitris Kounatidis
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Natalia G Vallianou
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece.
| | | | - Pelagia Katsimbri
- Department of Internal Medicine, Attikon University Hospital, Athens, Greece
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9
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Alam V, Nanzer AM. Eosinophilic granulomatosis with polyangiitis: case report and literature review. Breathe (Sheff) 2022; 18:220170. [PMID: 36865937 PMCID: PMC9973489 DOI: 10.1183/20734735.0170-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, is a multisystem disorder characterised by asthma, blood and tissue eosinophilia and small-vessel vasculitis. Eosinophilic tissue infiltration and extravascular granuloma formation can lead to damage in any organ, but it is classically seen to cause pulmonary infiltrates, sino-nasal disease, peripheral neuropathy, renal and cardiac involvement, and rashes. EGPA is part of the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis syndromes, with the antibody being detected in ∼30-40% of cases and mostly against myeloperoxidase. Two genetically and clinically distinct phenotypes, defined by the presence or absence of ANCA have been identified. Treatment for EGPA focuses on inducing and maintaining disease remission. To date, oral corticosteroids remain first-line agents whilst second-line treatments include immunosuppressants such as cyclophosphamide, azathioprine, methotrexate, rituximab and mycophenolate mofetil. However, long-term steroid usage results in multiple and well-known adverse health effects and new insights into the pathophysiology of EGPA have allowed for the development of targeted biologic therapies, like the anti-eosinophilic, anti-interleukin-5 monoclonal antibodies.
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Affiliation(s)
- Vardah Alam
- Guy's and St Thomas’ Hospitals NHS Trust, London, UK,Corresponding author: Vardah Alam ()
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10
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Janson C, Bjermer L, Lehtimäki L, Kankaanranta H, Karjalainen J, Altraja A, Yasinska V, Aarli B, Rådinger M, Hellgren J, Lofdahl M, Howarth PH, Porsbjerg C. Eosinophilic airway diseases: basic science, clinical manifestations and future challenges. Eur Clin Respir J 2022; 9:2040707. [PMID: 35251534 PMCID: PMC8896196 DOI: 10.1080/20018525.2022.2040707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Valentyna Yasinska
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge, Sweden
| | - Bernt Aarli
- Department of Clinical Science, University of Bergen and Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Madeleine Rådinger
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Johan Hellgren
- Department of Otorhinolaryngology, University of Gothenburg, Gothenburg, Sweden
| | | | - Peter H Howarth
- Respiratory Medical Franchise, GSK, Brentford, Middlesex, UK
| | - Celeste Porsbjerg
- Department of Respiratory Medicine, Bispebjerg Hospital and Copenhagen University, Copenhagen, Denmark
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11
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Detoraki A, Tremante E, Poto R, Morelli E, Quaremba G, Granata F, Romano A, Mormile I, Rossi FW, de Paulis A, Spadaro G. Real-life evidence of low-dose mepolizumab efficacy in EGPA: a case series. Respir Res 2021; 22:185. [PMID: 34162391 PMCID: PMC8220666 DOI: 10.1186/s12931-021-01775-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/09/2021] [Indexed: 12/26/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, small vessel, necrotizing vasculitis. The disease is mainly characterized by hypereosinophilia and asthma with frequent sinonasal involvement, although multiple organs can be affected, including the heart, lungs, skin, gastrointestinal tract, kidneys, and nervous system. IL-5 production is pathogenetically central for the development of the disease by promoting proliferation, transvascular migration and functional activation of eosinophils. The degree of blood and tissue eosinophilia appears to be associated with disease pathogenesis and eosinophil depletion represents a promising treatment approach for EGPA. We prospectively evaluated the efficacy and safety of a low dose (100 mg q4w), 12-month course of mepolizumab, an anti-IL-5 monoclonal antibody, in eight patients with severe asthma and active EGPA. Patients were recruited by the tertiary care center of Clinical Immunology and Allergy, University of Naples Federico II. The following outcomes were assessed before (T0), and after 6 (T6) and 12 months (T12) of mepolizumab treatment: Birmingham Vasculitis Activity Score (BVAS), prednisone intake, Sino-Nasal Outcome Test (SNOT-22), Total Endoscopic Polyp Score (TENPS), Asthma Control Test (ACT), Forced Expiratory Volume one second (FEV1)%, blood eosinophilia. BVAS score significantly decreased showing a sharp reduction in disease activity score. Clinical improvements in terms of sinonasal scores and asthma symptoms were observed, in parallel with a drastic drop in eosinophil blood count. Prednisone intake was significantly reduced. In two patients, asthma exacerbations led to discontinuation in mepolizumab therapy after 6 and 12 months despite BVAS reduction. Mepolizumab treatment was well tolerated, and no severe adverse drug effects were registered. In conclusion, our 12-month real-life study suggests that mepolizumab may be beneficial and safe in active EGPA patients by improving disease activity score, sinonasal and asthma outcomes while reducing the burden of prednisone intake.
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Affiliation(s)
- Aikaterini Detoraki
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy.
| | | | - Remo Poto
- Post Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Emanuela Morelli
- Post Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Giuseppe Quaremba
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Francescopaolo Granata
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
| | - Antonio Romano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxilofacial Surgery Unit, University of Naples Federico II, Naples, Italy
| | - Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy.,Allergy and Clinical Immunology Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
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12
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Nishihara M, Hamaguchi M, Ikumi N, Nishiwaki A, Sugiyama K, Nagasawa Y, Tsuzuki H, Yoshizawa S, Tanikawa Y, Asatani S, Kobayashi H, Takei M, Kitamura N. Successful early introduction of mepolizumab for peripheral neuropathy with a peripheral circulatory disorder in a patient with myeloperoxidase anti-neutrophil cytoplasmic antibody-negative eosinophilic granulomatosis with polyangiitis. Mod Rheumatol Case Rep 2021; 5:354-359. [PMID: 33970058 DOI: 10.1080/24725625.2021.1916159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A 26-year-old woman presented with abdominal pain, diarrhoea, vomiting, fever, and progressive paralysis in the lower limbs. She had a history of bronchial asthma and experienced sinusitis, progressive peripheral neuropathy, polyarthritis, and leukocytosis with prominent eosinophilia. The patient was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). Abdominal pain was considered to be an ischaemic enteritis associated with EGPA. She was administered 1,000 mg/day of methylprednisolone for 3 days and intravenous immunoglobulin (400 mg/kg/day of γ-globulin for 5 days) followed by 50 mg (1 mg/kg)/day of oral prednisolone due to rapidly progressing peripheral neuropathy. Her symptoms temporarily improved; however, peripheral neuropathy recurred after a week, and the eosinophil count increased. Eighteen days after following the resumed treatment, 300 mg of mepolizumab, a humanised monoclonal antibody, was administered. Subjective symptoms, nerve conduction velocity, and skin perfusion pressure (an index of peripheral circulation in the lower extremities) improved after 4 weeks. Although mepolizumab has been approved for EGPA, there is no evidence of its efficacy against peripheral neuropathy. Early introduction of mepolizumab may contribute to an the early improved progressive peripheral neuropathy with eosinophilia.
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Affiliation(s)
- Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Marina Hamaguchi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Natsumi Ikumi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsuma Nishiwaki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kaita Sugiyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuzuki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shoei Yoshizawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Tanikawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shinya Asatani
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masami Takei
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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13
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Burtson KM, Bishop J. Prevasculitic Eosinophilic Granulomatosis With Polyangiitis. Cureus 2021; 13:e14649. [PMID: 34055509 PMCID: PMC8144070 DOI: 10.7759/cureus.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is an exceptionally rare systemic necrotizing vasculitis. The disease is clinically characterized by asthma with concomitant blood and tissue eosinophilia, often progressing to eosinophilic vasculitis. From the onset of asthma, there is usually a three to nine year delay of EGPA diagnosis. We report a case of this highly uncommon disease identified in an early stage.
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Affiliation(s)
- Kathryn M Burtson
- Internal Medicine, Wright Patterson Air Force Base/Wright State University, Dayton, USA
| | - Jonathan Bishop
- Critical Care Medicine, University of Pittsburgh Medical Center Mercy, Pittsburgh, USA
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14
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Improvement of Chronic Rhinosinusitis and Reduction of the Myeloperoxidase-Antineutrophil Cytoplasmic Antibody Titer in a Patient with Eosinophilic Granulomatosis with Polyangiitis by Additional Mepolizumab. Case Rep Rheumatol 2021; 2021:5561762. [PMID: 33859858 PMCID: PMC8024092 DOI: 10.1155/2021/5561762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/23/2021] [Accepted: 03/18/2021] [Indexed: 12/26/2022] Open
Abstract
A case of eosinophilic granulomatosis with polyangiitis (EGPA) in which chronic rhinosinusitis (CRS) was improved with a reduction in the myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titer after the addition of mepolizumab is reported. A 55-year-old woman with EGPA receiving prednisolone 5 mg/day developed CRS with increases in the eosinophil count and the MPO-ANCA titer. Although it improved with prednisolone 15 mg/day in addition to mizoribine 150 mg/day, because azathioprine could not be taken orally due to side effects, it relapsed after prednisolone was tapered to 5 mg/day. There was no exacerbation of other vasculitis symptoms such as mononeuropathy multiplex. The patient was treated with additional mepolizumab 300 mg every 4 weeks, which resulted in the improvement of CRS and marked reductions of the eosinophil count and MPO-ANCA titer, and the reduction of prednisolone to 2 mg/day. Furthermore, even after tapering mepolizumab to 200 mg every 4 weeks, her condition remained stable without relapse of EGPA and without increases in the eosinophil count and MPO-ANCA titer. The clinical course of mepolizumab treatment in this patient suggests that the IL5-dependent inflammatory cascade is one of the factors contributing to the increase in MPO-ANCA in EGPA.
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15
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Wang Z, Han L, Yu L. Effects of surgery and topical medication on eosinophilic granulomatosis with polyangiitis with otitis media and sinusitis: a case report. J Int Med Res 2021; 48:300060520920049. [PMID: 32345078 PMCID: PMC7218976 DOI: 10.1177/0300060520920049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is eosinophil-rich, necrotizing granulomatous inflammation often involving the respiratory tract. Furthermore, EGPA is necrotizing vasculitis that predominantly affects small to medium vessels and is associated with asthma and eosinophilia. Most patients with EGPA have sinusitis and some complain of hearing loss and refractory otitis media with effusion. Systemic use of immunosuppressants and glucocorticoids is currently recommended, despite the inevitable associated side effects. However, systemic treatment is not always effective for nasal and ear symptoms. We report a case of EGPA with refractory otitis media and chronic sinusitis, which were resistant to systemic high-dose steroids and immunosuppressants. However, these symptoms responded well to functional endoscopic sinus surgery and myringotomy and grommet insertion. We also administered budesonide nasal irrigation and glucocorticoid injection by intratympanic and postaural methods in this patient. The therapeutic effect was satisfactory.
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Affiliation(s)
- Zijing Wang
- Department of Otolaryngology, Peking University People's Hospital, Beijing, China
| | - Lin Han
- Department of Otolaryngology, Peking University People's Hospital, Beijing, China
| | - Lisheng Yu
- Department of Otolaryngology, Peking University People's Hospital, Beijing, China
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16
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Kitamura N, Hamaguchi M, Nishihara M, Ikumi N, Sugiyama K, Nagasawa Y, Tsuzuki H, Yoshizawa S, Tanikawa Y, Oshima M, Asatani S, Kobayashi H, Takei M. The effects of mepolizumab on peripheral circulation and neurological symptoms in eosinophilic granulomatosis with polyangiitis (EGPA) patients. Allergol Int 2021; 70:148-149. [PMID: 32967778 DOI: 10.1016/j.alit.2020.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Marina Hamaguchi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Natsumi Ikumi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kaita Sugiyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuzuki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shoei Yoshizawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Tanikawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masashi Oshima
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shinya Asatani
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masami Takei
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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17
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Tombetti E, Mulè A, Tamanini S, Matteucci L, Negro E, Brucato A, Carnovale C. Novel Pharmacotherapies for Recurrent Pericarditis: Current Options in 2020. Curr Cardiol Rep 2020; 22:59. [PMID: 32562029 PMCID: PMC7303578 DOI: 10.1007/s11886-020-01308-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recent advances have shown impressive results by anti-interleukin 1 (IL-1) agents in refractory idiopathic recurrent pericarditis. PURPOSE OF REVIEW: We critically discuss the current state of the art of therapy of relapsing pericarditis, with a focus on new pharmacological approaches and on specific clinical settings such as pregnancy, pediatric patients, and secondary forms of relapsing pericarditis. RECENT FINDINGS: Antagonism of the IL-1 is highly effective in idiopathic recurrent pericarditis with autoinflammatory features. Currently, available anti-IL-1 agents are anakinra and canakinumab. Rilonacept is another IL-1 antagonist, currently studied in the phase-3 clinical trial RHAPSODY. Available data suggest similar efficacy and safety profiles of these three agents, although only anakinra has been tested in randomized clinical trials. These agents have slightly different pharmacological properties, being canakinumab a specific IL-1ß antagonist while anakinra and rilonacept are unselective IL-1α and IL-1ß blockers. To date, there is no evidence that specificity against IL-1ß affects safety and efficacy in patients with relapsing pericarditis, although it has been proposed that unspecific blockage might be useful in severe disease. Anakinra is the first anti-IL-1 agent with well-documented efficacy and safety in adult and pediatric patients with idiopathic relapsing pericarditis. Other anti-IL-1 agents are currently under study. Future research should clarify the optimal duration of therapy and tapering schedule of treatment with these agents. Moreover, biomarkers would be required to understand which patients will benefit from early administration of IL-1 blockers due to refractoriness to conventional therapy and which others will suffer from recurrences during the tapering of these agents. Lastly, future studies should focus on the subjects with the autoimmune or the pauci-inflammatory phenotype of idiopathic refractory pericarditis.
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Affiliation(s)
- Enrico Tombetti
- Department of Biomedical and Clinical Sciences, Università di Milano, Fatebenefratelli Hospital, Milan, Italy
| | - Alice Mulè
- Internal Medicine, Fatebefratelli Hospital, Milan, Italy
| | | | - Luca Matteucci
- Internal Medicine, Fatebefratelli Hospital, Milan, Italy
| | - Enrica Negro
- Internal Medicine, Fatebefratelli Hospital, Milan, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, Università di Milano, Fatebenefratelli Hospital, Milan, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Via GB Grassi 74, 20157 Milan, Italy
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18
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Melemeni A, Tympa Grigoriadou A, Karachanidi S, Tsaroucha A. Severe anaphylactic shock after anesthesia induction: An unusual initial manifestation of Churg-Strauss syndrome. Int J Immunopathol Pharmacol 2020; 34:2058738420980260. [PMID: 33287613 PMCID: PMC7727078 DOI: 10.1177/2058738420980260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Churg-Strauss syndrome or eosinophilic granulomatosis with polyangiitits (EGPA) is a rare multisystem disorder. A case of anaphylactic shock after induction of anesthesia, as the initial clinical presentation of Churg-Strauss syndrome in a 15-year-old girl is reported. It is extremely rare to see pediatric patients with previous perioperative anaphylaxis receiving future anesthesia; a multidisciplinary approach including allergist, rheumatologist, anesthesiologist, and surgeon is necessary in order to provide a better future anesthetic plan.
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Affiliation(s)
- Aikaterini Melemeni
- 1st Department of Anesthesiology, Aretaieion University Hospital, Athens, Greece
| | | | | | - Athanasia Tsaroucha
- 1st Department of Anesthesiology, Aretaieion University Hospital, Athens, Greece
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19
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Ekeigwe NL, Adelowo O, Anaba EL, Olaosebikan H. Eosinophilic granulomatosis with polyangiitis in a Nigerian woman. BMJ Case Rep 2019; 12:12/6/e228901. [PMID: 31217209 DOI: 10.1136/bcr-2018-228901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), previously called Churg-Strauss Syndrome, is a systemic autoimmune disease that is usually associated with asthma and eosinophilia. It is a rare condition associated with antineutrophil cytoplasmic antibodies (ANCA). We report a case of a 52-year-old Nigerian woman who presented with bilateral leg swelling with multiple ulcers, background history of allergic rhinitis and chronic sinusitis since adolescence. There were also associated symptoms of peripheral neuropathy, weight loss, peripheral blood eosinophilia and positive perinuclear ANCA and she was previously managed for rheumatoid arthritis and asthma. She fulfilled the American College of Rheumatology criteria for EGPA and was treated with glucocorticoids and methotrexate which led to significant improvement of her symptoms.
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Affiliation(s)
- Ngozi Lina Ekeigwe
- Department of Internal Medicine, Federal Medical Center Owerri, Owerri, Nigeria
| | - Olufemi Adelowo
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Ehiaghe Lonia Anaba
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Hakeem Olaosebikan
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
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20
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Schroeder JW, Folci M, Losappio LM, Chevallard M, Sinico RA, Mirone C, De Luca F, Nichelatti M, Pastorello EA. Anti-Neutrophil Cytoplasmic Antibodies Positivity and Anti-Leukotrienes in Eosinophilic Granulomatosis with Polyangiitis: A Retrospective Monocentric Study on 134 Italian Patients. Int Arch Allergy Immunol 2019; 180:64-71. [PMID: 31189169 DOI: 10.1159/000500544] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis associated with asthma, anti-neutrophil cytoplasmic antibodies (ANCA) positivity, and tissue eosinophilia. OBJECTIVE To describe the presenting clinical features, significant biochemical alterations, and also potential pathogenic factors in adult patients diagnosed in our Center over a period of >20 years. METHOD A retrospective study of EGPA patients diagnosed from 1994 to 2019 at ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan (Italy), which was performed according to the 1990 American College of Rheumatology criteria and Chapel Hill Consensus Conference definition. A dataset was compiled, registering demographic and clinical features, biochemical analysis at onset, and also the therapies received 3 months prior to EGPA diagnose. Statistical analyses were subsequently conducted dividing patients in 2 groups based on ANCA positivity and comparing them. RESULTS Two groups were clearly identified by ANCA serology and specific organ involvement in accordance with literature reports; however, our data underline for the first time the association between anti-leukotriene receptor antagonists (LTRAs) and ANCA positivity. The group of previously treated patients presents an OR of 6.42 to be ANCA positive. This finding could be attributed to an imbalanced stimulation of leukotriene receptors, inducing both mast cells activation and an increased neutrophil extracellular traps release from neutrophils. CONCLUSION Despite the limitations of this retrospective study, the association between LTRAs and ANCA antibodies elucidates the mechanism by which innate immunity is directly involved in tolerance breakdown and autoantibodies production. Validation of our results with targeted studies could clarify the differences between ANCA-positive and ANCA-negative patients with important consequences on the use of some drug classes in the treatment of EGPA and asthmatic subjects.
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Affiliation(s)
- Jan Walter Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Marco Folci
- Department of Internal Medicine, Division of Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy
| | - Laura Michelina Losappio
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Michel Chevallard
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy.,DISCCO, University of Study of Milan, Milan, Italy
| | - Renato Alberto Sinico
- Department of Medicine and Surgery, Nephrology Unit, University of Milano-Bicocca, Monza, Italy
| | - Corrado Mirone
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Fabrizio De Luca
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Michele Nichelatti
- Service of Biostatistics, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Elide Anna Pastorello
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy, .,DISCCO, University of Study of Milan, Milan, Italy,
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21
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P-ANCA negative eosinophilic granulomatosis with polyangiitis. Respir Med Case Rep 2019; 27:100830. [PMID: 30989049 PMCID: PMC6446216 DOI: 10.1016/j.rmcr.2019.100830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 11/21/2022] Open
Abstract
Vasculitis refers to inflammation of the systemic vessels. Eosinophilic granulomatosis with polyangiitis (EGPA) is a medium and small vessel vasculitis characterized by hypereosinophilia, pulmonary infiltrates, difficult to treat asthma and polyneuropathies. Diagnosis can often be challenging. In this article, we present a case of a young lady who was diagnosed ANCA negative EGPA.
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22
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Faverio P, Bonaiti G, Bini F, Vaghi A, Pesci A. Mepolizumab as the first targeted treatment for eosinophilic granulomatosis with polyangiitis: a review of current evidence and potential place in therapy. Ther Clin Risk Manag 2018; 14:2385-2396. [PMID: 30573961 PMCID: PMC6292233 DOI: 10.2147/tcrm.s159949] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Mepolizumab is an anti-interleukin-5 (IL-5) humanized monoclonal antibody that binds to free IL-5. It induces bone marrow eosinophil maturation arrest and decreases eosinophil progenitors and subsequent maturation in the blood and bronchial mucosa. Its use has been extensively studied in severe eosinophilic asthma at a dose of 100 mg subcutaneously (SC) every 4 weeks and, more recently, in other hypereosinophilic syndromes. Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis that may involve multiple organs. Characteristic clinical manifestations are asthma, sinusitis, transient pulmonary infiltrates and neuropathy. Among the numerous pathways involved in the pathogenesis of EGPA, the Th-2 phenotype has a main role, as suggested by the prominence of the asthmatic component, in triggering the release of key cytokines for the activation, maturation and survival of eosinophils. In particular, IL-5 is highly increased in active EGPA and its inhibition can represent a potential therapeutic target. In this scenario, mepolizumab may play a therapeutic role. After some positive preliminary observations on the use of mepolizumab in small case series of EGPA patients with refractory or relapsing disease despite standard of care treatment, a randomized controlled trial was published in 2017. Mepolizumab at a dose of 300 mg administered by SC injection every 4 weeks proved effective in prolonging the period of remission of the disease, allowing for reduced steroid use. The positive results of this study, which met both of the primary endpoints, led to the approval in the USA of mepolizumab in adult patients with EGPA by the Food and Drug Administration in 2017. Therefore, mepolizumab can be officially considered as an add-on therapy with steroid-sparing effect in cases of relapsing or refractory EGPA. However, the most appropriate dose and duration of therapy still need to be determined. Future studies on larger multinational populations with prolonged follow-up are warranted.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
| | - Giulia Bonaiti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
| | - Francesco Bini
- ASST-Rhodense, UOC Pneumologia, Garbagnate Milanese, Milan, Italy
| | - Adriano Vaghi
- ASST-Rhodense, UOC Pneumologia, Garbagnate Milanese, Milan, Italy
| | - Alberto Pesci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
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23
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Matsuno O, Minamoto S. Flare of eosinophilic granulomatosis with polyangiitis related to pregnancy: Case report and review of the literature. Respir Med Case Rep 2018; 26:23-26. [PMID: 30456168 PMCID: PMC6234254 DOI: 10.1016/j.rmcr.2018.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by excessive eosinophil accumulation in the peripheral blood and affected tissues with development of granulomatous vasculitic organ damage. It is strongly associated with asthma and ear-nose-throat disease. It often affects patients between the ages of 40 and 60 years. It is unknown whether pregnancy impacts the disease activity of EGPA, including initial diagnosis or relapse. Because of its rarity and age of susceptibility, there are few reported cases describing pregnancy in women with quiescent or active EGPA. Here, we describe a young woman who experienced EGPA relapse during pregnancy and subsequently underwent an elective caesarean section for non-reassuring fetal status at 37 weeks without complication.
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Serum periostin as a biomarker in eosinophilic granulomatosis with polyangiitis. PLoS One 2018; 13:e0205768. [PMID: 30308057 PMCID: PMC6181402 DOI: 10.1371/journal.pone.0205768] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/01/2018] [Indexed: 12/02/2022] Open
Abstract
Objective Identification of a biomarker for disease activity in eosinophilic granulomatosis with polyangiitis (EGPA; Churg-Strauss) remains an unmet need. This study examined the value of serum periostin, a marker of type 2 inflammation, as a measure of disease activity in patients with EGPA. Methods Participants enrolled in a multicenter, prospective cohort of patients with EGPA were included in this study if they had disease activity (defined as Birmingham Vasculitis Activity Score [BVAS] > 0) during follow-up. Serum levels of periostin were measured at flare visit as well as two pre- and two post-flare visits, if available. The outcome of disease activity was assessed either with BVAS or Physician Global Assessment (PGA). Mixed-effect models were used to examine the association between periostin levels and disease activity. Comparisons were made with a historical cohort of healthy individuals and patients with asthma. Results In the 49 patients included in the study, the median periostin level was 60 ng/ml (IQR 50 to 73) in all visits and did not significantly change across visits. Multivariate analyses found no association between periostin level and presence or absence of flare according to the BVAS (adjusted OR 1.00 [95% CI 0.98 to 1.02], p = 0.98) but an increase in periostin level was significantly associated with greater disease severity during a flare according to the PGA (adjusted beta-coefficient 0.02 [95% CI 0.004 to 0.03], p = 0.01). Periostin levels in EGPA were significantly higher than previously studied healthy controls and patients with asthma. Conclusion In EGPA serum periostin level is modestly associated with greater disease severity during a flare but does not discriminate active from inactive disease. Periostin levels in EGPA are higher than in other previously studied cohorts, including healthy populations and patients with asthma, and are relatively stable over time.
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Abstract
Human eosinophils have characteristic morphologic features, including a bilobed nucleus and cytoplasmic granules filled with cytotoxic and immunoregulatory proteins that are packaged in a specific manner. Eosinophil production in the bone marrow is exquisitely regulated by timely expression of a repertoire of transcription factors that work together via collaborative and hierarchical interactions to direct eosinophil development. In addition, proper granule formation, which occurs in a spatially organized manner, is an intrinsic checkpoint that must be passed for proper eosinophil production to occur. In eosinophil-associated disorders, eosinophils and their progenitors can be recruited in large numbers into tissues where they can induce proinflammatory organ damage in response to local signals. Eosinophils are terminally differentiated and do not proliferate once they leave the bone marrow. The cytokine IL-5 specifically enhances eosinophil production and, along with other mediators, promotes eosinophil activation. Indeed, eosinophil depletion with anti-IL-5 or anti-IL-5Rα is now proven to be clinically beneficial for several eosinophilic disorders, most notably severe asthma, and several therapeutics targeting eosinophil viability and production are now in development. Significant progress has been made in our understanding of eosinophil development and the consequences of tissue eosinophilia. Future research efforts focused on basic eosinophil immunobiology and translational efforts to assist in the diagnosis, treatment selection, and resolution of eosinophil-associated disorders will likely be informative and clinically helpful.
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Affiliation(s)
- Patricia C Fulkerson
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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Aguirre-Valencia D, Posso-Osorio I, Bravo JC, Bonilla-Abadía F, Tobón GJ, Cañas CA. Sequential rituximab and omalizumab for the treatment of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Clin Rheumatol 2017; 36:2159-2162. [PMID: 28762062 DOI: 10.1007/s10067-017-3780-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/13/2017] [Accepted: 07/21/2017] [Indexed: 11/30/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome (CSS), is a small vessel vasculitis associated with eosinophilia and asthma. Clinical manifestations commonly seen in patients presenting with EGPA range from upper airway and lung involvement to neurological, cardiac, cutaneous, and renal manifestations. Treatment for severe presentations includes steroids, cyclophosphamide, plasmapheresis, and recently, rituximab. Rituximab is associated with a good response in the treatment of vasculitis, but a variable response for the control of allergic symptoms. Here, we report a 16-year-old female patient with severe EGPA (gastrointestinal and cutaneous vasculitis, rhinitis and asthma) refractory to conventional treatment. She was treated with rituximab, which enabled rapid control of the vasculitis component of the disease, but there was no response to rhinitis and asthma. Additionally, she developed severe bronchospasm during rituximab infusion. Sequential rituximab and omalizumab were initiated, leading to remission of all manifestations of vasculitis, rhinitis, and asthma, in addition to bronchospasm related to rituximab infusion.
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Affiliation(s)
- David Aguirre-Valencia
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Fundación Valle del Lili and Univesidad Icesi, Cali, Colombia
| | - Iván Posso-Osorio
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Fundación Valle del Lili and Univesidad Icesi, Cali, Colombia
| | | | - Fabio Bonilla-Abadía
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Fundación Valle del Lili and Univesidad Icesi, Cali, Colombia
| | - Gabriel J Tobón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Fundación Valle del Lili and Univesidad Icesi, Cali, Colombia. .,Immunology Laboratory, Fundación Valle del Lili, Cali, Colombia.
| | - Carlos A Cañas
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Fundación Valle del Lili and Univesidad Icesi, Cali, Colombia
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Yılmaz İ, Türk M, Bahçecioğlu SN. Classification of eosinophilic granulomatosis with polyangiitis phenotypes and treatment based on phenotypes. Autoimmun Rev 2017; 16:992-993. [PMID: 28711579 DOI: 10.1016/j.autrev.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 01/27/2023]
Affiliation(s)
- İnsu Yılmaz
- Erciyes University School of Medicine, Department of Chest Diseases, Division of Immunology and Allergy, Kayseri, Turkey.
| | - Murat Türk
- Erciyes University School of Medicine, Department of Chest Diseases, Division of Immunology and Allergy, Kayseri, Turkey
| | - Sakine Nazik Bahçecioğlu
- Erciyes University School of Medicine, Department of Chest Diseases, Division of Immunology and Allergy, Kayseri, Turkey
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Wechsler ME, Akuthota P, Jayne D, Khoury P, Klion A, Langford CA, Merkel PA, Moosig F, Specks U, Cid MC, Luqmani R, Brown J, Mallett S, Philipson R, Yancey SW, Steinfeld J, Weller PF, Gleich GJ. Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis. N Engl J Med 2017; 376:1921-1932. [PMID: 28514601 PMCID: PMC5548295 DOI: 10.1056/nejmoa1702079] [Citation(s) in RCA: 577] [Impact Index Per Article: 82.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis is an eosinophilic vasculitis. Mepolizumab, an anti-interleukin-5 monoclonal antibody, reduces blood eosinophil counts and may have value in the treatment of eosinophilic granulomatosis with polyangiitis. METHODS In this multicenter, double-blind, parallel-group, phase 3 trial, we randomly assigned participants with relapsing or refractory eosinophilic granulomatosis with polyangiitis who had received treatment for at least 4 weeks and were taking a stable prednisolone or prednisone dose to receive 300 mg of mepolizumab or placebo, administered subcutaneously every 4 weeks, plus standard care, for 52 weeks. The two primary end points were the accrued weeks of remission over a 52-week period, according to categorical quantification, and the proportion of participants in remission at both week 36 and week 48. Secondary end points included the time to first relapse and the average daily glucocorticoid dose (during weeks 48 through 52). The annualized relapse rate and safety were assessed. RESULTS A total of 136 participants underwent randomization, with 68 participants assigned to receive mepolizumab and 68 to receive placebo. Mepolizumab treatment led to significantly more accrued weeks of remission than placebo (28% vs. 3% of the participants had ≥24 weeks of accrued remission; odds ratio, 5.91; 95% confidence interval [CI], 2.68 to 13.03; P<0.001) and a higher percentage of participants in remission at both week 36 and week 48 (32% vs. 3%; odds ratio, 16.74; 95% CI, 3.61 to 77.56; P<0.001). Remission did not occur in 47% of the participants in the mepolizumab group versus 81% of those in the placebo group. The annualized relapse rate was 1.14 in the mepolizumab group, as compared with 2.27 in the placebo group (rate ratio, 0.50; 95% CI, 0.36 to 0.70; P<0.001). A total of 44% of the participants in the mepolizumab group, as compared with 7% of those in the placebo group, had an average daily dose of prednisolone or prednisone of 4.0 mg or less per day during weeks 48 through 52 (odds ratio, 0.20; 95% CI, 0.09 to 0.41; P<0.001). The safety profile of mepolizumab was similar to that observed in previous studies. CONCLUSIONS In participants with eosinophilic granulomatosis with polyangiitis, mepolizumab resulted in significantly more weeks in remission and a higher proportion of participants in remission than did placebo, thus allowing for reduced glucocorticoid use. Even so, only approximately half the participants treated with mepolizumab had protocol-defined remission. (Funded by GlaxoSmithKline and the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT02020889 .).
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Affiliation(s)
- Michael E Wechsler
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Praveen Akuthota
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - David Jayne
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Paneez Khoury
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Amy Klion
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Carol A Langford
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Peter A Merkel
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Frank Moosig
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Ulrich Specks
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Maria C Cid
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Raashid Luqmani
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Judith Brown
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Stephen Mallett
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Richard Philipson
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Steve W Yancey
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Jonathan Steinfeld
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Peter F Weller
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
| | - Gerald J Gleich
- From the Department of Medicine, National Jewish Health, Denver (M.E.W.); the Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla (P.A.); Beth Israel Deaconess Medical Center, Boston (P.A., P.F.W.); the Department of Medicine, University of Cambridge, Cambridge (D.J.), the Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford (R.L.), Research and Development, Immuno-Inflammation Therapy Area Unit (J.B.), and Research and Development, Statistics, Programming, and Data Standards (S.M.), GlaxoSmithKline, Uxbridge, and Trizell, Oxford (R.P.) - all in the United Kingdom; the Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.K., A.K.); the Center for Vasculitis Care and Research, Cleveland Clinic, Cleveland (C.A.L.); the Division of Rheumatology and the Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania (P.A.M.), and the Respiratory Therapy Area Unit and Flexible Discovery Unit, GlaxoSmithKline (J.S.), Philadelphia; Rheumazentrum, Schleswig-Holstein Mitte, Neumünster, Germany (F.M.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona (M.C.C.); the Respiratory Therapeutic Area, GlaxoSmithKline, Research Triangle Park, NC (S.W.Y.); and the Departments of Dermatology and Medicine, University of Utah School of Medicine, Salt Lake City (G.J.G.)
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Santos YAP, Silva BRA, Lira PNZBA, Vaz LCA, Mafort TT, Bruno LP, Lopes AJ. Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome) as a differential diagnosis of hypereosinophilic syndromes. Respir Med Case Rep 2017; 21:1-6. [PMID: 28337408 PMCID: PMC5352719 DOI: 10.1016/j.rmcr.2017.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 01/01/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare systemic disease situated between primary small vessel vasculitides associated with antineutrophil cytoplasmic antibodies (ANCAs) and hypereosinophilic syndromes (HES). Here, we present a case of EGPA in a 38-year-old male, with a previous diagnosis of asthma, who presented with fever, migratory lung infiltrates and systemic eosinophilia that was refractory to previous courses of antibiotics. This case highlights the importance of the primary care physician understanding the differential diagnosis of pulmonary eosinophilic syndromes.
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Affiliation(s)
- Yuri Albuquerque Pessoa Santos
- Department of Clinical Medicine, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 3º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Bruno Rangel Antunes Silva
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil; Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
| | | | - Luiz Carlos Aguiar Vaz
- Department of Anatomic Pathology, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 3º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
| | - Thiago Thomaz Mafort
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Leonardo Palermo Bruno
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil; Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
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Kim DS, Song JJ, Park YB, Lee SW. Five factor score of more than 1 is associated with relapse during the first 2 year-follow up in patients with eosinophilic granulomatosis with polyangiitis. Int J Rheum Dis 2017; 20:1261-1268. [DOI: 10.1111/1756-185x.13056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dae Sik Kim
- Division of Rheumatology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul South Korea
| | - Jason Jungsik Song
- Division of Rheumatology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul South Korea
| | - Yong-Beom Park
- Division of Rheumatology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul South Korea
| | - Sang-Won Lee
- Division of Rheumatology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul South Korea
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Pecoraro A, Crescenzi L, Carucci L, Genovese A, Spadaro G. Heart failure not responsive to standard immunosuppressive therapy is successfully treated with high dose intravenous immunoglobulin therapy in a patient with Eosinophilic Granulomatosis with Polyangiitis (EGPA). Int Immunopharmacol 2017; 45:13-15. [PMID: 28152445 DOI: 10.1016/j.intimp.2017.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/23/2022]
Abstract
Glucocorticoids and immunosuppressive drugs represent the first-line treatment of eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss syndrome), even though the combined therapy is not successful in achieving the disease remission in some patients with neurological or cardiac involvement. We describe a case of an EGPA male patient with impaired left ventricular function not responsive to glucocorticoid and immunosuppressive therapy. We observed that high-dose (2g/kg/4weeks) intravenous immunoglobulin (IVIG) therapy significantly improved cardiac function, which was deteriorated after reducing IVIG dose at 0.5g/kg/4weeks, and was restored increasing again IVIG dose to 2g/kg/4weeks. The finding highlights the relevance of IVIG as treatment of choice in EGPA patients with cardiac involvement not responsive to the standard glucocorticoid and immunosuppressive therapy. Moreover, at a follow-up of 24months, the continuance of high dose IVIG therapy was required to maintain a sustained remission of the heart failure.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy.
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Laura Carucci
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
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Chen Y, Ding Y, Liu Z, Zhang H, Liu Z, Hu W. Long-term outcomes in antineutrophil cytoplasmic autoantibody-positive eosinophilic granulomatosis with polyangiitis patients with renal involvement: a retrospective study of 14 Chinese patients. BMC Nephrol 2016; 17:101. [PMID: 27461086 PMCID: PMC4962371 DOI: 10.1186/s12882-016-0319-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinic-pathological features and outcomes of Chinese patients with antineutrophil cytoplasmic autoantibody (ANCA)-positive eosinophilic granulomatosis with polyangiitis (EGPA) and renal involvement have not been studied. METHODS Fourteen EGPA patients with renal involvement were included. All patients underwent renal biopsy. Clinic-pathological features and outcomes were retrospectively analyzed. RESULTS The most common initial symptom of EGPA was asthma (57.1 %), followed by hemoptysis (21.4 %), gross hematuria (14.3 %), and arthritis (7.1 %). All patients had positive serum ANCA (anti-MPO in 12, anti-PR3 in 2). Elevated eosinophils (median 15 %, range 10-45 %) were found in all patients. The median serum IgE level was 463 g/L (range 200-1000 g/L). All patients presented with renal dysfunction, with a median SCr of 5.4 mg/dL (range 1.47-11 mg/dL), seven patients (50 %) required initial renal replacement therapy. Thirteen patients showed hematuria and proteinuria (median 1.1 g/24 h, range 0.5-7.8 g/24 h). Renal biopsy showed pauci-immune segmental necrotizing glomerulonephritis with crescents in 13 patients and acute interstitial nephritis in one patient. Twelve patients (85.7 %) showed renal interstitial eosinophil infiltration, among whom three had eosinophilic granuloma. Among seven patients (71.4 %) who required initial dialysis, 5 discontinued dialysis, one died, one received maintenance dialysis after glucocorticoids plus immunosuppressive for induction treatment. Twelve patients were followed up for a median of 43.5 months (range 6-83 months), during follow-up, two patients progressed to end-stage renal disease, nine had chronic kidney disease with eGFR < 60 mL/min, and two patients had normal eGFR. CONCLUSIONS Renal involvement in ANCA-positive EGPA could be severe and showed varied renal histology. Although intensive immunosuppressive therapy effectively improved the renal function, the long-term renal survival was poor. Early diagnosis and treatment are essential to improve long-term renal survival.
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Affiliation(s)
- Yinghua Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Yuemei Ding
- Jiangsu Jiangyin People's Hospital, Jiangyin, China
| | - Zhengzhao Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Weixin Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China.
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Bitar AY, Thompson CD, Tan CW, Allem K, Khachatrian A, Weis PJ, Garg V, Srivastava A. Coronary artery vasospasm and cardiogenic shock as the initial presentation for eosinophilic granulomatosis with polyangiitis. J Cardiol Cases 2015; 13:105-108. [PMID: 30546619 DOI: 10.1016/j.jccase.2015.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/10/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022] Open
Abstract
A 68-year-old woman presented to our hospital with unstable angina and was admitted for further evaluation. While hospitalized, she developed persistent angina with hypotension along with ST-segment elevation in leads V1-V2 along with lead aVR elevation on 12-lead electrocardiogram. Coronary angiography revealed diffuse multi-vessel coronary vasospasm most notably in the left anterior descending artery (LAD). Due to incomplete resolution of vasospasm with intracoronary verapamil and nitroglycerin, along with hemodynamic compromise requiring an intra-aortic balloon pump, percutaneous coronary intervention (PCI) of the LAD was performed. Clinical workup revealed hypereosinophlia and elevated IgE; diagnosis of eosinophilic granulomatosis with polyangiitis was confirmed with evidence of radiographic migratory pulmonary infiltrates and airway obstruction on spirometry. The patient had recurrent angina after PCI but her symptoms resolved fully after a course of corticosteroids. We attribute her refractory vasospastic angina to previously undiagnosed small/medium-vessel vasculitis. <Learning objective: We present a case of refractory coronary artery vasospasm in the setting of eosinophilic granulomatosis with polyangiitis (EGPA). Typically, calcium channel blockers and nitrates are used to treat hyperreactive narrowing of the coronary vasculature but we propose this case was refractory to standard treatment due to the underlying pathology of EGPA. Alternative causes of coronary vasospasm when standard therapies fail should be considered.>.
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Affiliation(s)
- Abdallah Y Bitar
- Division of Cardiovascular Disease, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Caleb D Thompson
- Division of Cardiovascular Disease, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Christina W Tan
- Division of Cardiovascular Disease, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Kavitta Allem
- Division of Rheumatology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Aelita Khachatrian
- Division of Rheumatology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Peter J Weis
- Division of Rheumatology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Vikram Garg
- Division of Rheumatology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
| | - Ajay Srivastava
- Division of Cardiovascular Disease, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, USA
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Abstract
Churg-Strauss angiitis is a rare vasculitic disorder affecting small- and medium-sized blood vessels. It is clinically characterized by the presence of a wide spectrum of multisystem organ involvement, with allergic rhinitis, asthma and peripheral blood eosinophilia as the most typical manifestations. The authors describe 2 cases of Churg-Strauss angiitis from an urban community of Southern Louisiana, exhibiting an atypical presentation with myocardial ischemia and cerebrovascular complications. Epidemiology, pathophysiology and clinical overview are presented. The therapeutic management is also discussed.
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Unizony SH, Stone JH. Antineutrophil cytoplasmic antibody–associated vasculitis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Oh SH, Park W, Kwon SR, Lim MJ, Joo KW, Lee OH, Lee HY, Oh SY, Jung KH. A Case of Eosinophilic Granulomatosis with Polyangiitis Presenting with Subarachnoid Hemorrhage and Mononeuritis Multiplex. JOURNAL OF RHEUMATIC DISEASES 2015. [DOI: 10.4078/jrd.2015.22.3.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Se Hwan Oh
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Won Park
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seong Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Mie Jin Lim
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Ko Woon Joo
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Oh Hyun Lee
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Ha Young Lee
- Department of Radiology, Inha University School of Medicine, Incheon, Korea
| | - Se Yang Oh
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Kyong-Hee Jung
- Division of Rheumatology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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"Peripheral neuropathy crippling bronchial asthma": two rare case reports of churg-strauss syndrome. Case Rep Pulmonol 2014; 2014:673906. [PMID: 25580342 PMCID: PMC4280653 DOI: 10.1155/2014/673906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/23/2014] [Accepted: 12/01/2014] [Indexed: 12/03/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is a rare cause of vasculitic neuropathy. Although rare and potentially fatal, Churg-Strauss syndrome (CSS) is easily diagnosable and treatable. The presence of bronchial asthma with peripheral neuropathy in a patient alerts a physician to this diagnosis. This is vividly illustrated by the presented two cases who had neuropathy associated with bronchial asthma, eosinophilia, sinusitis, and positive perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) test, which improved with administration of steroids.
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Abstract
Churg-Strauss syndrome (CSS), alternatively known as eosinophilic granulomatosis with polyangiitis (EGPA), was first described in 1951 by Churg and Strauss as a rare disease characterized by disseminated necrotizing vasculitis with extravascular granulomas occurring exclusively among patients with asthma and tissue eosinophilia. EGPA is classified as a small-vessel vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs) and the hypereosinophilic syndromes (HESs) in which vessel inflammation and eosinophilic proliferation are thought to contribute to organ damage. Although still considered an idiopathic condition, EGPA is classically considered a Th2-mediated disease. Emerging clinical observations provide compelling evidence that ANCAs are primarily and directly involved in the pathogenesis of AASVs, although recent evidence implicates B cells and the humoral response as further contributors to EGPA pathogenesis. EGPA has traditionally been described as evolving through a prodromic phase characterized by asthma and rhino-sinusitis, an eosinophilic phase marked by peripheral eosinophilia and organ involvement, and a vasculitic phase with clinical manifestations due to small-vessel vasculitis. The American College of Rheumatology defined the classification criteria to distinguish the different types of vasculitides and identified six criteria for EGPA. When four or more of these criteria are met, vasculitis can be classified as EGPA. The French Vasculitis Study Group has identified five prognostic factors that make up the so-called five-factor score (FFS). Patients without poor prognosis factors (FFS=0) have better survival rates than patients with poor prognosis factors (FFS≥1). The treatment of patients with CSS must be tailored to individual patients according to the presence of poor prognostic factors. A combination of high-dose corticosteroids and cyclophosphamide is still the gold standard for the treatment of severe cases, but the use of biological agents such as rituximab or mepolizumab seems to be a promising therapeutic alternative.
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Parent ME, Larue S, Ellezam B. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) presenting as diffuse myositis. BMC Musculoskelet Disord 2014; 15:388. [PMID: 25414144 PMCID: PMC4247662 DOI: 10.1186/1471-2474-15-388] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 11/17/2014] [Indexed: 11/25/2022] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis is a complex multisystemic syndrome with heterogeneous presentation. Most often, there is a clinical history of asthma or other atopic conditions, and current presentation generally includes signs of cutaneous or pulmonary involvement. Very few reports described myalgia or weakness as the chief complaint. Of these, only a few included muscle biopsy evaluation and none showed convincing evidence of primary myositis. We believe this report is the first to demonstrate true myositis in the setting of early eosinophilic granulomatosis with polyangiitis. Case presentation This report describes a 74 year old Caucasian man, with no known allergies, presenting severe myalgia, muscle weakness, jaw claudication, and fever. Blood work showed marked eosinophilia and high creatine kinase levels. Biceps brachialis muscle biopsy revealed eosinophilic necrotizing vasculitis and true myositis with myophagocytosis of non-necrotic fibers and strong sarcolemmal MHC-1 overexpression by immunohistochemistry. This patient was successfully treated with prednisone and azathioprine. Conclusion Our finding of true myositis in a case of eosinophilic granulomatosis with polyangiitis suggests that primary auto-immunity against muscle fibers, distinct from the secondary effects of vasculitis, can occur in this entity and may represent an overlap syndrome. Early recognition of eosinophilic granulomatosis with polyangiitis in patients presenting with myositis may provide an opportunity to treat the vasculitis before onset of severe multisystemic disease. We recommend the use of muscle biopsy with immunohistochemistry for MHC-1 to confirm the diagnosis of myositis in the setting of eosinophilic granulomatosis with polyangiitis. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-388) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marc-Etienne Parent
- Department of Internal Medicine, Université de Sherbrooke, 3001 12e Avenue, Fleurimont, QC J1H 5N4, Canada.
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Ye L, Lu X, Xue J. Eosinophilic granulomatosis with polyangiitis complicated by cholecystitis: a case report and review of the literature. Clin Rheumatol 2014; 35:259-63. [DOI: 10.1007/s10067-014-2521-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 11/30/2022]
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Kim MY, Sohn KH, Song WJ, Park HW, Cho SH, Min KU, Kang HR. Clinical features and prognostic factors of Churg-Strauss syndrome. Korean J Intern Med 2014; 29:85-95. [PMID: 24574837 PMCID: PMC3932399 DOI: 10.3904/kjim.2014.29.1.85] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 03/20/2013] [Accepted: 07/10/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Churg-Strauss syndrome (CSS) is a rare systemic necrotizing small-vessel vasculitis, with accompanying bronchial asthma, eosinophilia, and eosinophilic infiltration of various tissues. The purposes of our study were to characterize the clinical features of CSS and to identify factors associated with CSS prognosis in Koreans. METHODS Medical records were reviewed retrospectively for all physician-diagnosed CSS patients in the Seoul National University Hospital between January 1990 and March 2011. RESULTS Data from 52 CSS patients were analyzed. The respiratory tract was the most commonly involved organ (90.4%). Renal involvement was less frequent in antineutrophilic cytoplasmic antibody (ANCA)(-) patients than in ANCA(+) patients (p = 0.048). Clinical remission occurred in 95.3% of patients, but 16.3% of them relapsed. Patients who maintained remission for more than 6 months were relatively older (median, 51 years) at diagnosis (p = 0.004), had been diagnosed in earlier stages (p = 0.027), showed more frequent respiratory involvement (p = 0.024) and generalized symptoms (p = 0.039), and showed less frequent cutaneous involvement (p = 0.030) than those who did not achieve persistent (> 6 months) remission. Patients who achieved persistent remission also showed higher C-reactive protein (CRP) levels (p = 0.031) than those who did not. CONCLUSIONS ANCA(-) CSS patients showed less frequent renal involvement. Characteristics of good responders were older age, diagnosis at earlier stages, less cutaneous involvement, more respiratory involvement, high CRP values, and more generalized symptoms.
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Affiliation(s)
- Mi-Yeong Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Kyoung-Hee Sohn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Heung-Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyung-Up Min
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
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Abstract
Asthma is a heterogeneous syndrome of cough, wheeze, dyspnea, and chest tightness. However, in a subset of patients, these symptoms may indicate a different underlying disease process with variable responsiveness to classic asthma therapies. Disease may progress while practitioners attempt conventional asthma therapy. Additionally, some types of asthma may require alternative approaches to relieve symptoms successfully. This article describes the differential diagnosis of asthma and discusses some of the more common asthma variants and asthma mimickers.
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Affiliation(s)
- Patrick R Aguilar
- Department of Internal Medicine, Washington University, 660 Euclid, PO Box 8052, St. Louis, MO 63110, USA
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Takayasu V, Felipe-Silva A. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) syndrome and pulmonary thromboembolism: an overlooked concomitance. AUTOPSY AND CASE REPORTS 2013; 3:11-19. [PMID: 31528603 PMCID: PMC6673679 DOI: 10.4322/acr.2013.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 06/06/2013] [Indexed: 11/23/2022] Open
Abstract
The Eosinophilic Granulomatosis with Polyangiitis (formerly Churg- Strauss Syndrome) (EGPA) is a systemic inflammatory disease characterized by the presence of rhinitis, asthma, peripheral eosinophilia, and vasculitis-the latter being characteristic of the late stage of the disease. After several years from the onset of the disease, small- and medium-sized vessel vasculitis ensues, undertaking various organs and systems. Upper and lower airways, skin, nervous system, gastrointestinal tract, heart, and kidneys are the most commonly involved organs. It is believed that tissue injury is the result of processes mediated by antineutrophil cytoplasmic antibody (ANCA), or toxic mediators released by eosinophils. Although it is classified as ANCA-associated vasculitis, these autoantibodies are present in only 40% of cases. The authors report the case of a patient with EGPA, who had a history of asthma, peripheral and central neuropathy, palpable purpura, gastrointestinal micro perforation, peripheral eosinophilia, and the presence of myeloperoxidase-antineutrophil cytoplasmic antibody. Inflammatory parameters improved after the initiation of treatment, but 1 month after hospital discharge the patient developed symptoms compatible with pulmonary embolism and died. Thrombophilia that occurs in EGPA is due to the interaction between the inflammatory response and eosinophilia with the clotting system resulting in a pro-thrombotic state. Although not yet well-determined, the authors call attention to the possibility of the impact of thromboembolic events on the prognosis of patients with EGPA. In addition to the adequate immunosuppressive treatment, prophylaxis and treatment for thrombosis should never be overlooked.
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Affiliation(s)
- Vilma Takayasu
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Aloísio Felipe-Silva
- Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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Schmid G, Schmid L, Fischer A. [Churg-Strauss syndrome--an interdisciplinary challenge]. MMW Fortschr Med 2012; 154:58-60. [PMID: 23297542 DOI: 10.1007/s15006-012-1692-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Gernot Schmid
- Universitätsklinik für Rheumatologie und klinische Immunologie, Inselspital, CH-Bern.
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Vázquez-Triñanes C, Sopeña B, González-González L, Díaz R, Rivera A, Freire M, Martínez-Vázquez C. Synovial fluid eosinophilia: a case series with a long follow-up and literature review. Rheumatology (Oxford) 2012; 52:346-51. [PMID: 23041597 DOI: 10.1093/rheumatology/kes236] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To establish the frequency and describe the characteristics of a cohort of patients with SF eosinophilia (SFE) and a long clinical follow-up. A systematic review of the literature on this topic was performed. METHODS From November 2005 to May 2010, 982 consecutive arthrocentesis procedures performed at a tertiary care hospital were reviewed. Clinical and analytical data of patients with SFE at the time of diagnosis and during follow-up until 31 January 2012, were recorded. According to the percentage of eosinophils in SF, SFE was classified as minor (<10%) or major (>10%). Also, a literature search of all publications on eosinophilic synovitis found in MEDLINE, EMBASE and Web of Science without publication date restrictions was performed. RESULTS Eosinophils in SF were found in 10 of 982 (1.02%) patients: minor SFE was recorded in three patients, all of them with haemorrhagic fluid and without peripheral eosinophilia. Major SFE was found in seven patients, and only two of them had peripheral eosinophilia. In six patients, an underlying cause of the arthritis was found. Only one patient was classified as having idiopathic SFE. Most SFE promptly resolved with NSAIDs without relapses or new deformities. The literature search identified 56 patients with SFE; 49 of them (88%) had major SFE and 7 (12%) had minor SFE. CONCLUSIONS Eosinophils are infrequently found in SF, and in most cases peripheral eosinophilia was not detected. Most patients with SFE had a benign course with prompt resolution and few relapses.
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Affiliation(s)
- Caritina Vázquez-Triñanes
- Thrombosis and Vasculitis Unit, Internal Medicine Service, Complexo Hospitalario Universitario of Vigo, Vigo, Pontevedra,Spain
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Amini-Vaughan ZJ, Martinez-Moczygemba M, Huston DP. Therapeutic strategies for harnessing human eosinophils in allergic inflammation, hypereosinophilic disorders, and cancer. Curr Allergy Asthma Rep 2012; 12:402-12. [PMID: 22875242 PMCID: PMC3729434 DOI: 10.1007/s11882-012-0290-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The eosinophil is a multifunctional granulocyte best known for providing host defense against parasites. Paradoxically, eosinophils are also implicated in the pathogenesis of allergic inflammation, asthma, and hypereosinophilic syndromes. Emerging evidence also supports the potential for harnessing the cytotoxic power of eosinophils and redirecting it to kill solid tumors. Central to eosinophil physiology is interleukin-5 (IL-5) and its receptor (IL-5R) which is composed of a ligand-specific alpha chain (IL-5Rα) and the common beta chain (βc). Eosinophil activation can lead to their degranulation, resulting in rapid release of an arsenal of tissue-destructive proinflammatory mediators and cytotoxic proteins that can be both beneficial and detrimental to the host. This review discusses eosinophil immunobiology and therapeutic strategies for targeting of IL-5 and IL-5R, as well as the potential for harnessing eosinophil cytotoxicity as a tumoricide.
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Affiliation(s)
- Zhaleh J Amini-Vaughan
- Department of Microbial and Molecular Pathogenesis, Texas A&M College of Medicine, Clinical Science and Translational Research Institute, Texas A&M Health Science Center, 2121 West Holcombe Boulevard, Houston, TX 77030, USA
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Is it acute coronary syndrome or Churg-Strauss syndrome? Am J Emerg Med 2012; 31:270.e5-8. [PMID: 22809775 DOI: 10.1016/j.ajem.2012.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/02/2012] [Indexed: 11/21/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is a rare vasculitic disorder characterized by chronic rhinosinusitis, asthma, and persistent eosinophilia. Although not a usual prominent initial presentation, cardiac involvement is a major cause of morbidity and mortality in patients with CSS. We report a case of a 72-year-old white man who presented with chest pain and was subsequently diagnosed with CSS with biopsy-proven eosinophilic myopericarditis. We have also included a review of the literatures on cardiac involvement in CSS.
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Kukita CC, Gobatto ALN, Lobo AZ, Taniguchi LU. Spinal hematoma complicating a Churg-Strauss syndrome patient: a previously unreported association. Clinics (Sao Paulo) 2012; 67:855-7. [PMID: 22892936 PMCID: PMC3400184 DOI: 10.6061/clinics/2012(07)26] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Camila Cristina Kukita
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Discipline of Emergency Medicine, São Paulo/SP, Brazil
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