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Cai Q, Wei B, Tai Y, Wu H. Case Report: Interventional therapy for portal venous stenosis caused by systemic vasculitis. Front Immunol 2022; 13:1005300. [DOI: 10.3389/fimmu.2022.1005300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Systemic vasculitis are multisystem blood vessel disorders. However, Portal venous involvement is extremely rare, which represents a diagnostic and therapeutic challenge due to the heterogeneous nature, a lack of diagnostic criteria and limited effective therapy of vasculitis. We have reported a 48-year-old woman who was previously diagnosed with systemic vasculitis and was treated with prednisone, presented with gastrointestinal (GI) bleeding on admission. Further abdominal contrast-enhanced computed tomography (CT) with three-dimensional reconstruction suggested atrophic left hepatic lobe, enlarged spleen, and severe stenosis of main portal vein. Liver biopsy showed no evidence of fibrosis/cirrhosis. To prevent rebleeding, portal venous angioplasty by balloon dilation with collateral varices embolization was performed, and the GI hemorrhage was resolved completely. However, refractory ascites presented 8 months postoperatively. Abdominal CT angiography confirmed the recurrence of portal venous stenosis. Portal venous angioplasty by stent implantation was then performed to treat the portal hypertension (PHT)-related complications. After the intervention, the patient received anticoagulation therapy and continued immunosuppressive therapy. During the 5-year follow-up, the patient did not experience any onset of GI bleeding or ascites. Therefore, portal venous angioplasty with stent placement could be an effective treatment to prevent PHT-related complications when immunosuppression therapy failed.
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Miyabe C, Dong Y, Ikeda T, Takahashi K, Miyabe Y, Kawakami T. Immune checkpoint molecule expression is altered in the skin and peripheral blood in vasculitis. Sci Rep 2021; 11:20019. [PMID: 34625602 PMCID: PMC8501116 DOI: 10.1038/s41598-021-99558-5] [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] [Received: 05/17/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
Dysfunction of immunoinhibitory signals and persistent T cell activation reportedly play important roles in the development of vasculitis. The skin is one of the most accessible organs, and it is suitable for the characterization of immune cell signatures. However, the inhibitory checkpoint molecules in the skin and their relevance to vasculitis have not been studied. Here, we investigated the profile of immune checkpoint molecules in the skin and peripheral blood of patients with vasculitis and healthy donors. We found that some of the inhibitory checkpoint molecules, including programmed cell death 1 receptor (PD-1), were elevated in T-cells in the blood of patients with systemic and cutaneous vasculitis. In addition, programmed death-ligand 1 (PD-L1) expression was elevated in the skin of patients with cutaneous vasculitis. Histologically, PD-L1 was highly expressed in the vessels in the skin along with CD4+ and CD8+ T-cell infiltration in patients with cutaneous vasculitis. Notably, plasma soluble PD-L1 levels were increased, and these correlated with C-reactive protein in patients with systemic vasculitis. Our findings suggest that inhibitory checkpoint molecules might be differentially modulated in the skin and peripheral blood of patients with vasculitis, and that the alteration of the PD-L1/PD-1 axis may be associated with the regulation of T-cell activation in vasculitis.
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Affiliation(s)
- Chie Miyabe
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan. .,Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yupeng Dong
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takaharu Ikeda
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuo Takahashi
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yoshishige Miyabe
- Department of Cell Biology, Institute for Advanced Medical Sciences, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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3
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Scolding N. CNS involvement in systemic vasculitides. J Neurol Sci 2021; 424:117423. [PMID: 33840508 DOI: 10.1016/j.jns.2021.117423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
Both the CNS and the PNS can be involved in almost all of the vasculitides - including the primary systemic vasculitic disorders, such as microscopic polyangiitis and polyarteritis nodosa, and in non-vasculitic systemic disorders, such as systemic lupus erythematosis and sarcoidosis. The latter diseases also include infections and toxininduced disorders - particularly drugs of abuse such as cocaine and amphetamines. Here we will summarise the spectrum of these disorders as they affect the CNS, concentrating in particular on their distinguishing clinical and investigational features.
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Affiliation(s)
- Neil Scolding
- Burden Professor of Clinical Neurosciences, University of Bristol Institute of Clinical Neurosciences, UK, Gulu University Faculty of Medicine, Uganda.
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Melduni RM, Cooper LT, Gersh BJ, Warrington KJ, Bailey KR, McEvoy MT, Kita H, Lee HC. Association of Autoimmune Vasculitis and Incident Atrial Fibrillation: A Population-Based Case-Control Study. J Am Heart Assoc 2020; 9:e015977. [PMID: 32893708 PMCID: PMC7727002 DOI: 10.1161/jaha.120.015977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Recent investigations suggest that inflammation and autoimmunity might have a role in the pathophysiology of atrial fibrillation (AF). Given that abnormal ventriculovascular coupling often coexists with AF, we hypothesize that autoimmune vasculitis plays a significant role in the pathogenetic mechanism of AF. Methods and Results A standardized retrospective population‐based case–control study was conducted to evaluate the association between autoimmune vasculitis and AF, and all‐cause mortality. The study included 8459 patients with a new diagnosis of AF and 8459 age‐, sex‐, and registration calendar year–matched controls in Olmsted County, Minnesota, between January 1, 1980 and December 31, 2010. The association of each clinical characteristic, diagnosis, and treatment was assessed using conditional logistic regression to account for the matched case–control study design. Cox proportional hazards regression models and Kaplan‐Meier curves were used to detect independent predictors of mortality and examine cumulative survival. Of a total of 16 918 patients (mean age 72.3+14.4 years; 48.7% women), 320 (1.9%) were diagnosed with autoimmune vasculitis before the index date during the 30‐year period. Among the cases, the prevalence of any autoimmune vasculitis was 2.3%, whereas the frequency of autoimmune vasculitis in controls was 1.5% (P<0.001). After adjusting for potential confounders, the odds of autoimmune vasculitis in AF cases was 1.5 times higher than in controls (odds ratio, 1.47; 95% CI, 1.04–2.01; P=0.03). Patients with AF and autoimmune vasculitis had worse 5‐year survival than those without autoimmune vasculitis or AF (44.7% versus 77.2%; log‐rank P<0.001). Conclusions Autoimmune vasculitis is significantly associated with AF and independently confers worse survival. These observations may represent one mechanism linking autoimmunity and inflammation to the pathogenesis and prognosis of AF.
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Affiliation(s)
- Rowlens M Melduni
- Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota USA
| | | | - Kent R Bailey
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester Minnesota USA
| | | | - Hirohito Kita
- Divisions of Allergy and Immunology Mayo Clinic Rochester Minnesota USA
| | - Hon-Chi Lee
- Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota USA
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Abstract
BACKGROUND Renal vasculitis presents as rapidly progressive glomerulonephritis and comprises of a group of conditions characterised by acute kidney injury (AKI), haematuria and proteinuria. Treatment of these conditions involve the use of steroid and non-steroid agents in combination with plasma exchange. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This 2019 publication is an update of a review first published in 2008 and updated in 2015. OBJECTIVES To evaluate the benefits and harms of any intervention used for the treatment of renal vasculitis in adults. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 21 November 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials investigating any intervention for the treatment of renal vasculitis in adults. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes or mean difference (MD) for continuous outcomes. MAIN RESULTS Forty studies (3764 patients) were included. Studies conducted earlier tended to have a higher risk of bias due to poor (or poorly reported) study design, broad inclusion criteria, less well developed disease definitions and low patient numbers. Later studies tend to have improved in all areas of quality, aided by the development of large international study groups. Induction therapy: Plasma exchange as adjunctive therapy may reduce the need for dialysis at three (2 studies: RR 0.43, 95% CI 0.23 to 0.78; I2 = 0%) and 12 months (6 studies: RR 0.45, 95% CI 0.29 to 0.72; I2 = 0%) (low certainty evidence). Plasma exchange may make little or no difference to death, serum creatinine (SCr), sustained remission or to serious or the total number of adverse events. Plasma exchange may increase the number of serious infections (5 studies: RR 1.26, 95% CI 1.03 to 1.54; I2 = 0%; low certainty evidence). Remission rates for pulse versus continuous cyclophosphamide (CPA) were equivalent but pulse treatment may increase the risk of relapse (4 studies: RR 1.79, 95% CI 1.11 to 2.87; I2 = 0%) (low certainty evidence) compared with continuous cyclophosphamide. Pulse CPA may make little or no difference to death at final follow-up, or SCr at any time point. More patients required dialysis in the pulse CPA group. Leukopenia was less common with pulse treatment; however, nausea was more common. Rituximab compared to CPA probably makes little or no difference to death, remission, relapse, severe adverse events, serious infections, or severe adverse events. Kidney function and dialysis were not reported. A single study reported no difference in the number of deaths, need for dialysis, or adverse events between mycophenolate mofetil (MMF) and CPA. Remission was reported to improve with MMF however more patients relapsed. A lower dose of steroids was probably as effective as high dose and may be safer, causing fewer infections; kidney function and relapse were not reported. There was little of no difference in death or remission between six and 12 pulses of CPA. There is low certainty evidence that there were less relapses with 12 pulses (2 studies: RR 1.57, 95% CI 0.96 to 2.56; I2 = 0%), but more infections (2 studies: RR 0.79, 95% CI 0.36 to 1.72; I2 = 45%). One study reported severe adverse events were less in patients receiving six compared to 12 pulses of CPA. Kidney function and dialysis were not reported. There is limited evidence from single studies about the effectiveness of intravenous immunoglobulin, avacopan, methotrexate, immunoadsorption, lymphocytapheresis, or etanercept. Maintenance therapy: Azathioprine (AZA) has equivalent efficacy as a maintenance agent to CPA with fewer episodes of leucopenia. MMF resulted in a higher relapse rate when tested against azathioprine in remission maintenance. Rituximab is an effective remission induction and maintenance agent. Oral co-trimoxazole did not reduce relapses in granulomatosis with polyangiitis. There were fewer relapses but more serious adverse events with leflunomide compared to methotrexate. There is limited evidence from single studies about the effectiveness of methotrexate versus CPA or AZA, cyclosporin versus CPA, extended versus standard AZA, and belimumab. AUTHORS' CONCLUSIONS Plasma exchange was effective in patients with severe AKI secondary to vasculitis. Pulse cyclophosphamide may result in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst CPA is standard induction treatment, rituximab and MMF were also effective. AZA, methotrexate and leflunomide were effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.
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Affiliation(s)
- Giles D Walters
- The Canberra HospitalDepartment of Renal MedicineYamba DriveCanberraACTAustralia2605
| | - Narelle S Willis
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Tess E Cooper
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
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Gadeyne L, Henckaerts L, Goffin KE, Gheysens O, Lerut E, Roskams T, Blockmans D, Floris G. Granulomatosis with polyangiitis with breast involvement mimicking metastatic cancer: Case report and literature review. Eur J Rheumatol 2019; 7:41-43. [PMID: 31782722 DOI: 10.5152/eurjrheum.2019.19065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/24/2019] [Indexed: 01/22/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic inflammatory disease, characterized by the presence of necrotizing vasculitis of small and medium-sized vessels, granulomatous inflammation and anti-neutrophil cytoplasmic antibodies (ANCAs). The diagnosis can be challenging due to the variable clinical presentation and possible involvement of virtually all organ systems. A correct diagnosis is indispensable for a timely start of medical treatment and to avoid unnecessary surgery. Therefore, cooperation with and the input of the pathologist is crucial. We report a case of a woman presenting with suspected metastatic cancer. The diagnosis of GPA was made mainly based on breast biopsy, and the patient was treated accordingly, with full recovery. This report provides a case description and a brief review of the literature.
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Affiliation(s)
- Laura Gadeyne
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Liesbet Henckaerts
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karolien E Goffin
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Belgium
| | - Olivier Gheysens
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Tania Roskams
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Blockmans
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Giuseppe Floris
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
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Agryropoulou O, Protogerou A, Argyris A, Tzioufas A, Vlachoyiannopoulos P. Extensive phenotyping of vascular damage in non-infectious primary vasculitides with the use of non-invasive vascular biomarkers: prevalence, pathogenesis and response to treatment. Mediterr J Rheumatol 2018; 29:173-177. [PMID: 32185320 PMCID: PMC7046042 DOI: 10.31138/mjr.29.3.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 11/06/2022] Open
Abstract
Non-Infectious Primary systemic vasculitides (NIPSV) encompass a subset of autoimmune diseases, characterized mainly by intramural inflammation of the vascular wall. The increased mortality that some exhibit is partially attributed to vascular complications involving both micro- and macro- circulation. Beyond the disease specific pathways of vascular damage, emerging evidence suggest that the classical pathways of arterial damage, namely, atheromatosis, inappropriate arterial remodeling and arteriosclerosis are accelerated in several NIPSV; thus participating in the development of vascular complications in NIPSV patients. The aim of the current research protocol is to optimize the understanding of vascular pathology in NIPSV and to identify useful, easy to measure, non-invasive vascular tools for the diagnosis and follow-up of NIPSV patients. Moreover, the study aims to generate hypothesis regarding the molecular basis of the association of inflammation with classical vascular pathology.
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Affiliation(s)
- Ourania Agryropoulou
- Department of Pathophysiology, "Laiko" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanase Protogerou
- Department of Pathophysiology, "Laiko" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonis Argyris
- Department of Pathophysiology, "Laiko" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Tzioufas
- Department of Pathophysiology, "Laiko" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis Vlachoyiannopoulos
- Department of Pathophysiology, "Laiko" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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8
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Accelerated atheromatosis and arteriosclerosis in primary systemic vasculitides: current evidence and future perspectives. Curr Opin Rheumatol 2018; 30:36-43. [DOI: 10.1097/bor.0000000000000453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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9
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Mohammad AJ, Mortensen KH, Babar J, Smith R, Jones RB, Nakagomi D, Sivasothy P, Jayne DRW. Pulmonary Involvement in Antineutrophil Cytoplasmic Antibodies (ANCA)-associated Vasculitis: The Influence of ANCA Subtype. J Rheumatol 2017; 44:1458-1467. [PMID: 28765242 DOI: 10.3899/jrheum.161224] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe pulmonary involvement at time of diagnosis in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV), as defined by computed tomography (CT). METHODS Patients with thoracic CT performed on or after the onset of AAV (n = 140; 75 women; granulomatosis with polyangiitis, n = 79; microscopic polyangiitis MPA, n = 61) followed at a tertiary referral center vasculitis clinic were studied. Radiological patterns of pulmonary involvement were evaluated from the CT studies using a predefined protocol, and compared to proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA specificity. RESULTS Of the patients, 77% had an abnormal thoracic CT study. The most common abnormality was nodular disease (24%), of which the majority were peribronchial nodules, followed by bronchiectasis and pleural effusion (19%, each), pulmonary hemorrhage and lymph node enlargement (14%, each), emphysema (13%), and cavitating lesions (11%). Central airways disease and a nodular pattern of pulmonary involvement were more common in PR3-ANCA-positive patients (p < 0.05). Usual interstitial pneumonitis (UIP) and bronchiectasis were more prevalent in MPO-ANCA-positive patients (p < 0.05). Alveolar hemorrhage, pleural effusion, lymph node enlargement, and pulmonary venous congestion were more frequent in MPO-ANCA-positive patients. CONCLUSION Pulmonary involvement is frequent and among 140 patients with AAV who underwent a thoracic CT study, almost 80% have pulmonary abnormalities on thoracic CT. Central airway disease occurs exclusively among patients with PR3-ANCA while UIP were mainly seen in those with MPO-ANCA. These findings may have important implications for the investigation, management, and pathogenesis of AAV.
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Affiliation(s)
- Aladdin J Mohammad
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK. .,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital.
| | - Kristian H Mortensen
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Judith Babar
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Rona Smith
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Rachel B Jones
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Daiki Nakagomi
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Pasupathy Sivasothy
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - David R W Jayne
- From the Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden; Vasculitis and Lupus Clinic, and Department of Radiology, and Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK.,A.J. Mohammad, MD, PhD, Department of Clinical Sciences, Section of Rheumatology, Lund University, and Vasculitis and Lupus Clinic, Addenbrooke's Hospital; K.H. Mortensen, MD, PhD, Department of Radiology, Addenbrooke's Hospital; J. Babar, MBChB, MRCP, FRCR, Department of Radiology, Addenbrooke's Hospital; R. Smith, MA, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; R.B. Jones, MD, MRCP, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; D. Nakagomi, MD, PhD, Vasculitis and Lupus Clinic, Addenbrooke's Hospital; P. Sivasothy, MBBS, PhD, Department of Respiratory Medicine, Addenbrooke's Hospital; D.R. Jayne, FMedSci, Vasculitis and Lupus Clinic, Addenbrooke's Hospital
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Pugnet G, Gouya H, Puéchal X, Terrier B, Kahan A, Legmann P, Guillevin L, Vignaux O. Cardiac involvement in granulomatosis with polyangiitis: a magnetic resonance imaging study of 31 consecutive patients. Rheumatology (Oxford) 2017; 56:947-956. [PMID: 28339663 DOI: 10.1093/rheumatology/kew490] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Specific cardiac involvement in granulomatosis with polyangiitis (GPA) is probably underestimated since many of these conditions are subclinical. The objective of this study was to assess the prevalence and patterns of cardiac abnormalities detected by cardiac MRI (CMRI) in patients with GPA. Methods Thirty-one consecutive patients with newly diagnosed or relapsing GPA underwent CMRI to assess morphological, functional, perfusion at rest and delayed enhancement abnormalities. Results At least one abnormality was observed on CMRI for 19 of 31 patients (61%). Four patients (13%) had an impaired left ventricle ejection fraction (LVEF). LV regional wall motion abnormalities were found in 11 patients (35%). Late gadolinium enhancement (LGE) was detected in 10 of 31 patients (32%). LGE was mostly nodular ( n = 9). Myocardial early contrast enhancement was detected in 5 of the 31 patients (16%), which was systematically associated with LGE in the same territory. CMRI detected pericarditis in eight patients (26%). GPA with <18 months duration was associated with a higher LVEF ( P = 0.03), fewer CMRI abnormalities ( P = 0.04) and less LV hypokinesia ( P = 0.04) than GPA with a longer duration. Patients with recent-onset GPA had a higher LVEF ( P = 0.01) and less LV hypokinesia ( P = 0.006) than patients experiencing a relapse ( P = 0.02). Conclusion CMR is an accurate technique for detecting heart involvement in GPA. This unique non-invasive technique may provide information with important clinical implications for the accurate early assessment of cardiac lesions in GPA patients and for detecting cumulative, irreversible damage. It may also have prognostic implications.
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Affiliation(s)
- Grégory Pugnet
- Service de Médecine Interne, Centre National de Référence Vascularites Nécrosantes et Sclérodermie Systémique, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris.,Service de Médecine Interne, Hôpital Purpan, Toulouse
| | | | - Xavier Puéchal
- Service de Médecine Interne, Centre National de Référence Vascularites Nécrosantes et Sclérodermie Systémique, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris
| | - Benjamin Terrier
- Service de Médecine Interne, Centre National de Référence Vascularites Nécrosantes et Sclérodermie Systémique, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris
| | - André Kahan
- Service de Rhumatologie A, Hôpital Cochin, AP-HP, Paris, France
| | | | - Loïc Guillevin
- Service de Médecine Interne, Centre National de Référence Vascularites Nécrosantes et Sclérodermie Systémique, Hôpital Cochin, AP-HP, Université Paris Descartes, Paris
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A Rare Case of Digital Ischemia and Gangrene in ANCA-Associated Vasculitis with Review of the Literature. Case Rep Rheumatol 2017; 2017:2421760. [PMID: 28348913 PMCID: PMC5350346 DOI: 10.1155/2017/2421760] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/19/2016] [Accepted: 01/24/2017] [Indexed: 11/26/2022] Open
Abstract
This paper describes one patient with Antineutrophil Cytoplasmic Antibody- (ANCA-) associated vasculitis who initially presented with multiple ischemic fingers and toes. On further evaluation, the patient was also found to have pulmonary-renal involvement and episcleritis. The diagnosis was supported with a positive cANCA (anti-proteinase 3) and a bronchoscopy consistent with diffuse alveolar hemorrhage. Although the patient refused a tissue biopsy, clinical presentation including nasal ulceration, sinus congestion, and epistaxis and anti-proteinase 3 antibody were more consistent with Granulomatosis with Polyangiitis (GPA) rather than Microscopic Polyangiitis (MPA) or Eosinophilic Granulomatosis with Polyangiitis (EGPA) based on the recently presented ACR/EULAR Provisional 2017 Classification Criteria for GPA (Luqmani et al., 2016). The patient responded well to therapy including high dose steroids and cyclophosphamide, with improvement of all organs involved and had no further digital ischemia or gangrene on follow-up. We include a review of the English literature summarizing presentation, management, and outcome of 16 similar cases.
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12
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Abstract
BACKGROUND The primary vasculitides are rare conditions in childhood. The most common disease subtypes are Schönlein-Henoch purpura and Kawasaki's syndrome, which frequently have a self-limiting course. In the majority of vasculitides, the etiology remains unknown. Environmental exposure, including infections, is suspected to trigger an autoinflammatory response in predisposed individuals. GOAL The aim of this review is to present the various aspects of childhood vasculitis. MATERIALS AND METHODS Reviews and special original papers on childhood vasculitis, published classification criteria and current therapy guidelines were reviewed and summarized. RESULTS The classification of vasculitides in childhood has been modified from the previous adult Chapel Hill classification for vasculitides in 2008. Most therapy recommendations for children are adapted from results of studies in adults. This review covers the current classifications, pathogenesis, clinical manifestations and therapy recommendations for children. DISCUSSION Although etiology and pathogenesis of many vasculitides in childhood are still unknown, clarifying diagnostic methods and effective therapeutic options are available. The knowledge about various forms of disease manifestation may contribute to an early diagnosis and timely initiation of treatment, which may prevent devastating irreversible impairment.
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Abstract
Vasculitides are uncommon disorders, characterized by inflammation of the blood vessels resulting either in ischemia or hemorrhage. They are commonly classified as small-, medium-, or large-vessel vasculitides. Antineutrophil cytoplasmic antibody-associated vasculitis is an important group of small-vessel vasculitis. This group includes granulomatous vasculitides, namely, granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and nongranulomatous vasculitis, namely, microscopic polyangiitis (MPA). Classic polyarteritis nodosa (PAN) is a granulomatous medium-vessel vasculitis. This review discusses the classification, etiopathogenesis, clinical features, and management of GPA, MPA, EGPA and PAN.
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Affiliation(s)
- Aman Sharma
- Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leperology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Lionaki S, Boletis JN. The Prevalence and Management of Pauci-Immune Glomerulonephritis and Vasculitis in Western Countries. KIDNEY DISEASES 2015; 1:224-34. [PMID: 27536682 DOI: 10.1159/000442062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 11/05/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pauci-immune glomerulonephritis is the most common cause of aggressive glomerulonephritis and occurs as a renal-limited disease or as a component of systemic necrotizing small-vessel vasculitis. It is characterized by paucity of staining for immunoglobulins, by immunofluorescence along with fibrinoid necrosis and crescent formation by light microscopy, while the vast majority of patients have anti-neutrophil cytoplasmic antibodies (ANCA) in their circulation, which also participate in the pathogenesis of the disease. SUMMARY Pauci-immune glomerulonephritis often manifests with rapidly deteriorating kidney function, which may be accompanied by distinctive clinical features of systemic necrotizing small-vessel vasculitis of one the following clinical phenotypes: microscopic polyangiitis, granulomatosis with polyangiitis or eosinophilic granulomatosis with polyangiitis. These are associated with a wide spectrum of vasculitic manifestations in different organ systems at clinical presentation and during the course of the disease. ANCA specificity is associated with distinct clinical syndromes and different prognostic profiles among patients. The key element of the management of patients with pauci-immune glomerulonephritis, with or without systemic vasculitis, is the clinical acumen, which results in timely diagnosis. Speed in diagnosis is crucial for the quick institution of immunosuppressive therapy aimed at removing circulating autoantibodies and quelling the inflammatory process. KEY MESSAGES The introduction of ANCA testing in routine clinical practice has increased the ability of disease suspicion and recognition, resulting in earlier establishment of diagnosis by seeking a tissue confirmation of pauci-immune vasculitis. ANCA specificity is associated with distinct clinical syndromes and different prognostic profiles among patients. The management of patients with ANCA glomerulonephritis and/or vasculitis includes two major elements: prompt diagnosis and institution of immunosuppressive therapy to avoid irreversible kidney damage or death, and consideration of the predictors, which are associated with relapsing disease for planning of therapy in the long term. FACTS FROM EAST AND WEST Treatment options for ANCA-associated vasculitis are shared between the East and West, with corticosteroid combined with cyclophosphamide being the standard regimen for inductive therapy and switching to azathioprine after remission. The major cause of death in treated patients is infection related to immunosuppressive therapy within the first year after diagnosis, and this rate might be higher in China than in Western countries. Western studies demonstrated the efficacy and safety of rituximab for induction of remission in cases with relatively mild disease and maintenance therapy, but this agent is rarely used in China.
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Affiliation(s)
- Sophia Lionaki
- Department of Nephrology, Laiko Hospital, Athens, Greece; Transplantation Unit, Laiko Hospital, Athens, Greece
| | - John N Boletis
- Department of Nephrology, Laiko Hospital, Athens, Greece; Transplantation Unit, Laiko Hospital, Athens, Greece
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Abstract
BACKGROUND Renal vasculitis presents as rapidly progressive glomerulonephritis which comprises of a group of conditions characterised by acute kidney injury (AKI), haematuria and proteinuria. Treatment of these conditions comprises steroid and non-steroid agents in combination with plasma exchange. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This an update of a review first published in 2008. OBJECTIVES To evaluate the benefits and harms of any intervention used for the treatment of renal vasculitis in adults. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 27 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials investigating any intervention for the treatment of renal vasculitis in adults. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes or mean difference (MD) for continuous outcomes. MAIN RESULTS Thirty one studies (2217 patients) were included. Studies conducted earlier tended to have a higher risk of bias due to poor (or poorly reported) study design, broad inclusion criteria, less well developed disease definitions and low patient numbers. Later studies tend to have improved in all areas of quality, aided by the development of large transnational study groups.Plasma exchange as adjunctive therapy significantly reduces the risk of end-stage kidney disease at three months (2 studies: RR 0.43, 95% CI 0.23 to 0.78) and 12 months (6 studies: RR 0.45, 95% CI 0.29 to 0.72). Four studies (300 patients) compared the use of pulse and continuous administration of cyclophosphamide. Remission rates were equivalent but pulse treatment causes an increased risk of relapse (4 studies: RR 1.79, 95% CI 1.11 to 2.87) compared with continuous cyclophosphamide. Azathioprine has equivalent efficacy as a maintenance agent to cyclophosphamide with fewer episodes of leucopenia. Mycophenolate mofetil may be equivalent to cyclophosphamide as an induction agent but resulted in a higher relapse rate when tested against azathioprine in remission maintenance. Rituximab is an effective remission induction agent. Methotrexate or leflunomide are potential choices in remission maintenance therapy. Oral co-trimoxazole did not reduce relapses significantly in granulomatosis with polyangiitis. AUTHORS' CONCLUSIONS Plasma exchange was effective in patients with severe AKI secondary to vasculitis. Pulse cyclophosphamide results in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst cyclophosphamide is standard induction treatment, rituximab and mycophenolate mofetil were also effective. Azathioprine, methotrexate and leflunomide were effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.
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Affiliation(s)
- Giles Walters
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, ACT, Australia, 2605
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Grayson PC, Amudala NA, McAlear CA, Leduc RL, Shereff D, Richesson R, Fraenkel L, Merkel PA. Causal attributions about disease onset and relapse in patients with systemic vasculitis. J Rheumatol 2014; 41:923-30. [PMID: 24634202 DOI: 10.3899/jrheum.131096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Patients vary in their beliefs related to the cause of serious illness. The effect of these beliefs among patients with systemic vasculitis is not known. Our study aimed to describe causal attributions about disease onset and relapse in systemic vasculitis and to examine whether causal beliefs differ by type of vasculitis or are associated with negative health outcomes. METHODS Patients with vasculitis were recruited to complete an online questionnaire. Categories of causal beliefs were assessed with the Revised Illness Perception Questionnaire (IPQ-R). Differences in beliefs about disease onset versus relapse were compared across different forms of vasculitis. Causal beliefs were assessed in association with several health outcomes including fatigue, functional impairments, and personal understanding of the condition. RESULTS The questionnaire was completed by 692 patients representing 9 forms of vasculitis. The majority (90%) of patients had beliefs about the cause of their illness. Causal attributions were highly variable, but altered immunity and stress were the most commonly agreed-upon causal beliefs. Frequencies of causal beliefs were strikingly similar across different forms of vasculitis, with a few notable exceptions primarily in Behçet disease. Beliefs differed about causes of disease onset versus relapse. Specific beliefs about disease onset and relapse were weakly associated with fatigue, functional impairments, and understanding of the condition. CONCLUSION Patient beliefs related to the cause of systemic vasculitis are highly variable. Patterns of causal beliefs are associated with important negative health outcomes. Clinicians who care for patients with vasculitis should be mindful of these associations and consider asking about patients' causal beliefs.
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Affiliation(s)
- Peter C Grayson
- From the US National Institutes of Health (NIH), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Bethesda, Maryland; The Vasculitis Center, Section of Rheumatology, and the Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania; University of South Florida, Tampa, Florida; School of Nursing, Duke University, Durham, North Carolina; Division of Rheumatology, Yale University, New Haven, Connecticut, USA
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Ortu E, Pietropaoli D, Baldi M, Marzo G, Giannoni M, Monaco A. Polyarteritis nodosa involving the hard palate: a case report. J Med Case Rep 2013; 7:79. [PMID: 23506354 PMCID: PMC3607961 DOI: 10.1186/1752-1947-7-79] [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] [Received: 11/06/2012] [Accepted: 02/12/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Polyarteritis nodosa is a rare disease resulting from blood vessel inflammation (vasculitis), causing damage to organ systems and featuring an extended range of possible symptoms. The cause of polyarteritis nodosa is unknown. Case presentation In the present report we describe the presentation and treatment of polyarteritis nodosa involving the hard palate in an 88-year-old Caucasian woman. Clinical and laboratory analyses showed stenosis of the greater palatine artery, which led to necrosis of the affected area. At one year after pharmacological treatment, the lesion has regressed completely. Conclusions We successfully treated a case of polyarteritis nodosa via a pharmacological approach, which we describe here.
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Affiliation(s)
- Eleonora Ortu
- Unit of Dentistry; Building Delta 6, Department of Life, Health and Environmental Sciences, University of L'Aquila; San Salvatore Hospital, Via Vetoio, L'Aquila, 67100, Italy.
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Yegin EG, Can M, Yilmaz N, Aydin SZ, Yavuz S, Tuglular S, Direskeneli H. Activity and damage in granulomatosis with polyangiitis. Int J Rheum Dis 2013; 16:61-71. [PMID: 23441774 DOI: 10.1111/1756-185x.12022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIM To retrospectively analyze disease activity and damage-associated factors in granulomatosis with polyangiitis (GPA) in Turkey. METHOD A retrospective analysis was carried out in 21 GPA patients. Assessments for activity were performed with the Birmingham Vasculitis Activity Score for GPA (BVAS/GPA) and for permanent organ damage by the Vasculitis Damage Index (VDI). RESULTS Lower BVAS/GPA (P = 0.002), absence of renal involvement (P = 0.003) and higher creatinine clearence (P = 0.000) at diagnosis increased the likelihood of achieving remission at 6 weeks. Relapses were associated with high creatinine clearence (P = 0.021), low BVAS/GPA (P = 0.014), absence of renal involvement (P = 0.036) and proteinuria (< 0.5/24 h) (P = 0.013) at diagnosis, whereas achieving remission at 6 weeks (P = 0.012) was associated with absence of co-trimoxazole usage (P = 0.038) and less severe clinical subgroup (P = 0.034). Lower cumulative first 6 months of cyclophosphamide and methylprednisolone were associated with earlier (≤ 12 months) relapses (P = 0.048 and P = 0.083, respectively). Baseline damage (VDI ≥ 1) was associated with a delay in diagnosis (P = 0.032), presentation with milder clinical subgroups (P = 0.052) and low serum creatinine (P = 0.013). The increase in VDI in the first 12 months (early damage) constituted most (91%) of the total damage measured at the end of follow-up. CONCLUSIONS Despite high early remission rates, relapse represents a major problem in localized GPA in our study. Baseline damage was associated with longer diagnostic delay and lower baseline serum creatinine. The initial phase of the disease seems to be the most crucial period for mortality and accumulated damage.
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Affiliation(s)
- Ender G Yegin
- Department of Internal Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey.
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Antineutrophil Cytoplasmic Autoantibody Associated Systemic Vasculitis Is Associated with Epstein - Barr virus in the Setting of HIV Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2013; 21:50-53. [PMID: 23483275 DOI: 10.1097/ipc.0b013e3182601ea1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION EBV has been a leading candidate as a trigger for several autoimmune diseases. We describe an antineutrophil cytoplasmic autoantibody (ANCA) -associated systemic vasculitis as the initial presenting illness of AIDS. CASE REPORT AND RESULTS The patient was diagnosed ANCA -associated systemic vasculitis in the setting of HIV infection because of a high level of ANCA level, crescent glomerulonephritis in pathology, and clinical signs and symptoms compatible with systemic vasculitis. He also had HIV associated lymphadenopathy with scattered. EBV-RNA positive cells and reactive germinal centers. CONCLUSION EBV genome was found in reactive lymph nodes and, therefore, may be associated with the immunopathogenesis of vasculitis.
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Affiliation(s)
- Renato A Sinico
- Clinical Immunology Unit and Renal Unit, Department of Medicine, Azienda Ospedaliera Ospedale San Carlo Borromeo, via Pio Secondo, 3 - 20153 - Milano, Italy.
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Abstract
Renal involvement is a common and often severe complication of anti-neutrophil cytoplasmic autoantibody (ANCA) associated vasculitides (AAV). With the exception of Churg-Strauss syndrome (CSS), where kidney involvement is not a prominent feature, renal disease is present in about 70% of patients with Wegener's granulomatosis, now called granulomatosis with polyangiitis (GPA) and in almost 100% of patients with microscopic polyangiitis (MPA). Kidney involvement is generally characterized by a pauci-immune necrotizing and crescentic glomerulonephritis with a very rapid decline of renal function (rapidly progressive glomerulonephritis). Even though there are not qualitative differences in glomerular lesions in patients with GPA or with MPA, chronic damage is significantly higher in MPA (and/or P-ANCA positive patients) than in GPA (and/or C-ANCA positive patients). If untreated necrotizing and crescentic glomerulonephritis has an unfavorable course leading in a few weeks or months to end stage renal disease. Serum creatinine at diagnosis, sclerotic lesions and the number of normal glomeruli at kidney biopsy are the best predictors of renal outcome. Corticosteroids and cyclophosphamide (with the addition of plasma exchange in the most severe cases) are the cornerstone of induction treatment of ANCA-associated renal vasculitis, followed by azathioprine for maintenance. Rituximab is as effective as cyclophosphamide in inducing remission in AAV and probably superior to cyclophosphamide in patients with severe flare, and could be preferred in younger patients in order to preserve fertility and in patients with serious relapses.
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Yunt ZX, Frankel SK, Brown KK. Diagnosis and management of pulmonary vasculitis. Ther Adv Respir Dis 2012; 6:375-90. [DOI: 10.1177/1753465812454693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The pulmonary vasculitides are a heterogeneous group of disorders characterized pathologically by vascular destruction with cellular inflammation and necrosis. These disorders can affect small, medium, and large vessels and may be primary or occur secondary to a variety of conditions. Vasculitis involving the lungs is most commonly due to primary, idiopathic, small-vessel antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, which includes granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), Churg–Strauss syndrome, and microscopic polyangiitis. From a clinical perspective these remain among the most challenging of diseases both in terms of diagnosis and treatment. This review will focus on diagnosis and management of ANCA-associated vasculitides.
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Affiliation(s)
- Zulma X. Yunt
- National Jewish Health, A542, 1400 Jackson Street, Denver, CO 80206, USA
| | - Stephen K. Frankel
- Division of Pulmonary Medicine, Department of Medicine, National Jewish Health, and Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, CO, USA
| | - Kevin K. Brown
- Division of Pulmonary Medicine, Department of Medicine, National Jewish Health, and Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, CO, USA
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Belhassen-Garcia M, Velasco-Tirado V, Alvela-Suaréz L, Carpio-Pérez A, Lledías JP, Novoa N, Iglesias-Gómez A, Cordero-Sánchez M. Spontaneous pneumothorax in Wegener's granulomatosis: case report and literature review. Semin Arthritis Rheum 2012; 41:455-60. [PMID: 22152488 DOI: 10.1016/j.semarthrit.2011.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 05/03/2011] [Accepted: 05/04/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulmonary manifestations of Wegener's granulomatosis (WG) are present in 45% of cases at the onset of the disease, and they reach 85% of the patients during its evolution. Pulmonary affection usually starts with unspecific symptoms such as cough, dyspnea, hemoptysis, and pleuritis. Pulmonary nodules are 1 of the most common manifestations. The prevalence of pleural affection is 10 to 20%. However, spontaneous pneumothorax is extremely rare. Although its real incidence is unknown, according to different classic series, it ranges between 3 and 5% of the cases. OBJECTIVE To present a new case of spontaneous pneumothorax in a patient suffering WG and a brief review on this subject. METHODS We report our experience in a case of spontaneous pneumothorax due to WG. We also review the literature through a PubMed search between 1960 and 2010, using a broad range of keywords related to WG and spontaneous pneumothorax. Publications were evaluated for the demographic features of patients, manifestations of the disease, and outcome. RESULTS Despite the large prevalence of the respiratory involvement, spontaneous pneumothorax is extremely rare, with only 21 cases reported in the literature. CONCLUSION Pneumothorax is a rare complication in WG cases, without a clear pathogenic mechanism involved.
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[19-year-old asthma patient with pronounced eosinophilia and acute coronary syndrome]. Internist (Berl) 2012; 52:1479-83. [PMID: 21505837 DOI: 10.1007/s00108-011-2847-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Diagnosis of Churg-Strauss syndrome should be considered in young asthmatics with fatigue and eosinophilia. On the base of the etiopathology of a 19-year old man, who was initially admitted because of dyspnoea, fever and acute chest pain, we show that eosinophilia gives an important hint for further diagnostic and is the key trend parameter. Histologically an eosinophilic myocarditis could be shown in the myocardial biopsy. High dose prednisolone induced a clear improvement in symptoms, with decrease of the inflammatory signs and the eosinophilia and a clear improvement of the left ventricular function.
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Mahr A, Chaigne-Delalande S, De Menthon M. Therapeutic plasma exchange in systemic vasculitis. Curr Opin Rheumatol 2012; 24:261-6. [DOI: 10.1097/bor.0b013e3283526509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
UNLABELLED Vasculitis is a systemic autoimmune inflammatory disease, characterized by inflammation in and around vessel walls leading to perturbed vessel patency and tissue damage. Many different organs may be involved. In this review, pathogenetic mechanisms of vasculitis are discussed, with special reference to activation of the kinin system. Mechanisms of kinin system activation are described, ultimately leading to release of kinins from high molecular weight kininogen. These vasoactive peptides promote inflammation. CONCLUSION Kinin system activation during vasculitis promotes inflammation.
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Affiliation(s)
- Robin Kahn
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
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Dillon MJ, Eleftheriou D, Brogan PA. Medium-size-vessel vasculitis. Pediatr Nephrol 2010; 25:1641-52. [PMID: 19946711 PMCID: PMC2908435 DOI: 10.1007/s00467-009-1336-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 09/10/2009] [Accepted: 09/11/2009] [Indexed: 01/20/2023]
Abstract
Medium-size-artery vasculitides do occur in childhood and manifest, in the main, as polyarteritis nodosa (PAN), cutaneous PAN and Kawasaki disease. Of these, PAN is the most serious, with high morbidity and not inconsequential mortality rates. New classification criteria for PAN have been validated that will have value in epidemiological studies and clinical trials. Renal involvement is common and recent therapeutic advances may result in improved treatment options. Cutaneous PAN is a milder disease characterised by periodic exacerbations and often associated with streptococcal infection. There is controversy as to whether this is a separate entity or part of the systemic PAN spectrum. Kawasaki disease is an acute self-limiting systemic vasculitis, the second commonest vasculitis in childhood and the commonest cause of childhood-acquired heart disease. Renal manifestations occur and include tubulointerstitial nephritis and renal failure. An infectious trigger and a genetic predisposition seem likely. Intravenous immunoglobulin (IV-Ig) and aspirin are effective therapeutically, but in resistant cases, either steroid or infliximab have a role. Greater understanding of the pathogenetic mechanisms involved in these three types of vasculitis and better long-term follow-up data will lead to improved therapy and prediction of prognosis.
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Affiliation(s)
- Michael J Dillon
- Nephrourology Unit, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Walters GD, Willis NS, Craig JC. Interventions for renal vasculitis in adults. A systematic review. BMC Nephrol 2010; 11:12. [PMID: 20573267 PMCID: PMC2914014 DOI: 10.1186/1471-2369-11-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 06/24/2010] [Indexed: 12/25/2022] Open
Abstract
Background Renal vasculitis presents as rapidly progressive glomerulonephritis and comprises of a group of conditions characterised by acute kidney failure, haematuria and proteinuria. Treatment of these conditions involves the use of steroid and non-steroid agents with or without adjunctive plasma exchange. Although immunosuppression has been successful, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This systematic review was conducted to determine the benefits and harms of any intervention for the treatment of renal vasculitis in adults. Methods We searched the Cochrane Central Register of Controlled Trials, the Cochrane Renal Group Specialised Register, MEDLINE and EMBASE to June 2009. Randomised controlled trials investigating any intervention for the treatment of adults were included. Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio with 95% confidence intervals for dichotomous outcomes or mean difference for continuous outcomes. Results Twenty two studies (1674 patients) were included. Plasma exchange as adjunctive therapy significantly reduces the risk of end-stage kidney disease at 12 months (five studies: RR 0.47, CI 0.30 to 0.75). Four studies compared the use of pulse and continuous administration of cyclophosphamide. Remission rates were equivalent but pulse treatment causes an increased risk of relapse (4 studies: RR 1.79, CI 1.11 to 2.87) compared with continuous cyclophosphamide. Azathioprine has equivalent efficacy as a maintenance agent to cyclophosphamide with fewer episodes of leukopenia. Mycophenolate mofetil may be equivalent to cyclophosphamide as an induction agent but resulted in a higher relapse rate when tested against Azathioprine in remission maintenance. Rituximab is an effective remission induction agent. Methotrexate or Leflunomide are potential choices in remission maintenance therapy. Oral co-trimoxazole did not reduce relapses significantly in Wegener's granulomatosis. Conclusions Plasma exchange is effective in patients with severe ARF secondary to vasculitis. Pulse cyclophosphamide results in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst cyclophosphamide is standard induction treatment, rituximab and mycophenolate mofetil are also effective. Azathioprine, methotrexate and leflunomide are effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.
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Recent advances to achieve remission induction in antineutrophil cytoplasmic antibody-associated vasculitis. Curr Opin Rheumatol 2010; 22:37-42. [PMID: 19770660 DOI: 10.1097/bor.0b013e328331cfeb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Significant advances in the treatment of antineutrophil cytoplasmic antibody-associated vasculitis have been made in the past 10 years. This review aims to detail advances in treatment aimed at induction of remission. RECENT FINDINGS Cyclophosphamide-based regimes remain the standard of care, at least in generalized disease. Safer therapeutic regimes with reduced cumulative dose of cyclophosphamide have been developed such as the use of pulsed cyclophosphamide. Preliminary data are available, suggesting rituximab may be an alternative to cyclophosphamide, but additional safety data are required. Evidence suggests that plasma exchange should be added to those with more severe disease and it is acceptable to use methotrexate as an induction agent for those with limited or early systemic disease. Using current regimens, remission is achieved in over 90% of patients, but toxicity remains an important issue. Attention should be paid to reducing treatment toxicity. SUMMARY Findings of recent clinical trials should change clinical practice and improve outcome of patients with antineutrophil cytoplasmic antibody-associated vasculitis.
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Abdulahad WH, Kallenberg CGM, Limburg PC, Stegeman CA. Urinary CD4+ effector memory T cells reflect renal disease activity in antineutrophil cytoplasmic antibody-associated vasculitis. ACTA ACUST UNITED AC 2009; 60:2830-8. [PMID: 19714581 DOI: 10.1002/art.24747] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Numbers of circulating CD4+ effector memory T cells are proportionally increased in patients with proteinase 3 antineutrophil cytoplasmic antibody-associated vasculitis (AAV) whose disease is in remission and are decreased during active disease, which presumably reflects their migration toward sites of inflammation. Since renal infiltrating cells may appear in urine, we investigated the presence of CD4+ effector memory T cells in urinary sediment as a reflection of renal disease activity in AAV. METHODS CD4+ effector memory (CD45RO+CCR7-CD3+CD4+) T cells were quantitated in the urine and peripheral blood of patients with AAV with renal involvement (n = 33), patients with AAV without renal involvement (n = 18), patients with AAV whose disease was in remission (n = 29), and patients with active disease (n = 22), using 4-color flow cytometric analysis. Numbers and percentages of urine CD4+ effector memory T cells in 12 patients with AAV with active renal disease were obtained over several weeks of followup during remission induction. RESULTS A notable increase in urine CD4+ effector memory T cell numbers was observed in patients with active renal AAV compared with patients whose disease was in remission and patients with active disease without renal involvement. The increase in these cells in the urine of patients with active renal AAV was accompanied by a reciprocal decrease in these cells in peripheral blood. Results from followup analysis showed a clear reduction in urine CD4+ effector memory T cells following treatment. Moreover, a negative correlation was observed between percentages of circulating and urine CD4+ effector memory T cells, consistent with their migration toward sites of inflammation. CONCLUSION Our findings indicate that the presence of CD4+ effector memory T cells in urine reflects renal involvement in AAV. Flow cytometric analysis of these cells in urine may contribute to assessing renal disease activity in patients with AAV.
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Affiliation(s)
- Wayel H Abdulahad
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands. ,nl
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Kasmani R, Okoli K, Naraharisetty K, Gunning W, Shapiro JI, Ratnam S. Microscopic polyangiitis triggered by recurrent methicillin-resistant Staphylococcus aureus bacteremia. Int Urol Nephrol 2009; 42:821-4. [PMID: 19795220 DOI: 10.1007/s11255-009-9652-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 09/10/2009] [Indexed: 11/29/2022]
Abstract
Most of the purported links between microbial agents and primary small-vessel anti-neutrophilic antibody-positive (ANCA) vasculitides remain speculative. There is strong circumstantial evidence for the role of Staphylococcus aureus in the development of Wegener's granulomatosis, but its role in other ANCA-positive vasculitis syndromes is less clear. We describe a patient who developed a non-granulomatous, necrotizing small-vessel vasculitis with a positive anti-neutrophil cytoplasmic antibody of a perinuclear type (p-ANCA), along with anti-myeloperoxidase antibodies after recurrent episodes of methicillin-resistant Staphylococcus aureus bacteremia.
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Affiliation(s)
- Rahil Kasmani
- Department of Internal Medicine, St Vincent Mercy Medical Center, 2213, Cherry Street, Toledo, OH 43608, USA.
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Wegener's granulomatosis presenting with life-threatening lung hemorrhage in a 7-year-old child. Rheumatol Int 2009; 30:1665-8. [PMID: 19777238 DOI: 10.1007/s00296-009-1132-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 09/13/2009] [Indexed: 10/20/2022]
Abstract
Wegener's granulomatosis (WG) is an idiopathic systemic disease that usually onsets in adolescence and is rare in young children. Its diagnosis is usually based on the presence of fever with arthralgia and weight loss, associated with symptoms of upper and/or lower respiratory tract involvement and renal disorders. We describe the appearance of a life-threatening lung hemorrhage in the absence of hemoptysis in a 7-year-old girl with a completely negative previous clinical history, who was subsequently diagnosed as having WG. The teaching message is that immediate bronchoscopy with bronchoalveolar lavage seems to be advisable in the presence of severe respiratory distress and bilateral lung as well as renal involvement. When a diffuse alveolar hemorrhage syndrome is demonstrated, WG should be considered among the main etiologies even in a relatively young child without a clinically suggestive history.
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Abstract
Churg-Strauss angiitis or syndrome (CSA) is defined as an eosinophil-rich and granulomatous inflammation involving the respiratory tract, and necrotising vasculitis affecting small- to medium-sized vessels, and is associated with asthma and eosinophilia. It is usually classified among the so-called anti-neutrophil antibody (ANCA)-associated systemic vasculitides (AASVs) because of its clinical and pathological features that overlap with those of the other AASVs. However, two recent studies on large cohorts of patients have found that ANCAs, usually P-ANCAs/MPO-ANCAs, were present in only 38% of patients. Moreover, the ANCA status was shown to segregate with clinical phenotype. ANCA-positive patients were significantly more likely to have disease manifestations associated with small-vessel vasculitis, including necrotising glomerulonephritis, mononeuritis and purpura, whereas ANCA-negative cases were significantly more likely to have cardiac and lung involvement. Vasculitis was documented less frequently in histological specimens from ANCA-negative patients in comparison with ANCA-positive ones. These findings have led to postulate the predominance of distinct pathogenetic mechanisms in the two subsets of patients: an ANCA-mediated process in ANCA-positive patients and tissue infiltration by eosinophils with subsequent release of toxic product in ANCA-negative cases. Preliminary results suggest that ANCA-positive and ANCA-negative patients also might have a different genetic background. Corticosteroids remain the cornerstone of the initial treatment of CSA. The addition of cyclophosphamide is indicated in treatment of patients with poor-prognosis factors or in patients without poor-prognosis factors but those that are prone to relapses. The length of the maintenance therapy remains to be established. However, the vast majority of patients require long-term corticosteroids treatment to control asthma.
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Affiliation(s)
- Renato A Sinico
- Clinical Immunology Unit and Renal Unit, Department of Medicine, Azienda Ospedaliera Ospedale San Carlo Borromeo, Milano, Italy.
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Kahn R, Hellmark T, Leeb-Lundberg LMF, Akbari N, Todiras M, Olofsson T, Wieslander J, Christensson A, Westman K, Bader M, Müller-Esterl W, Karpman D. Neutrophil-Derived Proteinase 3 Induces Kallikrein-Independent Release of a Novel Vasoactive Kinin. THE JOURNAL OF IMMUNOLOGY 2009; 182:7906-15. [DOI: 10.4049/jimmunol.0803624] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
BACKGROUND Renal vasculitis presents as rapidly progressive glomerulonephritis (RPGN) which comprises of a group of conditions characterised by acute kidney failure (AKF), haematuria and proteinuria. Treatment of these conditions comprises steroid and non-steroid agents in combination with plasma exchange in several situations. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy and the use of plasma exchange. OBJECTIVES To determine the benefits and harms of any intervention for the treatment of renal vasculitis in adults. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Renal Group Specialised Register, MEDLINE and EMBASE without language restriction, reference lists of articles and abstracts from conference proceedings. SELECTION CRITERIA Randomised controlled trials investigating any intervention for the treatment of in adults. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals for dichotomous outcomes or mean difference (MD) for continuous outcomes. MAIN RESULTS Thirteen studies (702 patients) were included. Plasma exchange as adjunctive therapy significantly reduces the risk of end-stage kidney disease (ESKD) at three months (one study: RR 0.45, 95% CI 0.24 to 0.84) and 12 months (five studies: RR 0.47, CI 0.24 to 0.86). Three studies compared the use of pulse and continuous administration of cyclophosphamide (CPA). Overall analysis showed a significant increase in remission with pulse CPA (2 studies: RR 1.17; 95%CI 1.02-1.35) and fewer relapses with continuous CPA. A single study addressed the use of azathioprine (AZA) after three months of CPA therapy, showing no difference in outcome except for significantly less leukopenia in patients on AZA. One study into the use of antibiotics to prevent relapse in Wegener's granulomatosis failed to show a significant effect. AUTHORS' CONCLUSIONS Plasma exchange is effective in patients with severe ARF secondary to vasculitis. On current data, the use of pulse CPA results in an increased risk of relapse when compared to continuous use but a reduced total dose. The use of cotrimoxazole is likely to be beneficial to prevent relapse of vasculitis. AZA is effective as maintenance therapy once remission has been achieved.
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Affiliation(s)
- Giles Walters
- Renal Department, The Canberra Hospital, PO Box 11, Woden, ACT, Australia, 2606.
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Tamei N, Sugiura H, Takei T, Itabashi M, Uchida K, Nitta K. Ruptured arterial aneurysm of the kidney in a patient with microscopic polyangiitis. Intern Med 2008; 47:521-6. [PMID: 18344639 DOI: 10.2169/internalmedicine.47.0624] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present the case of a 55-year-old man with ruptured arterial aneurysm accompanied by microscopic polyangiitis in the kidney. He was admitted to our hospital because of general fatigue, fever and serious numbness of his extremities. Microscopic polyangiitis (MPA) was diagnosed on the basis of cardinal symptoms, including rapidly progressive glomerular nephritis, peripheral nerve disorder and the lung abnormality, as well as positive MPO-ANCA findings. Hemodialysis had to be started on admission because of renal failure. Renal biopsy demonstrated necrotizing glomeruli, crescent formation with interstitial infiltrates. There were no immune deposits on immunofluorescence study or electron micrographs. The pathological diagnosis was necrotizing glomerulonephritis involving small and medium-sized arteries. He was treated with intravenous semi-pulse methylprednisolone therapy because of the intensely pathological renal activation and the abnormal shadow on chest X-ray. The inflammatory reaction subsequently improved, MPO-ANCA decreased and the lung lesions diminished. He complained of sharp pain of sudden onset on his left side. His hemoglobin dropped from 9.8 g/dl to 6.0 g/dl developed in the subsequent hours, but there were no sign of hemorrhage. Abdominal CT scan showed a large left-sided perinephric, intracapsular hematoma. Selective arterial angiography showed multiple aneurysms in renal and hepatic arteries. No active bleeding was present and he recovered with transfusion, supportive therapy and monitoring alone. Multiple aneurysms detected by angiography in the renal and hepatic arteries showed improvement. He is currently stable on regular hemodialysis treatment with a low dose of oral prednisolone.
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Affiliation(s)
- Noriko Tamei
- Department of Medicine, Kidney Center, Tokyo Women's Medical University
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Bottero P, Bonini M, Vecchio F, Grittini A, Patruno GM, Colombo B, Sinico RA. The common allergens in the Churg-Strauss syndrome. Allergy 2007; 62:1288-94. [PMID: 17919144 DOI: 10.1111/j.1398-9995.2007.01486.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The asthmatic-prodromal phase of Churg-Strauss syndrome (CSS) is usually considered allergic, but data about the involved allergens are scarce. The aim of our work was to examine the prevalence of allergy in a group of CSS patients and in two control groups of persistent asthmatic subjects selected for eosinophilia >10% [first control group patients (CGP1)] and eosinophils <6% [second control group patients (CGP2)]. METHODS The respiratory symptoms, and the results of prick test and/or RAST for the common allergens, performed before the vasculitic phase in 51 CSS, were retrospectively evaluated and compared with those of 46 CGP1 and 50 CGP2. RESULTS 31.4% of CSS vs 67.4% of CGP1 (P = 0.0004) and vs 58.0% CGP2 (P = 0.007) were allergic. The number of subjects with seasonal allergies was lower in CSS vs CGP1 (P = 0.0069) and vs CGP2 (P = 0.0002). The number of perennial allergies was significantly higher in CSS than in both control groups (CSS vs CGP1, P = 0.0108; CSS vs CGP2, P = 0.0079). The subjects allergic to Dermatophagoides were prevalent in CSS vs CGP1 (P = 0.0045) but not vs CGP2. CONCLUSIONS The evidence of allergy, considered as the demonstration of specific IgE consistent with the clinical history, is present in less than one-third of CSS and the higher prevalence of seasonal allergies in the controls disagrees with persistent asthma. Allergy may be only one of several mechanisms triggering exacerbation of asthma or supporting chronic airway inflammation as in asthma in general. Alternatively, unidentified allergens may play a role.
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Affiliation(s)
- P Bottero
- Ambulatorio di Allergologia e Immunologia Clinica, Azienda Ospedaliera Legnano Ospedale di Magenta, Magenta, Italy
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Lionaki S, Jennette JC, Falk RJ. Anti-neutrophil cytoplasmic (ANCA) and anti-glomerular basement membrane (GBM) autoantibodies in necrotizing and crescentic glomerulonephritis. Semin Immunopathol 2007; 29:459-74. [DOI: 10.1007/s00281-007-0093-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 09/28/2007] [Indexed: 10/22/2022]
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Cattaneo L, Chierici E, Pavone L, Grasselli C, Manganelli P, Buzio C, Pavesi G. Peripheral neuropathy in Wegener's granulomatosis, Churg-Strauss syndrome and microscopic polyangiitis. J Neurol Neurosurg Psychiatry 2007; 78:1119-23. [PMID: 17299018 PMCID: PMC2117551 DOI: 10.1136/jnnp.2006.111013] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the clinical aspects of peripheral neuropathy associated with Wegener's granulomatosis (WG), Churg-Strauss syndrome (CSS) and microscopic polyangiitis (MP). METHODS Cohort study conducted in a single university hospital. Patients were included when a definite diagnosis of WG, CSS or MP was made according to the current classification criteria in our hospital, between 1999 and 2006. All patients underwent periodically clinical and electrophysiological screening for peripheral neuropathy, assessment of disability, and clinical and laboratory evaluation during a mean follow-up of 38 months. RESULTS Sixty-four consecutive patients diagnosed with WG (26 patients), CSS (26 patients) and MP (12 patients) were recruited. Peripheral neuropathy occurred in 27/64 patients: six with WG, 15 with CSS and six with MP. Neuropathy occurred earlier in the disease history in CSS and MP compared with WG. Among patients with WG, those who developed peripheral neuropathy during follow-up were older than those without neuropathy both at the time of onset and of diagnosis of vasculitis. Distal symmetric polyneuropathy was present in 11 patients, and single or multiple mononeuropathy in 16. Patients with WG had a less severe form of mononeuritis multiplex than CSS or MPA patients. Disability and pain were greater in patients with mononeuropathy, although one-third of them were painless. Relapses of neuropathy were extremely infrequent. CONCLUSIONS Peripheral neuropathy in WG occurs less frequently, later in the disease course and in a milder form than in CSS and MP. Single or multiple mononeuropathy associated with these subsets of vasculitis can often be painless.
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Affiliation(s)
- Luigi Cattaneo
- Sezione di Neurologia, Dipartimento di Neuroscienze, Università degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy.
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Aouba A, Pagnoux C, Bienvenu B, Mahr A, Guillevin L. Analysis of Wegener's granulomatosis responses to rituximab: current evidence and therapeutic prospects. Clin Rev Allergy Immunol 2007; 34:65-73. [PMID: 18270860 DOI: 10.1007/s12016-007-8026-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Accepted: 07/26/2007] [Indexed: 10/22/2022]
Abstract
Available data on small numbers of patients with refractory and/or relapsing Wegener's granulomatosis support very good overall outcomes with rituximab, an anti-CD20 biotherapy targeting B cells, in combination with ongoing immunosuppressants, apparently independently of antineutrophil cytoplasm antibody (ANCA) status. However, clearly dissociated responses were observed, with constitutional and vasculitis-related symptoms often achieving complete responses within days or weeks, and granulomatous-related manifestations regressing more slowly over a few weeks to several months or not at all, particularly for orbital pseudotumors. Tolerance was good with few side effects, and when relapses occurred, more often after 12 months, a second or even a third rituximab cycle was almost always able to obtain another complete remission. Randomized trials are needed to define rituximab's best place, compared to cyclophosphamide, in initial and maintenance regimens; to determine optimally combined drugs, considering the various responses of granulomatous-related manifestations; and to delineate the role of circulating B-cell monitoring for pre-emptive management decisions. This promising biotherapy opens the way for other therapeutic agents targeting B lymphocytes and to improve our understanding of the pathophysiology of ANCA-associated vasculitis.
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Affiliation(s)
- Achille Aouba
- Department of Internal Medicine and the French Vasculitis Study Group, Assistance Publique-Hôpitaux de Paris, Université Paris, 5-René-Descartes, Hôpital Cochin, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
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Chamsuddin AA, Dodson TF, Nazzal L, Page A. SIR 2006 annual meeting film panel case: polyarteritis nodosa in upper extremity arteries. J Vasc Interv Radiol 2007; 18:1069-71. [PMID: 17804766 DOI: 10.1016/j.jvir.2007.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Abbas A Chamsuddin
- Department of Radiology, Division of Vascular and Interventional Radiology, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA 30322, USA.
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Hachicha M, Kammoun T, Ben Romdhane W, Ben Abdallah R, Mahfoudh A, Kammoun K, Hachicha J, Triki A. Vascularite avec atteinte rénale et anticorps anticytoplasme des polynucléaires neutrophiles (ANCA) après prise de benzylthio-uracile chez l'enfant. Nephrol Ther 2007; 3:147-51. [PMID: 17658441 DOI: 10.1016/j.nephro.2007.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 03/26/2007] [Accepted: 04/11/2007] [Indexed: 11/15/2022]
Abstract
Vasculitis associated to antineutrophil cytoplasmic antibodies (ANCA) is a rare complication of therapy with antithyroid medication. They were mainly described in patients treated with propylthiouracil (PTU), carbimazole, methimazole and rarely by benzylthiouracil (Basden). We report a case of 12-years-old girl treated by benzylthiouracil for Grave's disease who developed after 2 years vasculitis associated with cutaneous involvement (generalized ulcer necrotic purpura) and glomerulonephritis with proteinuria of 24 hours at 26 mg/kg/day, microscopic hematuria and renal failure with creatinemia level at 135 micromol/l. The ANCA type antiMPO (myeloperoxidase) was positive. The histology study of the renal needle biopsy was in favour with focal necrotizing glomerulonephritisand crescents with different evolutive stages. The discontinuation of benzylthiouracil and the treatment by the corticoids involved a disappearance of cutaneous lesions, a negative result of proteinuria, a normalization of the renal function (creatinemia=84 micromol/l) and a disappearance of hematuria and ANCA. These results permitted to announce hypothesis that benzylthiouracil was implicated in development of vasculitis associated to ANCA.
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de Lind van Wijngaarden RAF, Hauer HA, Wolterbeek R, Jayne DRW, Gaskin G, Rasmussen N, Noël LH, Ferrario F, Waldherr R, Bruijn JA, Bajema IM, Hagen EC, Pusey CD. Chances of Renal Recovery for Dialysis-Dependent ANCA-Associated Glomerulonephritis. J Am Soc Nephrol 2007; 18:2189-97. [PMID: 17596637 DOI: 10.1681/asn.2007010066] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In patients who have anti-neutrophil cytoplasm autoantibody (ANCA)-associated glomerulonephritis and are on dialysis at time of diagnosis, renal function is sometimes insufficiently restored by immunosuppressive treatment, which often coincides with potentially lethal adverse effects. This study investigated the clinical and histologic variables that determine the chances of dialysis independence, dialysis dependence, or death after 12 mo in these patients. Sixty-nine patients who had ANCA-associated glomerulonephritis and were dialysis dependent at diagnosis received uniform, standard immunosuppressive therapy plus either intravenous methylprednisolone or plasma exchange. Eleven clinical and histologic variables were assessed. Univariate and binary logistic regression analyses were performed. Predictive parameters were entered into a two-step binary logistic regression analysis to differentiate among the outcomes of dialysis independence, dialysis dependence, or death. The point at which the chance of therapy-related death exceeded the chance of dialysis independence was determined. The chance of recovery exceeded the chance of dying in most cases. Intravenous methylprednisolone as adjunctive therapy plus <18% normal glomeruli and severe tubular atrophy increased the chance of therapy-related death over the chance of dialysis independence. Plasma exchange treatment plus severe tubular atrophy and <2% normal glomeruli increased the chance of therapy-related death over that of dialysis independence. Even with ominous histologic findings, the chance of renal recovery exceeds the chance of therapy-related death when these patients are treated with plasma exchange as adjunctive therapy.
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Abdulahad WH, Stegeman CA, Limburg PC, Kallenberg CGM. CD4-Positive Effector Memory T Cells Participate in Disease Expression in ANCA-Associated Vasculitis. Ann N Y Acad Sci 2007; 1107:22-31. [PMID: 17804529 DOI: 10.1196/annals.1381.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although the cause of ANCA-associated vasculitis (AAV) remains undetermined, the presence of lymphocytic infiltrates in inflammatory lesions of patients suggests that vascular damage is immune mediated. Studies over the past decade have implicated a role for T cells in the pathogenesis of AAV as altered T cell phenotype has been observed in this disorder. The distribution of T cell subpopulations has been analyzed most intensely in Wegener's granulomatosis (WG), where an expanded population of circulating CD4(+) effector memory T cells (CD4(+)T(EM)) was demonstrated. CD4(+)T(EM) cells play a major role in the pathogenesis of several autoimmune diseases. Specific suppression of CD4(+)T(EM) cells inhibits delayed-type hypersensitivity (DTH) and has therapeutic potential in autoimmune disease. Thus, CD4(+)T(EM) cells may act as inducers of tissue injury and participate in the development of AAV. Therapies that target CD4(+)T(EM), without impairing the activity of other lymphocyte subsets, may hold therapeutic promise for AAV.
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Affiliation(s)
- Wayel H Abdulahad
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
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Williams JM, Pettitt TR, Powell W, Grove J, Savage COS, Wakelam MJO. Antineutrophil Cytoplasm Antibody–Stimulated Neutrophil Adhesion Depends on Diacylglycerol Kinase–Catalyzed Phosphatidic Acid Formation. J Am Soc Nephrol 2007; 18:1112-20. [PMID: 17360949 DOI: 10.1681/asn.2006090973] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Patients with certain forms of systematic vasculitis, such as Wegener's granulomatosis, have circulating antineutrophil cytoplasmic antibodies (ANCA). These inappropriately stimulate circulating neutrophils adhere to and thereby obstruct small vessels. This, together with ANCA-induced degranulation and an oxidative burst, leads to local tissue damage. The signaling pathways that are activated by ANCA IgG are distinct from those that are involved in normal neutrophil activation. This study shows that diacylglycerol kinase is selectively activated by ANCA and that the generated phosphatidic acid is responsible for promoting neutrophil adhesion, in part through integrin activation. The data presented point to diacylglycerol kinase alpha as a novel but selective target for the development of drugs to treat this potentially fatal disorder.
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Affiliation(s)
- Julie M Williams
- CR-UK Institute for Cancer Studies, Birmingham University, Birmingham B15 2TT, UK
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Abstract
Polyarteritis nodosa (PAN) is a systemic vasculitis characterized by multi-organ involvement with protean manifestations. We evaluated the clinical features of PAN in Korea. Twenty-seven patients were diagnosed as PAN at Seoul National University Hospital between January 1990 and July 2003. The male-to-female ratio was 1.7:1 and mean age at onset (+/-SD) was 47.4+/-20 yr. Their presenting features at diagnosis were similar to those reported previously, i.e., myalgia, muscle weakness or leg tenderness (70%), fever (52%), weight loss >4 kg (44%), skin rash (44%), peripheral edema (33%), abdominal pain (33%), and arthralgia/arthritis (30%). However, the prevalence of testicular pain or tenderness was higher (24%) than reported previously and only three (11.5%) had HBsAg positivity without liver enzyme elevation. Nine patients (33%) had a five-factor score (FFS) of 2. Fourteen patients (52%) responded to treatment, 2 patients relapsed and 4 died within 1 yr of diagnosis. During a median follow-up of 55.5 months, three of the four PAN-related deaths had an initial FFS of 2. The clinical features of PAN were not significantly different from those reported previously. However, testicular pain or tenderness was more frequent and patients with a high FFS tended to have a poorer prognosis.
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Affiliation(s)
- Young Deok Bae
- Division of Rheumatology, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Chan Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeong Jin Park
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University, Jinju, Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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de Lind van Wijngaarden RAF, Hauer HA, Wolterbeek R, Jayne DRW, Gaskin G, Rasmussen N, Noël LH, Ferrario F, Waldherr R, Hagen EC, Bruijn JA, Bajema IM. Clinical and Histologic Determinants of Renal Outcome in ANCA-Associated Vasculitis: A Prospective Analysis of 100 Patients with Severe Renal Involvement. J Am Soc Nephrol 2006; 17:2264-74. [PMID: 16825335 DOI: 10.1681/asn.2005080870] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This study aimed to identify clinical and histologic prognostic indicators of renal outcome in patients with ANCA-associated vasculitis and severe renal involvement (serum creatinine >500 micromol/L). One hundred patients who were enrolled in an international, randomized, clinical trial to compare plasma exchange with intravenous methylprednisolone as an additional initial treatment were analyzed prospectively. Diagnostic renal biopsies were performed upon entry into the study. Thirty-nine histologic and nine clinical parameters were determined as candidate predictors of renal outcome. The end points were renal function at the time of diagnosis (GFR0) and 12 mo after diagnosis (GFR12), dialysis at entry and 12 mo after diagnosis, and death. Multivariate analyses were performed. Predictive of GFR0 were age (r = -0.40, P = 0.04), arteriosclerosis (r = -0.53, P = 0.01), segmental crescents (r = 0.35, P = 0.07), and eosinophilic infiltrate (r = -0.41, P = 0.04). Prognostic indicators for GFR12 were age (r = -0.32, P = 0.01), normal glomeruli (r = 0.24, P = 0.04), tubular atrophy (r = -0.28, P = 0.02), intraepithelial infiltrate (r = -0.26, P = 0.03), and GFR0 (r = 0.29, P = 0.01). Fibrous crescents (r = 0.22, P = 0.03) were predictive of dialysis at entry. Normal glomeruli (r = -0.30, P = 0.01) and treatment arm (r = -0.28, P = 0.02) were predictive of dialysis after 12 mo. No parameter predicted death. Both chronic and acute tubulointerstitial lesions predicted GFR12 in severe ANCA-associated glomerulonephritis, whereas plasma exchange was a positive predictor of dialysis independence after 12 mo for the entire patient group. Plasma exchange remained a positive predictor when patients who were dialysis dependent at presentation were analyzed separately (r = -0.36, P = 0.01). Normal glomeruli were a positive predictor of dialysis independence and improved renal function after 12 mo, indicating that the unaffected part of the kidney is vital in determining renal outcome.
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50
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Sinico RA, Di Toma L, Maggiore U, Tosoni C, Bottero P, Sabadini E, Giammarresi G, Tumiati B, Gregorini G, Pesci A, Monti S, Balestrieri G, Garini G, Vecchio F, Buzio C. Renal involvement in Churg-Strauss syndrome. Am J Kidney Dis 2006; 47:770-9. [PMID: 16632015 DOI: 10.1053/j.ajkd.2006.01.026] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Accepted: 01/31/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND Churg-Strauss syndrome (CSS) is a rare disorder characterized by asthma, eosinophilia, and systemic vasculitis. Renal involvement is not regarded as a prominent feature, and its prevalence and severity vary widely in published reports that usually refer to small series of selected patients. METHODS We examined the prevalence, clinicopathologic features, and prognosis of renal disease in 116 patients with CSS. RESULTS There were 48 men and 68 women with a mean age of 51.9 years (range, 18 to 86 years). Signs of renal abnormalities were present in 31 patients (26.7%). Rapidly progressive renal insufficiency was documented in 16 patients (13.8%); urinary abnormalities, 14 patients (12.1%); and chronic renal impairment, 1 patient. There were 3 additional cases of obstructive uropathy. Sixteen patients underwent renal biopsy, which showed necrotizing crescentic glomerulonephritis in 11 patients. Other diagnoses were eosinophilic interstitial nephritis, mesangial glomerulonephritis, and focal sclerosis. Antineutrophil cytoplasmic antibody (ANCA) was positive in 21 of 28 patients (75.0%) with nephropathy versus 19 of 74 patients without (25.7%; P < 0.001). In particular, all patients with necrotizing crescentic glomerulonephritis were ANCA positive. After a median follow-up of 4.5 years, 10 patients died (5 patients with nephropathy) and 7 patients developed mild chronic renal insufficiency. Five-year mortality rates were 11.7% (95% confidence interval, 3.9 to 33.3) in patients with nephropathy and 2.7% (95% confidence interval, 0.7 to 10.7) in those without (P = 0.10). CONCLUSION Renal abnormalities are present in about one quarter of patients with CSS. The prevailing picture is ANCA-associated necrotizing crescentic glomerulonephritis; however, other forms of nephropathy also may occur. Outcome and long-term follow-up usually are good.
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Affiliation(s)
- Renato Alberto Sinico
- Dipartimento Area Medica, Azienda Ospedaliera Ospedale San Carlo Borromeo, Milan, Italy.
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