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Wiik A, Cervera R, Haass M, Kallenberg C, Khamashta M, Meroni PL, Piette JC, Schmitt R, Shoenfeld Y. European Attempts to Set Guidelines for Improving Diagnostics of Autoimmune Rheumatic Disorders. Lupus 2016; 15:391-6. [PMID: 16898171 DOI: 10.1191/0961203306lu2322oa] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The rational way to set a diagnosis and estimate a prognosis in rheumatology is to start by setting a tentative diagnosis and then follow a fixed scheme for laboratory testing, eg, by using an agreed algorithm. The use of order algorithms can be extended to post-test algorithms that will assist clinicians in approaching the right diagnosis and prognosis. New methods used in autoimmune serology do not deliver results that can be directly compared to those of older methods, and thus the new methods need to be thoroughly tested with sera from differential diagnostically relevant disease controls to set a clinically meaningful cut-off for positivity. Borderline positive results need to be treated with special care to avoid misuse. Early diagnosis is of great importance, and serological results can be very useful if used the right way. European efforts to secure rational diagnostic work-up in autoimmune rheumatic disease have led to a better dialogue between clinicians and laboratory scientists in several countries.
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Affiliation(s)
- A Wiik
- Department of Autoimmunology, Statens Serum Institut, Copenhagen, Denmark.
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Wiik A. Clinical and pathophysiological significance of anti-neutrophil cytoplasmic autoantibodies in vasculitis syndromes. Mod Rheumatol 2014. [DOI: 10.3109/s10165-009-0219-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Perel SB, Prain KM, Wilson RJ, Hogan PG, Gillis D, Wong RCW. Diagnostic value of distinguishing and reporting different perinuclear ANCA (P-ANCA) immunofluorescence patterns: a prospective study. Am J Clin Pathol 2013; 140:184-92. [PMID: 23897253 DOI: 10.1309/ajcp4y8admkoscxv] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To investigate whether discriminating the classic perinuclear antineutrophil cytoplasmic antibody (P-ANCA) pattern from atypical P-ANCA and uninterpretable patterns improves the diagnostic utility of ANCA testing. METHODS All ANCA requests (n = 3,544) referred to Pathology Queensland were analyzed prospectively over 4 months for P-ANCA pattern subtypes and myeloperoxidase (MPO)-ANCA/PR3-ANCA results and correlated with clinical, laboratory, and radiologic evidence of necrotizing small vessel vasculitis. RESULTS Of the 436 perinuclear immunofluorescence-positive samples, 45 were classic P-ANCA, 163 were atypical P-ANCA, and 228 were antinuclear antibodies/uninterpretable. The classic P-ANCA pattern had a significantly stronger association with vasculitis (30/45) than atypical P-ANCA (2/163) (P <.0001) or ANA/uninterpretable patterns (8/228) (P <.0001). The combination of a classic P-ANCA pattern and positive MPO-ANCA/PR3-ANCA result was also more strongly associated with vasculitis than a positive MPO-ANCA/PR3-ANCA result in isolation (P = .003). CONCLUSIONS This study demonstrates that reporting different P-ANCA patterns (including ANA/uninterpretable patterns) provides additional diagnostic information to MPO-ANCA/PR3-ANCA results.
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Affiliation(s)
- Susan B. Perel
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Clinical Immunology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Kerri M. Prain
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Robert J. Wilson
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Patrick G. Hogan
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Clinical Immunology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - David Gillis
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Clinical Immunology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Richard C. W. Wong
- Division of Immunology, HSSA Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Clinical Immunology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Shankar S, Pathak A, Tewari R. Renal involvement in ANCA associated vasculitis. INDIAN JOURNAL OF RHEUMATOLOGY 2013. [DOI: 10.1016/j.injr.2013.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Campainha S, Gonçalves M, Tavares V, Castelões P, Marinho A, Neves S. Granulomatosis with polyangiitis initially misdiagnosed as lung cancer. REVISTA PORTUGUESA DE PNEUMOLOGIA 2012; 19:45-8. [PMID: 22748944 DOI: 10.1016/j.rppneu.2012.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 03/12/2012] [Indexed: 10/28/2022] Open
Abstract
Granulomatosis with Polyangiitis (GPA), which was formerly named Wegener's Granulomatosis (WG) is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract, as well as kidneys. Diagnosing GPA on the basis of transthoracic fine needle aspiration (TFNA) may be problematic, as it can be misdiagnosed as cancer. We describe a patient with a probable GPA which was originally diagnosed as malignancy, but who responded to lung cancer chemotherapy.
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Affiliation(s)
- S Campainha
- Serviço de Pneumologia, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal.
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Linder R, Orth I, Hagen EC, van der Woude FJ, Schmitt WH. Differentiation between Wegener's granulomatosis and microscopic polyangiitis by an artificial neural network and by traditional methods. J Rheumatol 2011; 38:1039-47. [PMID: 21324966 DOI: 10.3899/jrheum.100814] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the operating characteristics of the American College of Rheumatology (ACR) traditional format criteria for Wegener's granulomatosis (WG), the Sørensen criteria for WG and microscopic polyangiitis (MPA), and the Chapel Hill nomenclature for WG and MPA. Further, to develop and validate improved criteria for distinguishing WG from MPA by an artificial neural network (ANN) and by traditional approaches [classification tree (CT), logistic regression (LR)]. METHODS All criteria were applied to 240 patients with WG and 78 patients with MPA recruited by a multicenter study. To generate new classification criteria (ANN, CT, LR), 23 clinical measurements were assessed. Validation was performed by applying the same approaches to an independent monocenter cohort of 46 patients with WG and 21 patients with MPA. RESULTS A total of 70.8% of the patients with WG and 7.7% of the patients with MPA from the multicenter cohort fulfilled the ACR criteria for WG (accuracy 76.1%). The accuracy of the Chapel Hill criteria for WG and MPA was only 35.0% and 55.3% (Sørensen criteria: 67.2% and 92.4%). In contrast, the ANN and CT achieved an accuracy of 94.3%, based on 4 measurements (involvement of nose, sinus, ear, and pulmonary nodules), all associated with WG. LR led to an accuracy of 92.8%. Inclusion of antineutrophil cytoplasmic antibodies did not improve the allocation. Validation of methods resulted in accuracy of 91.0% (ANN and CT) and 88.1% (LR). CONCLUSION The ACR, Sørensen, and Chapel Hill criteria did not reliably separate WG from MPA. In contrast, an appropriately trained ANN and a CT differentiated between these disorders and performed better than LR.
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Affiliation(s)
- Roland Linder
- Scientific Institute of TK for Benefit and Efficiency in Health Care (WINEG), Hamburg, Germany
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Affiliation(s)
- Allan S Wiik
- Department of Autoimmunology, Statens Serum Institut, DK-2300 Copenhagen S, Denmark.
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Miller A, Chan M, Wiik A, Misbah SA, Luqmani RA. An approach to the diagnosis and management of systemic vasculitis. Clin Exp Immunol 2010; 160:143-60. [PMID: 20070316 PMCID: PMC2857937 DOI: 10.1111/j.1365-2249.2009.04078.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2009] [Indexed: 11/28/2022] Open
Abstract
The systemic vasculitides are a complex and often serious group of disorders which, while uncommon, require careful management in order to ensure optimal outcome. In most cases there is no known cause. Multi-system disease is likely to be fatal without judicious use of immunosuppression. A prompt diagnosis is necessary to preserve organ function. Comprehensive and repeated disease assessment is a necessary basis for planning therapy and modification of treatment protocols according to response. Therapies typically include glucocorticoids and, especially for small and medium vessel vasculitis, an effective immunosuppressive agent. Cyclophosphamide is currently the standard therapy for small vessel multi-system vasculitis, but other agents are now being evaluated in large randomized trials. Comorbidity is common in patients with vasculitis, including the cumulative effects of potentially toxic therapy. Long-term evaluation of patients is important in order to detect and manage relapses.
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Affiliation(s)
- A Miller
- Nuffield Orthopaedic Centre, Oxford, UK
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Wiik A. Clinical and pathophysiological significance of anti-neutrophil cytoplasmic autoantibodies in vasculitis syndromes. Mod Rheumatol 2010; 19:590-9. [PMID: 19730973 DOI: 10.1007/s10165-009-0219-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 07/28/2009] [Indexed: 11/28/2022]
Abstract
Necrotizing vasculitis of small blood vessels is a rare condition, but when it affects important organs it can lead to life-threatening organ damage and death. Thus, recognizing these conditions at an early stage before they spread to become systemic is a constant challenge to clinical medicine. The objectives of this review are: to give advice on clinical indications for ANCA diagnostics and laboratory procedures for highly specifically detecting the most important ANCA; to provide some data on the autoantigens involved in ANCA reactivity in small vessel vasculitides; and to discuss at the occurrence of ANCA in different vasculitic populations and at different stages of disease. One important task for the near future will be to standardize the assays used for ANCA detection/quantification and to harmonize the results given to clinicians by ensuring that international reference reagents are used by laboratories and the diagnostic industry. Finally, the author has attempted to summarize the role that ANCA are currently believed to play in the immuno-inflammatory events that take place in tissues and that affect small vessels in idiopathic vasculitis. The review concludes that the presence of ANCA is likely to become an important criterion for diagnosing idiopathic small vessel vasculitis.
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Affiliation(s)
- Allan Wiik
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S, Denmark.
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Wiik AS. Anti‐nuclear autoantibodies: clinical utility for diagnosis, prognosis, monitoring, and planning of treatment strategy in systemic immunoinflammatory diseases. Scand J Rheumatol 2009; 34:260-8. [PMID: 16195158 DOI: 10.1080/03009740500202664] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The determination of serum autoantibodies to nuclear and cytoplasmic cell components is relevant to the diagnosis of chronic immunoinflammatory disorders. Detection is based on screening methods that allow antibody binding to intact cell structures, followed by use of assays to demonstrate their antigen target specificity. The results can be used to help clinicians set diagnosis and estimate prognosis, plan further diagnostic work-up, monitoring strategy and sometimes therapeutic approach. To obtain such accuracy of use clinicians need to be involved in revealing the differential diagnostic potential of the autoimmune serology test programme by furnishing detailed clinical data on patients from whom serum samples have been obtained. Borders between positive and negative values should aim at attaining a high diagnostic specificity towards clinically important disease controls.
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Affiliation(s)
- A S Wiik
- Department of Autoimmunology, Statens Serum Institut, Copenhagen S, Denmark.
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Seishima M, Mizutani Y, Shibuya Y, Arakawa C. Antineutrophil cytoplasmic antibody-associated vasculitis with oculomotor nerve palsy. Clin Exp Dermatol 2009; 34:171-3. [PMID: 19187297 DOI: 10.1111/j.1365-2230.2008.02746.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We report a patient with antineutrophil cytoplasmic antibody-associated vasculitis with oculomotor nerve palsy. The patient presented with a high fever, diplopia, blepharoptosis and impairment of ocular movement of the left eye except for lateral gaze. Multiple erythematous and livedoid lesions were observed on the forehead, both cheeks and both legs. Laboratory examination showed positive results for myeloperoxidase antineutrophil cytoplasmic antibodies. Skin biopsy revealed leucocytoclastic vasculitis of the small arteries in the lower dermis. The patient was successfully treated with systemic corticosteroids.
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Affiliation(s)
- M Seishima
- Department of Dermatology, Ogaki Municipal Hospital, Ogaki City, Japan.
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A proposed model for effective collaboration between rheumatologists and clinical pathologists for the diagnosis of autoimmune rheumatic diseases. Rheumatol Int 2008; 29:849-51. [DOI: 10.1007/s00296-008-0783-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/09/2008] [Indexed: 11/26/2022]
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Abstract
Vasculitis is characterized by an inflammatory reaction of vessel walls with damage to the dependent tissues. Forms of vasculitis which frequently have skin changes include leukocytoclastic angiitis (LcV), Henoch-Schönlein purpura (HSP), cutaneous polyarteriitis nodosum (cPAN), erythema elevatum et diutinum (EED) and urticarial vasculitis (UV). In other forms of vasculitis, systemic manifestations predominate but there are a variety of skin changes. Kawasaki disease (MK), cryoglobulinemic vasculitis (kV), Wegener granulomatosis (WG), Churg-Strauss syndrome (CSS) and microscopic polyangitis (MPA) belong to this group. The causes of vasculitis are heterogeneous. Triggers include infections, drugs, collagen vascular diseases, autoimmune diseases and lymphoproliferative disorders. Idiopathic vasculitis, particularly LcV and EED, occur only once and have a self-limited course. The diagnostic work up depends on the clinical picture and includes inflammatory markers, circulating immune complexes, different types of cryoglobulins and anti-neutrophilic cytoplasmic antibodies, collagen vascular disease specific autoantibodies and additional hematological studies. Vasculitis can manifest in many organs and requires a thorough work up specifically in cases where WG, MPA, CSS and PAN are under consideration.
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Affiliation(s)
- K Schäkel
- Klinik und Poliklinik für Dermatologie am Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
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Xu LY, Esparza EM, Anadkat MJ, Crone KG, Brasington RD. Cutaneous manifestations of vasculitis. Semin Arthritis Rheum 2008; 38:348-60. [PMID: 18355896 DOI: 10.1016/j.semarthrit.2008.01.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 12/11/2007] [Accepted: 01/05/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To discuss the clinical features, diagnostic evaluation, and treatment options for cutaneous vasculitis. METHODS The literature in the PubMed database was reviewed regarding the presentation, pathophysiology, clinical workup, and treatment of cutaneous vasculitis. RESULTS Available classification criteria of vasculitis are based on histopathologic criteria or clinicohistologic features. These have been designed more for research purposes than for clinical application. Skin findings such as palpable purpura, nodules, urticaria, ulcers, and infarction are clues to the presence of vasculitis. Pathologic findings of fibrinoid necrosis, infiltration by neutrophils or lymphocytes, and deposition of complement and immunoglobulin may be helpful in reaching a specific diagnosis. However, there is considerable overlap across different conditions. CONCLUSIONS The correct diagnosis of cutaneous manifestations of vasculitis requires an understanding of vasculitis classification, recognition of specific clinical patterns, and the ability to interpret histopathologic data.
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Affiliation(s)
- Lisa Y Xu
- Rheumatology and Dermatology, Department of Internal Medicine and Lauren V. Ackerman Laboratory of Surgical Pathology, Washington University School of Medicine, St. Louis, MO, USA
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Gonçalves C, Pinaffi JV, Carvalho JF, Pinna FR, Constantino GT, Voegels RL, Bueno C, Bonfá E, Viana VST. Antineutrophil cytoplasmic antibodies in chronic rhinosinusitis may be a marker of undisclosed vasculitis. ACTA ACUST UNITED AC 2008; 21:691-4. [PMID: 18201448 DOI: 10.2500/ajr.2007.21.3092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Upper airway manifestations are common features of antineutrophil cytoplasmic antibody (ANCA)-related vasculitis. Determining the presence of this antibody in patients with chronic rhinosinusitis (CRS) may allow early identification and treatment of underlying vasculitis. Methods Forty-nine consecutive CRS patients and 165 age- and sex-matched healthy controls were evaluated for vasculitis complaints. ANCA were detected by indirect immunofluorescence, and antibodies to proteinase 3 (PR3) and myeloperoxidase were determined by ELISA. RESULTS Patients and controls were comparable concerning the mean age (47.2 +/- 15 years versus 45 +/- 12.5 years; p = 0.303) and female predominance (73.5% versus 60%; p = 0.502). Vasculitis-associated complaints were reported in 8/49 (16.3%) patients: 7 patients reported a 10-year history of asthma and 1 patient had red/painful eyes associated with epistaxis. ANCA was positive in 5/49 (10%) patients and absent in controls (p < 0.0001). One patient had high titer cytoplasmic ANCA/PR3 and during the investigation developed clinical features of Wegener's granulomatosis. The other four patients had perinuclear ANCA, of whom three were asymptomatic and one is currently under surveillance for Churg-Strauss syndrome. Sinus computed tomography scan revealed that patients who were ANCA(+) had more extensive disease involvement than ANCA(-) patients (Lund-Mackay score median value, 21 versus 13; p = 0.008). CONCLUSION ANCA may identify a subset of difficult to treat CRS patients with underlying vasculitis and may be useful for establishing an early diagnosis of vasculitis in CRS.
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Affiliation(s)
- Carla Gonçalves
- Division of Rheumatology, School of Medicine, University of São Paulo, São Paulo-SP, Brazil
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A clinical approach to autoantibody testing in systemic autoimmune rheumatic disorders. Autoimmun Rev 2007; 7:77-84. [DOI: 10.1016/j.autrev.2007.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Nataraja A, Mukhtyar C, Hellmich B, Langford C, Luqmani R. Outpatient assessment of systemic vasculitis. Best Pract Res Clin Rheumatol 2007; 21:713-32. [PMID: 17678832 DOI: 10.1016/j.berh.2007.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The vasculitides are complex, multisystem diseases, the natural history of which has been transformed by the use of immunosuppressive therapy. In many cases, survival is characterized by the presence of ongoing low-grade disease activity and, now that patients can survive acute, life-threatening manifestations of vasculitis, the new challenge is to provide accurate descriptions of these problems so as to plan appropriate changes in therapy to ensure optimal control of disease, with minimal toxicity, damage, and impairment of function. To achieve these aims, it is necessary to undertake structured evaluation of patients, with a significant dependence on careful clinical observation, supported by appropriate laboratory investigation at all stages from diagnosis to long-term care of these patients. This chapter reviews the important aspects of disease assessment and recommends a strategy for managing these complex patients. We can make use of standardized disease assessment instruments, such as the Birmingham Vasculitis Assessment Score and the Vasculitis Damage Index, to serve as an aide memoire in documenting the clinical features of disease. Routine monitoring for drug toxicity in the short-term and long-term is essential. Above all, however, it is very important to review these patients regularly and see them urgently in case of flares or complications, which are a common problem in most forms of vasculitis.
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Abstract
In order to help the clinical rheumatologist set an early and precise diagnosis and plan a rational follow-up, a close collaboration between all parties involved in the diagnostic work-up must be established. Autoimmune serology plays a key role in achieving this goal by choosing test methods that are ideal from a clinical standpoint and by presenting results obtained in such a fashion that even less experienced clinicians can correctly use the information. Simple algorithms for test ordering and for the interpretation of laboratory findings are of great benefit in daily practice, but such tools must be mutually agreed upon by the laboratory and clinical scientists. A precise diagnosis and estimation of prognosis is instrumental for optimal decision making in the clinic, but this is too complicated to be left to chance due to the inappropriate use of information. Late or wrong decisions during follow-up lead to unnecessary suffering and far higher lifetime costs for chronic diseases such as those found in rheumatology.
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Affiliation(s)
- A S Wiik
- Department of Autoimmunology, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S, Dänemark.
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Samarkos M, Loizou S, Vaiopoulos G, Davies KA. The Clinical Spectrum of Primary Renal Vasculitis. Semin Arthritis Rheum 2005; 35:95-111. [PMID: 16194695 DOI: 10.1016/j.semarthrit.2005.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The vasculitides are potentially severe and often difficult to diagnose syndromes. Many forms of vasculitis may involve the kidneys. This review will focus on the clinical and histopathological aspects of renal involvement in the systemic vasculitides. METHODS We searched the MEDLINE database using as key terms the MeSH terms and textwords for different forms of vasculitis and for renal involvement, creating a database of more than 2200 relevant references. RESULTS The frequency of renal involvement in vasculitis varies among different syndromes. It is more frequent in Wegener's granulomatosis and microscopic polyarteritis, while it is uncommon to rare in other forms of vasculitis such as Behçet's disease and relapsing polychondritis. The vessels affected include the renal artery in Takayasu arteritis, medium-size renal parenchymal artery in classic polyarteritis nodosa, and glomerular involvement in Wegener's granulomatosis and microscopic polyarteritis. The clinical expression of renal vasculitis depends on the size of the affected vessels and includes renovascular hypertension, isolated nonnephrotic proteinuria, interstitial nephritis, and glomerulonephritis, which can be rapidly progressive. Diagnosis is established by a combination of history, clinical manifestations, laboratory findings (eg, urine sediment, urine protein, antineutrophil cytoplasmic antibodies), imaging techniques (renal angiography, especially when there is a suspicion of medium-to-large vessel disease, and chest radiograph), and finally, renal biopsy. Prognosis varies from unfavorable in the rapidly progressive glomerulonephritis of microscopic polyarteritis, which can lead to renal failure, chronic dialysis, and renal transplantation, to benign, as in the case of Henoch Schonlein purpura, in which the majority of patients recover. CONCLUSIONS The manifestations and prognosis of renal vasculitis range widely. Renal involvement greatly influences prognosis and dictates the need for early and prompt immunosuppressive therapy. Thus, the clinician should be alert for the timely diagnosis and treatment of renal vasculitis.
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Affiliation(s)
- Michael Samarkos
- 5th Department of Internal Medicine, Evangelismos Hospital, Athens, Greece.
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Abstract
Palpable purpura, the inflammation of blood vessels is the hallmark of vasculitis. It can be observed in a variety of settings, where vessels can be affected primarily or as a secondary event. Every patient with vasculitis should be considered to have a systemic disease unless proven otherwise. One or more systemic symptoms occur in at least 50% of patients and there is no way to predict systemic involvement. Patients may demonstrate mild systemic involvement like arthralgia and arthritis, fever and malaise or more severe symptoms such as massive proteinuria and raised creatinine leading to chronic renal failure, severe intestinal bleeding or perforation with a fatal outcome. In this article we will review the life-threatening aspects of purpura and vasculitis.
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Affiliation(s)
- Andreas Katsambas
- Department of Dermatology, Andreas Sygros Hospital, University of Athens, Greece.
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Tur BS, Süldür N, Ataman S, Tutkak H, Atay MB, Düzgün N. Anti-neutrophil cytoplasmic antibodies in patients with rheumatoid arthritis: clinical, biological, and radiological correlations. Joint Bone Spine 2004; 71:198-202. [PMID: 15182790 DOI: 10.1016/j.jbspin.2003.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2003] [Accepted: 04/23/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and the associations of anti-neutrophil cytoplasmic antibodies (ANCA) and subtypes with clinical, biological, and radiological findings in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS This is a transversal study of 85 patients with RA (followed in Ibn-i Sina Hospital, Ankara University School of Medicine) with disease duration of 8.7 +/- 6.4 years. Besides clinical, biological, and radiological disease activity parameters, ANCA and ANCA against myeloperoxidase (MPO) and proteinase 3 (PR3) were examined. RESULTS The prevalence of ANCA, perinuclear ANCA (p-ANCA) and atypical ANCA (a-ANCA) were 18% (15/85 patients), 6% and 12%, respectively. Anti-MPO was found in six patients while anti-PR3 was not found. No significant association could be found between clinical, biological, and radiological disease activity assessments and ANCA (including indirect immunoflorescence subtypes). Similarly, ANCA were not associated with features suggestive of underlying vasculitis (noticed in 11/85 patients), and/or other extra-articular features. CONCLUSIONS Our results confirm that ANCA of various specificities (mainly a-ANCA) occur in a minority of RA. However, those ANCA were not associated with more severe RA, including the 6/85 patients positive for MPO (who were all free from vasculitis). The over-representation in RA sera of a-ANCA, as compared to p-ANCA, should be further studied.
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Affiliation(s)
- Birkan Sonel Tur
- Department of Physical Medicine and Rehabilitation, Ankara University School of Medicine, Ankara, Turkey.
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Wiik AS, Gordon TP, Kavanaugh AF, Lahita RG, Reeves W, van Venrooij WJ, Wilson MR, Fritzler M. Cutting edge diagnostics in rheumatology: The role of patients, clinicians, and laboratory scientists in optimizing the use of autoimmune serology. Arthritis Care Res (Hoboken) 2004; 51:291-8. [PMID: 15077275 DOI: 10.1002/art.20229] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
BACKGROUND Pathologically expressed autoantibodies reflect ongoing immune-mediated inflammation in patients and may even be regarded as surrogate markers of disease prognosis and clinical outcome in certain clinical settings. MATERIALS AND METHODS The most appropriate way to decide about autoantibody testing is to set a tentative diagnosis before ordering a few clinically relevant autoantibody screening tests and then follow locally agreed rules for continued testing. RESULTS Different algorithms were applied considering both the possibility to obtain an initial tentative diagnosis by the clinician and another strategy to be adopted when the clinical information cannot be obtained. CONCLUSIONS Guidelines can only be formulated by close collaboration between clinical and laboratory experts that reach agreement on testing and reporting strategies and thereby ensure the highest possible compliance with both local and international recommendations for diagnostics.
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Affiliation(s)
- Allan S Wiik
- Department of Autoimmunology, Statens Serum Institut, Bldg. 81, 5th floor, Room 544, Artillerivej 5, DK-2300 Copenhagen S., Denmark.
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Fritzler MJ, Wiik A, Fritzler ML, Barr SG. The use and abuse of commercial kits used to detect autoantibodies. Arthritis Res Ther 2003; 5:192-201. [PMID: 12823850 PMCID: PMC165068 DOI: 10.1186/ar782] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2003] [Revised: 05/01/2003] [Accepted: 05/06/2003] [Indexed: 11/21/2022] Open
Abstract
The detection of autoantibodies in human sera is an important approach to the diagnosis and management of patients with autoimmune conditions. To meet market demands, manufacturers have developed a wide variety of easy to use and cost-effective diagnostic kits that are designed to detect a variety of human serum autoantibodies. A number of studies over the past two decades have suggested that there are limitations and concerns in the use and clinical application of test results derived from commercial kits. It is important to appreciate that there is a complex chain of users and circumstances that contributes to variations in the apparent reliability of commercial kits. The goal of this review is to identify the principal links in this chain, to identify the factors that weaken the chain and to propose a plan of resolution. It is suggested that a higher level of commitment and partnership between all of the participants is required to achieve the goal of improving the quality of patient care through the use of autoantibody testing and analysis.
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Mareen P, Van De Walle S, Bernaert P, Vanhouteghem H, Dierick J. Antineutrophil cytoplasmic antibodies (ANCA) and small vessel vasculitis. Acta Clin Belg 2003; 58:193-200. [PMID: 12945480 DOI: 10.1179/acb.2003.58.3.008] [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] [Indexed: 10/31/2022]
Abstract
We report on one patient with Wegener's granulomatosis (WG) and two patients with microscopic polyangiitis (MPA). The patient with WG had signs of a respiratory infection and showed a c-ANCA pattern with proteinase 3 (PR3) specificity. The patients with MPA presented with pulmonary haemorrhage and signs of renal damage and showed a p-ANCA pattern with myeloperoxidase (MPO) specificity. In the three patients histopathological findings confirmed the diagnosis. We discuss the clinical indications of ANCA testing and the current terminology for reporting ANCA results (c-ANCA, p-ANCA, c-ANCA (atypical) and atypical ANCA). The target antigens and diseases associated with these different patterns are considered. Finally we focus on the value of ANCA and more specific PR3-ANCA and MPO-ANCA in the diagnosis of WG and MPA. The new application domain of ANCA in Crohn's disease and ulcerative colitis is also discussed.
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Affiliation(s)
- P Mareen
- Ziekenhuis Maria Middelares Sint-Jozef, Kortrijksesteenweg 1026, 9000 Gent
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Jara LJ, Vera-Lastra O, Calleja MC. Pulmonary-renal vasculitic disorders: differential diagnosis and management. Curr Rheumatol Rep 2003; 5:107-15. [PMID: 12628041 DOI: 10.1007/s11926-003-0038-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary-renal syndrome (PRS) is a combination of diffuse pulmonary hemorrhage and glomerulonephritis. Pulmonary-renal syndrome is not a single entity and is caused by a variety of conditions, including Goodpasturés syndrome associated with autoantibodies to the glomerular and alveolar basement membranes, various forms of primary systemic vasculitis associated with serum positivity for antineutrophil cytoplasmic antibodies (ANCA), cryoglobulinemia, systemic lupus erythematosus, systemic sclerosis, antiphospholipid syndrome, environmental factors, and drugs. The majority of cases of PRS are associated with ANCAs. The antigen target in Goodpasturés syndrome is the alpha-3 chain of type IV collagen. The antigen target in PRS associated with systemic vasculitis is proteinase-3 and myeloperoxidase. Pulmonary-renal syndrome has been observed from the first to the ninth decade of life. The widespread adoption of serologic testing performed in an appropriate clinical context hopefully will limit diagnostic delay. The goals of treatment in PRS are to remove the circulating antibodies, to stop further production of autoantibodies, and to remove any antigen that stimulates antibody production. Treatment is based on plasmapheresis, steroids, and cyclophosphamide; however, infections are frequent contributors to death, and less toxic alternatives may improve outcome and prognosis resulting in a long-term survival. The degree of renal function and the percent of crescents on renal biopsy are better predictors of outcome. Renal transplantation can be safely carried out in PRS.
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Affiliation(s)
- Luis J Jara
- Clinical Research Unit and Rheumatology Department, Hospital de Especialidades, Centro Medico La Raza, Mexico City, CP 02990, Mexico.
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Abstract
UNLABELLED Vasculitis can range in severity from a self-limited single-organ disorder to a life-threatening disease with the prospect of multiple-organ failure. This condition presents many challenges to the physician, including classification and diagnosis, appropriate laboratory workup, treatment, and the need for careful follow-up. The physician must not only be able to recognize vasculitis but also be able to provide a specific diagnosis (if possible) as well as recognize and treat any underlying etiologic condition. Most diagnostic criteria are based on the size of vessel involvement, which often correlates with specific dermatologic findings. This may allow the dermatologist to provide an initial diagnosis and direct the medical evaluation. This article reviews the classification and diagnosis of cutaneous vasculitic syndromes and current treatment options; it also presents a comprehensive approach to diagnosing and treating the patient with suspected cutaneous vasculitis. (J Am Acad Dermatol 2003;48:311-40.) LEARNING OBJECTIVE At the completion of this learning activity, participants should be familiar with the classification and clinical features of the various forms of cutaneous vasculitis. They should also have a rational approach to diagnosing and treating a patient with vasculitis.
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MESH Headings
- Drug Therapy, Combination
- Female
- Humans
- Incidence
- Male
- Prognosis
- Risk Factors
- Severity of Illness Index
- Skin Diseases, Vascular/diagnosis
- Skin Diseases, Vascular/drug therapy
- Skin Diseases, Vascular/epidemiology
- Vasculitis/diagnosis
- Vasculitis/drug therapy
- Vasculitis/epidemiology
- Vasculitis, Leukocytoclastic, Cutaneous/diagnosis
- Vasculitis, Leukocytoclastic, Cutaneous/drug therapy
- Vasculitis, Leukocytoclastic, Cutaneous/epidemiology
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Affiliation(s)
- David F Fiorentino
- Department of Dermatology, Stanford University School of Medicine, CA 94305, USA.
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Wiik A. Autoantibodies in vasculitis. Arthritis Res Ther 2003; 5:147-52. [PMID: 12723981 PMCID: PMC165052 DOI: 10.1186/ar758] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2003] [Revised: 03/05/2003] [Accepted: 03/14/2003] [Indexed: 11/10/2022] Open
Abstract
Before the mid-1980s the only autoantibody widely used to assist in diagnosing vasculitic disease was IgG antibody to the alpha(3) domain of the noncollagenous part of type IV collagen (anti-glomerular basement membrane). Since that time, antineutrophil cytoplasmic antibodies (ANCAs) directed at the azurophilic granule proteins proteinase-3 and myeloperoxidase have been established as clinically useful autoantibodies to support a diagnosis of Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and limited forms of these primary, small vessel necrotizing and often granulomatous vasculitides. The establishment of standardized methods for identifying those antibodies was needed before they could be used in clinical practice. The levels of both types of ANCAs tend to increase in parallel with the degree of clinical disease activity, and they decrease with successful immunosuppressive therapy. More than one assay may have to be used to discover imminent exacerbations in proteinase-3-ANCA associated syndromes. Although autoantibodies to endothelial cells may be important players in the pathogenesis of several vasculitic conditions, they have not gained clinical popularity because of lack of standardized detection methods.
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Affiliation(s)
- Allan Wiik
- Department of Autoimmunology, Statens Serum Institut, Copenhagen, Denmark.
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