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Alobaidi A, Albadry A, Murray A, Lytvak I. A Case of Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis Presenting With Diffuse Alveolar Hemorrhage and Renal Sparing. Cureus 2023; 15:e45397. [PMID: 37854734 PMCID: PMC10580867 DOI: 10.7759/cureus.45397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/20/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis disease that traditionally includes three variants classified based on their clinical and pathological appearance: microscopic polyangiitis (MPA), granulomatosis with polyangiitis, and eosinophilic granulomatosis with polyangiitis (alternatively, Churg-Strauss syndrome). The mainstay of AAV treatment is immunosuppressive treatments, which improve survival and lower rates of end-stage kidney disease. Here we describe a patient with MPA ANCA who presented with diffuse alveolar hemorrhage and, six months later, recurrent pulmonary hemorrhage with renal sparing while off therapy.
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Affiliation(s)
- Ahmed Alobaidi
- Department of Internal Medicine, Methodist Health System, Dallas, USA
| | - Ahmed Albadry
- Faculty of Medicine, Charles University in Prague, Prague, CZE
| | - Anne Murray
- Clinical Research Institute, Methodist Health System, Dallas, USA
| | - Irina Lytvak
- Department of Pathology, Methodist Health System, Dallas, USA
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Itoh R, Tomoda Y, Kobayashi R, Awaya Y. Granulomatosis with polyangiitis presenting as a pulmonary abscess. QJM 2022; 115:488-489. [PMID: 35348795 DOI: 10.1093/qjmed/hcac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- R Itoh
- From the Department of Respiratory Medicine, Itabashi Chuo Medical Center, 2-12-7 Azusawa, Itabashi-ku, Tokyo 174-0051, Japan
| | - Y Tomoda
- Department of General Medicine, Itabashi Chuo Medical Center, 2-12-7 Azusawa, Itabashi-ku, Tokyo 174-0051, Japan
| | - R Kobayashi
- Department of Thoracic Surgery, Itabashi Chuo Medical Center, 2-12-7 Azusawa, Itabashi-ku, Tokyo 174-0051, Japan
| | - Y Awaya
- From the Department of Respiratory Medicine, Itabashi Chuo Medical Center, 2-12-7 Azusawa, Itabashi-ku, Tokyo 174-0051, Japan
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Edrees A, Naguib S, El Menyawi M, Ismail I, Nagah H. Pulmonary manifestations in a group of patients with Behcet's disease. Int J Rheum Dis 2015; 20:269-275. [PMID: 26354676 DOI: 10.1111/1756-185x.12626] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM In this study we investigated the frequency and characteristics of pulmonary manifestations in a group of patients with Behcet's disease (BD) who were admitted to Cairo University Hospital. METHODS Fifteen patients were included in our study, 14 men (93.3%) and one woman (6.66%).Their mean age was 30.06 ± 9.8 years and the mean age of onset of BD was 23.7 ± 5.54 years. All patients were subjected to full history taking, clinical examination, plain chest X-ray and helical computed tomography (CT) study of the chest. RESULTS Pulmonary involvements were detected in 11 patients with BD, 73.3% of cases: 10 men (90.9%) and one woman (9.09%).Their mean age was 28.8 ± 8.07, the mean age of onset of BD was 23.2 ± 5.59 years and the mean disease duration until lung manifestations appear was 3.7 ± 4.8 years. The main pulmonary and constitutional symptoms in these 11 patients were as follows: dyspnea 81.8%, cough 63.6%, weight loss 63.6%, chest tightness 54.5%, hemoptysis 45%, massive hemoptysis 27.2%, fever 36.3% and expectoration 36.3. Analysis of both vascular and parenchymal lung lesions in helical CT scan in the 11 patients with BD were as follows: pulmonary artery aneurysm (PAA) occurred in 5/11 patients (45.4%), pulmonary nodules occurred in 3/11 patients (27.2%), pleural effusion occurred in 3/11 patients (27.2%), pulmonary embolism and infarction occurred in 1/11 patients (9.09%) and pneumonitis occurred in 1/11 patients (9.09%). CONCLUSION The higher frequency of pulmonary manifestations in our patients (73.3%) and the higher frequency of PAA (33.3%) could be related to the fact that this study was conducted on a group of patients who were admitted to the hospital with more severe illnesses.
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Affiliation(s)
- Amr Edrees
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sherif Naguib
- Department of Internal Medicine, Cairo University, Cairo, Egypt
| | | | - Ihab Ismail
- Department of Radiology, Cairo University, Cairo, Egypt
| | - Hamdy Nagah
- Department of Internal Medicine, Cairo University, Cairo, Egypt
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Naguib SM, El Menyawi MM, Nabih MI, Ismail I. Pulmonary manifestations in a group of patients with Behçet’s disease. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2015. [DOI: 10.4103/1110-7782.155827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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5
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Wilfong EM, Seo P. Vasculitis in the intensive care unit. Best Pract Res Clin Rheumatol 2013; 27:95-106. [PMID: 23507060 DOI: 10.1016/j.berh.2013.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
The systemic vasculitides are a diverse set of diseases linked by the presence of blood-vessel inflammation and are often associated with life-threatening or critical complications, including glomerulonephritis, diffuse alveolar haemorrhage, pulmonary arterial hypertension and airway compromise. The protean manifestations of the systemic vasculitides make them challenging to diagnose. Early recognition, however, is crucial to improving outcomes. This article serves as an introduction to these complex diseases, reviewing the manifestations of systemic vasculitis that may be encountered in an intensive care setting, and outlines an overall approach to their treatment.
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Affiliation(s)
- Erin M Wilfong
- Johns Hopkins University School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA.
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6
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Bilgin G, Sungur G, Kucukterzi V. Systemic and pulmonary screening of patients with Behçet's disease during periodic follow-up. Respir Med 2013; 107:466-71. [DOI: 10.1016/j.rmed.2012.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 04/04/2012] [Accepted: 04/10/2012] [Indexed: 10/27/2022]
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7
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Park JK, Askin F, Giles JT, Halushka MK, Rosen A, Levine SM. Increased generation of TRAP expressing multinucleated giant cells in patients with granulomatosis with polyangiitis. PLoS One 2012; 7:e42659. [PMID: 22905158 PMCID: PMC3414441 DOI: 10.1371/journal.pone.0042659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/10/2012] [Indexed: 11/19/2022] Open
Abstract
Background Tissue-infiltrating multinucleated giant cells (MNGs) within geographic necrosis are pathologic hallmarks of granulomatosis with polyangiitis (GPA). However, the origin, phenotype, and function of these cells in GPA remain undefined. Methodology/Principal Findings MNG phenotype in GPA lung tissue was examined by immunohistochemistry using antibody directed against cathepsin K and calcitonin-receptor. Tartrate-resistant-acid-phosphatase (TRAP) expression was assessed using enzymatic color reaction. Peripheral blood mononuclear cells (PBMCs) from 13 GPA patients (5 with localized and 8 with systemic disease) and 11 healthy controls were cultured in the presence of RANKL and M-CSF for 9 days, and TRAP+ MNGs containing 3 or more nuclei were identified. GPA lung granulomata contained numerous MNGs that expressed osteoclastic TRAP and cathepsin K but not calcitonin receptors. In the presence of RANKL and M-CSF, PBMCs of GPA patients formed significantly more MNGs than healthy controls (114±29 MNG/well vs. 22±9 MNG/well, P = 0.02). In a subgroup analysis, patients with systemic disease generated significantly more MNGs than patients with localized disease (161±35 MNG/well vs. 39±27 MNG/well, P<0.01) or healthy controls (P<0.01). MNG production did not differ between localized GPA and control subjects (P = 0.96). Conclusions/Significance MNGs in granulomata in the GPA lung express osteoclastic enzymes TRAP and cathepsin K. GPA patients have a higher propensity to form TRAP+ MNGs from peripheral blood than healthy controls. These data suggest that (i) the tendency to form MNGs is a component of the GPA phenotype itself, and (ii) that lesional MNGs might participate in the destructive process through their proteolytic enzymes.
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Affiliation(s)
- Jin Kyun Park
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
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Abstract
The pulmonary vasculitides are a heterogeneous group of diseases that often occur as a component of systemic vasculitic diseases. Most frequently, pulmonary vasculitis is observed in vasculitic syndromes that preferentially affect small vessels. Pulmonary involvement may develop because the lung has an extensive vascular and microvascular network. Sensitising antigens can easily reach the lung, and there are large numbers of vasoactive and activated immune cells in the lung. A diagnosis often can be made on the basis of clinical presentation and serologic studies, but biopsy of skin, nose, kidney, or lung may be necessary to ascertain the precise syndrome.
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Affiliation(s)
- Brian P O'Sullivan
- Department of Pediatrics, University of Mass. Memorial Health Care; Worcester, MA 01655, USA.
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Hayes D, Iocono JA, Bennett JS, Lachman DC, Ballard HO. Epistaxis due to Wegener's granulomatosis in a pediatric patient. Am J Otolaryngol 2010; 31:368-71. [PMID: 20015782 DOI: 10.1016/j.amjoto.2009.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 05/05/2009] [Indexed: 11/30/2022]
Abstract
Epistaxis is a common problem in children that typically is not severe and seldom requires hospitalization. The nose is a highly vascular structure with a large surface area; subsequently, it is highly predisposed to bleeding. Childhood vasculitides are very rare and are commonly diagnosed by characteristic lesions on imaging studies along with syndrome recognition by clinicians. We present a case of recurrent epistaxis that persisted over 3 months due to Wegener's granulomatosis in an adolescent that was misdiagnosed as a benign hemorrhage from Kiesselbach's plexus.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, University of Kentucky College of Medicine, J410 Kentucky Clinic, Lexington, KY 40536, USA.
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Sim YS, Choi MY, Oh JY, Lee JH, Moon JW, Choi KB, Ahn JH, Kim YK, Sung SH, Chang JH. A Case of Pulmonary Hemorrhage Associated with Henoch-Schönlein Purpura. Tuberc Respir Dis (Seoul) 2009. [DOI: 10.4046/trd.2009.67.3.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yun Su Sim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Moon Young Choi
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ji Young Oh
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jin Hwa Lee
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jin Wook Moon
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyu Bock Choi
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jae Ho Ahn
- Department of Chest Surgery, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yoo Kyung Kim
- Department of Diagnostic Radiology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Sun Hee Sung
- Department of Pathology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung Hyun Chang
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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Field S, Powell FC, Young V, Barnes L. Pyoderma gangrenosum manifesting as a cavitating lung lesion. Clin Exp Dermatol 2008; 33:418-21. [PMID: 18498409 DOI: 10.1111/j.1365-2230.2008.02756.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We present a case of pyoderma gangrenosum (PG) mimicking a lung carcinoma. A 52-year-old woman presented with an unremitting cough. Computed tomography revealed a cavitating lung lesion. Bronchoscopy and biopsy were interpreted as squamous cell carcinoma. Following a staging mediastinoscopy, a sleeve lobectomy and chest-wall resection was performed. The pulmonary histopathological features suggested Wegener's granulomatosis; no malignancy was found. Three months postoperatively, wound breakdown led to dermatological review. A clinical diagnosis of cutaneous PG was made on the basis of the classic appearance of the surgical wounds and an ulcer on the upper back that had been present before surgery. The patient has been consistently negative for cytoplasmic-staining antineutrophil cytoplasmic antibodies, which supports the diagnosis of PG with cutaneous and pulmonary involvement. Lung manifestations of PG are rare. PG is amenable to systemic therapy. Pulmonary PG is a rare but important differential diagnosis that is not familiar to many physicians and surgeons in this type of presentation.
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Affiliation(s)
- S Field
- Department of Dermatology, Mater Misericordiae Hospital, Dublin, Ireland
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Kalyoncu M, Cakir M, Erduran E, Okten A. Henoch-Schönlein purpura: a case with atypical presentation. Rheumatol Int 2005; 26:669-71. [PMID: 16180001 DOI: 10.1007/s00296-005-0032-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 07/07/2005] [Indexed: 11/25/2022]
Abstract
We report on a case of Henoch-Schönlein purpura (HSP) with pulmonary hemorrhage and severe renal involvement. The patient also had active carditis related to acute rheumatic fever. He died despite intensive treatment. Regarding this case, we discuss the pathogenesis and clinical findings of pulmonary hemorrhage and active carditis in HSP.
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Affiliation(s)
- Mukaddes Kalyoncu
- Department of Pediatrics, Faculty of Medicine, Karadeniz Technical University, 61080 Trabzon, Turkey
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13
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Capelozzi VL, Parras ER, Ab'Saber AM. Apresentação anatomopatológica das vasculites pulmonares. J Bras Pneumol 2005. [DOI: 10.1590/s1806-37132005000700005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A apresentação anatomopatológica das vasculites pulmonares inclui um processo inflamatório da parede dos vasos pulmonares que pode vir acompanhado de granulomas, células gigantes, eosinófilos, necrose e hemorragia pulmonar. O conhecimento dessas manifestações, em associação com o tipo de vaso acometido e reações de imunofluorescência auxiliam no diagnóstico diferencial das vasculites.
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14
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Abstract
A granulomatose de Wegener caracteriza-se por vasculite necrosante granulomatosa que acomete preferencialmente vias aéreas superiores, inferiores e rins. Seu diagnóstico é feito associando-se as manifestações clínicas, radiológicas (multiplos nódulos escavados) e os achados anatomopatológicos e o anticorpo anticitoplasma de neutrófilos positivo. O tratamento com corticosteróides e ciclofosfamida leva a 90% de remissão da doença em 1 ano.
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Pirot AL, Goldsmith D, Pascasio J, Beck SE. Pulmonary capillaritis with hemorrhage due to propylthiouracil therapy in a child. Pediatr Pulmonol 2005; 39:88-92. [PMID: 15532087 DOI: 10.1002/ppul.20072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We report on a case of pulmonary capillaritis with diffuse alveolar hemorrhage in a child due to propylthiouracil (PTU). PTU treatment is a rare cause of pulmonary capillaritis in adults; we report on the first case in a pediatric patient. The treatment of pulmonary capillaritis often requires corticosteroid therapy, other immunosuppressive medications, or withdrawal of the causative agent. Our patient recovered completely after treatment with a limited course of corticosteroids and removal of PTU.
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Affiliation(s)
- Anayansi Lasso Pirot
- Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania 19134, USA
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Luks AM, Lakshminarayanan S, Hirschmann JV. Leptospirosis presenting as diffuse alveolar hemorrhage: case report and literature review. Chest 2003; 123:639-43. [PMID: 12576395 DOI: 10.1378/chest.123.2.639] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The literature on diffuse alveolar hemorrhage heavily emphasizes the causal role of vasculitides. We present a patient with diffuse alveolar hemorrhage caused by leptospirosis. Although the pathology in leptospirosis occurs secondary to a vasculitic process, this disease is not listed as a cause of diffuse alveolar hemorrhage in the review literature. In the right clinical scenario, the disease should be considered in a patient presenting with diffuse alveolar hemorrhage.
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Affiliation(s)
- Andrew M Luks
- Department of Medicine (Dr. Luks), University of Washington, Seattle 98108, USA
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López-Campos Bodineau JL, Gómez Izquierdo L, Rodríguez Becerra E, Martín Juan J, Fajardo Cascos M, Borderas Naranjo F, Castillo Gómez J. [Evaluation of clinical diagnostic guidelines for idiopathic pulmonary fibrosis]. Arch Bronconeumol 2003; 39:23-8. [PMID: 12550016 DOI: 10.1016/s0300-2896(03)75310-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To analyze the international consensus statement on diagnostic criteria for idiopathic pulmonary fibrosis. METHODS All patients diagnosed of any interstitial lung disease by means of open lung biopsy since 1980 were included. The patients' clinical records were examined to determine whether they fulfilled the diagnostic criteria, and their biopsies were reviewed to find those with the usual interstitial pneumonia pattern. We calculated sensitivity, specificity, positive and negative predictive values and likelihood ratios for the diagnostic criteria in the consensus statement. Afterwards, we performed the analyses again using only one of the two conditions for fulfilling the function criterion. RESULTS Of 39 patients enrolled in the study, 17 had idiopathic pulmonary fibrosis. Specificity and positive predictive value were both 100%, but sensitivity was 41.2% and negative predictive value was 68.7%. The likelihood ratio for a negative result was 0.59. In the second analysis, sensitivity was 64.7% and negative predictive value was 78.5%, while specificity and positive predictive value remained unchanged. The likelihood ratio for a negative result was 0.35. CONCLUSIONS The criteria are sufficiently specific to allow us to diagnose confidently when the criteria are fulfilled. However, a slight change in the function criterion should be considered in order to increase diagnostic yield.
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Affiliation(s)
- J L López-Campos Bodineau
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocio, Sevilla, España.
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Abstract
Our knowledge about pulmonary complications of Behçet's disease continues to evolve, but we need controlled trials for the management of the disease. The main goal should be to elucidate the pathogenesis and standardize the management according to the underlying pathologic process.
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Affiliation(s)
- Feyza Erkan
- Department of Pulmonary Medicine, Istanbul Medical Faculty, University of Istanbul, 34 390 Capa-Istanbul, Turkey.
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Zinck SE, Schwartz E, Berry GJ, Leung AN. CT of noninfectious granulomatous lung disease. Radiol Clin North Am 2001; 39:1189-209, vi. [PMID: 11699668 DOI: 10.1016/s0033-8389(05)70338-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Noninfectious granulomatous diseases of the lung consist of a diverse group of disorders that logically can be subdivided into those with and without associated vasculitis. This article reviews the epidemiologic, clinical, pathologic, and radiologic features of sarcoidosis, hypersensitivity pneumonitis, berylliosis, and the five entities traditionally classified as pulmonary angiitis and granulomatosis.
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Affiliation(s)
- S E Zinck
- Department of Radiology, Stanford University Medical Center, California 94305-5105, USA.
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Affiliation(s)
- F Erkan
- Division of Pneumology, Istanbul Medical Faculty, University of Istanbul, Turkey.
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Abstract
Pulmonary artery aneurysms varying in size and number continue to be the principal feature of pulmonary involvement in Behçet disease (BD). Pulmonary aneurysms have been reported to be associated with cardiac thromboses, mainly in the right heart. Bronchiolitis obliterans organizing pneumonia has also been seen in the setting of pulmonary artery aneurysms. Aneurysms of the aortic arch and subclavian artery are rarely recognized thoracic manifestations of BD. Noninvasive imaging techniques, such as helical computed tomography and magnetic resonance angiography, are the safer and preferred methods for identifying aneurysms and thrombi. Digital substraction angiography has been found to be inadequate in showing thrombosed vessels. Follow-up computed tomography was performed in the documentation of the aneurysmal healing process. In patients receiving immunosuppressive treatment, intramural thrombus formation occurred and was followed by aneurysmal regression and disappearance. General principles for the treatment of systemic vasculitis are used in the treatment of BD.
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Affiliation(s)
- F Erkan
- Division of Pneumology, Istanbul Medical Faculty, University of Istanbul, Capa/Istanbul, Turkey
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