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Wolff L, Horisberger A, Moi L, Karampetsou MP, Comte D. Polyarteritis Nodosa: Old Disease, New Etiologies. Int J Mol Sci 2023; 24:16668. [PMID: 38068989 PMCID: PMC10706353 DOI: 10.3390/ijms242316668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
Polyarteritis nodosa (PAN), also known as panarteritis nodosa, represents a form of necrotizing vasculitis that predominantly affects medium-sized vessels, although it is not restricted to them and can also involve smaller vessels. The clinical presentation is heterogeneous and characterized by a significant number of patients exhibiting general symptoms, including asthenia, fever, and unintended weight loss. Although PAN can involve virtually any organ, it preferentially affects the skin, nervous system, and the gastrointestinal tract. Orchitis is a rare but specific manifestation of PAN. The absence of granulomas, glomerulonephritis, and anti-neutrophil cytoplasmic antibodies serves to distinguish PAN from other types of vasculitis. Major complications consist of hemorrhagic and thrombotic events occurring in mesenteric, cardiac, cerebral, and renal systems. Historically, PAN was frequently linked to hepatitis B virus (HBV) infection, but this association has dramatically changed in recent years due to declining HBV prevalence. Current epidemiological research often identifies a connection between PAN and genetic syndromes as well as neoplasia. This article provides a comprehensive review of PAN, specifically focusing on the progression of its clinical manifestations over time.
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Affiliation(s)
- Louis Wolff
- Department of Internal Medicine, Hôpital Universitaire de Bruxelles (H.U.B.), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium;
| | - Alice Horisberger
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medicine, Division of Immunology and Allergy, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Laura Moi
- Immunology and Allergology, Institut Central des Hôpitaux, Valais Hospital, 1951 Sion, Switzerland;
| | | | - Denis Comte
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, 1005 Lausanne, Switzerland
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de la Motte MB, Abbas R, Jouan F, van Gysel D, Chauveheid MP, Papo T, Sacre K. Systemic inflammatory disorders in patients admitted for aseptic meningitis. Clin Med (Lond) 2018; 18:132-137. [PMID: 29626017 PMCID: PMC6303440 DOI: 10.7861/clinmedicine.18-2-132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute meningitis can be the first manifestation of an underlying systemic inflammatory disorder (SID). In the current study, we aimed to identify clinical indicators for SIDs in patients admitted for acute aseptic meningitis. All patients hospitalised for acute aseptic meningitis over a 4-year period in a department of internal medicine were included retrospectively. Patients with neoplastic meningitis were excluded. Extraneurological signs were recorded using a systematic panel. Systemic inflammatory disorder diagnosis was made according to current international criteria. Forty-three (average age 46 years [range 19-82 years], 60% females) consecutive patients were analysed retrospectively. Of these, 23 patients had an SID (mostly sarcoidosis and Behçet's disease). -Multiple logistic regression analysis showed that the probability of an SID was 93.7% in patients with both neurological and extraneurological signs, but 14.9% in patients with neither neurological nor extraneurological signs. In conclusion, clinical sorting according to both neurological and extraneurological signs could help to identify patients with acute aseptic meningitis caused by an SID.
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Abstract
The chapter describes the epidemiology of cerebrovascular diseases, anatomy of the cerebral blood vessels, pathophysiology of ischemia, hypoxia, hypoxemia, anemic hypoxia, histotoxic hypoxia, carbon monoxide damage, hyperoxid brain damage and decompression sickness, and selective cell and regional vulnerability; diseases of the blood vessels including atherosclerosis, hypertensive angiopathy, small vessel disease, inflammatory vascular diseases, cerebral amyloid angiopathies, CADASIL, CARASIL and other diseases that can lead to cerebrovascular occlusion; intracranial and intraspinal aneurysms and vascular malformations; hematologic disorders that can cause cerebral infarct or hemorrhage; brain ischemic damage; and spontaneous intracranial bleeding. Within ischemic brain damage, focal cerebral ischemia, hemorrhagic infarct, brain edema, penumbra, global cerebral ischemia, venous thrombosis, lacunas and lacunar state, status cribosus, granular atrophy of the cerebral cortex, hippocampal sclerosis, vascular leukoencephalopathy Binswanger type and multi-infarct encephalopathy are discussed in detail. Cognitive impairment of vascular origin deserves an individual section.
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Affiliation(s)
- Isidro Ferrer
- Pathologic Anatomy Service, Institute of Neuropathology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.
| | - Noemi Vidal
- Pathologic Anatomy Service, Institute of Neuropathology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
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Cohen Tervaert JW. What to do when you suspect your patient suffers from pulmonary vasculitis? EXPERT OPINION ON MEDICAL DIAGNOSTICS 2013; 7:1-4. [PMID: 23530839 DOI: 10.1517/17530059.2013.739604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Making a diagnosis of pulmonary vasculitis is challenging. The most common cause of pulmonary vasculitis is small vessel anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Pulmonary involvement in other forms of vasculitis such as large vessel vasculitis is rare. Since correct and timely diagnosis is pivotal to start (immunosuppressive) therapy to avoid vasculitic damage, a complete patient history should be obtained and a physical examination performed. Initial laboratory evaluation should include inflammation markers, renal and liver function tests, and the determination of ANCA. New developments in ANCA testing result in tests with excellent predictive value for the diagnosis of AAV-related pulmonary vasculitis. Consequently, ANCA should be tested with these tests of the so-called second (capture ELISA) or third (anchor ELISA) generation. In patients who are ANCA negative, a simple algorithm is presented based on laboratory evaluation of autoantibodies and 18F-FDG-PET-CT scanning. Such an algorithm may be useful for accelerating the diagnostic process needed to make a diagnosis of pulmonary vasculitis, or alternatively, to quickly exclude such a diagnosis.
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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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Abstract
Most frequent reasons for intensive care unit (ICU) admission in vasculitis patients are severe respiratory insufficiency due to diffuse alveolar haemorrhage, sepsis and/or pneumonia and an acute abdomen due to bowel infarction. Other reasons are massive gastrointestinal bleeding, thromboembolism and/or scissures. In a patient, not previously diagnosed as having vasculitis, diagnosis can be difficult and must be made as soon as possible, since immunosuppressive therapy should be instituted immediately. Immunosuppressive therapy in severe cases consists of high-dose corticosteroids and cyclophosphamide. In addition, in many cases plasma exchange has to be instituted as well. Prognosis is related to disease activity scores of vasculitis and of severity of illness as measured by the APACHE III scoring system and/or the SOFA score. Septic shock is still the leading cause of death in patients with vasculitis. Nowadays, death due to active untreated vasculitis is rare in experienced clinics.
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Affiliation(s)
- J W Cohen Tervaert
- Department of Clinical and Experimental Immunology, Univerity Hospital Maastricht, The Netherlands.
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Vasculitides. PRIMER ON THE RHEUMATIC DISEASES 2008. [PMCID: PMC7193731 DOI: 10.1007/978-0-387-68566-3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Despite the spatial closeness of blood vessels and inflammatory cells, blood vessel walls are infrequently targeted by inflammation. Giant cell arteritis (GCA) and Takayasu’s arteritis (TA) are characterized by inflammation directed against the vessel wall. GCA and TA display stringent tissue tropism and affect defined vascular territories in a preferential manner. GCA predominantly affects the second- to fifth-order aortic branches, often in the extracranial arteries of the head. The aorta itself may also be affected in GCA, albeit less often than other regions. In contrast, in TA, the aorta and its major branches are the prime disease targets.
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Pettigrew HD, Teuber SS, Gershwin ME. Polyarteritis Nodosa. ACTA ACUST UNITED AC 2007; 33:144-9. [DOI: 10.1007/s12019-007-0012-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 11/30/1999] [Accepted: 05/09/2007] [Indexed: 01/05/2023]
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Seror R, Mahr A, Ramanoelina J, Pagnoux C, Cohen P, Guillevin L. Central nervous system involvement in Wegener granulomatosis. Medicine (Baltimore) 2006; 85:53-65. [PMID: 16523054 DOI: 10.1097/01.md.0000200166.90373.41] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Wegener granulomatosis (WG) is an antineutrophil cytoplasmic antibody (ANCA)-associated granulomatous vasculitis of small and medium-sized vessels. This vasculitis involves mainly the upper and lower respiratory tracts and kidneys, although WG may affect any organ. Central nervous system (CNS) involvement is an uncommon manifestation of WG, reported in 7%-11% of patients. Three major mechanisms have been incriminated as causing CNS disease in WG: contiguous invasion of granuloma from extracranial sites, remote intracranial granuloma, and CNS vasculitis. Herein we describe 6 patients with WG-related CNS involvement, 2 of whom had chronic hypertrophic pachymeningitis, 3 with pituitary involvement, and 1 with cerebral vasculitis. CNS involvement was present at disease onset in 2 patients and occurred 5-18 years after WG diagnosis in the remaining 4. Based on these observations and a review of the literature, we discuss the pathogenic mechanisms, clinical features, imaging findings, treatment, and outcome of meningeal, pituitary, and vascular involvement, with an emphasis on differential diagnoses, prognosis, and therapeutic management of WG-related CNS involvement.
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Affiliation(s)
- Raphaèle Seror
- From Department of Internal Medicine, Hôpital Cochin, Université René-Descartes Paris 5, Assistance Publique-Hôpitaux de Paris, Paris, France
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Abstract
PURPOSE OF REVIEW Peripheral nervous system (PNS) involvement is of great diagnostic value in systemic vasculitides, because it occurs frequently and often early during the course of these diseases, despite the supposed blood-nerve barrier that should prevent or at least minimize PNS damage. However, it carries no poor prognostic value in vasculitides. Recent advances have been made in understanding the pathogenetic mechanisms of PNS involvement. RECENT FINDINGS Vasculitic neuropathy may result from primary or secondary systemic vasculitides, or may be restricted to the PNS, in a form that is now also considered to be a systemic vasculitis. The blood-nerve barrier is not as efficient as the blood-brain barrier. Inflammatory cell infiltration into the vasa nervorum and epineurial arteries leads to ischemic axonal nerve injury and is facilitated by additional breaches in the blood-nerve barrier, induced by proinflammatory cytokines, oxidative stress-derived molecules, and matrix metalloproteinases. Although animal models of myeloperoxidase or, now, proteinase 3-antineutrophil cytoplasmic autoantibody-inducing vasculitis have been developed, they do not support a role for antineutrophil cytoplasmic autoantibodies in PNS involvement. Treatment should be chosen based on the other organ involvement and the patient's general condition. When PNS involvement is isolated, corticosteroids alone should be used as first-line treatment. SUMMARY Apart from the so-called nonsystemic nerve vasculitis, PNS involvement is rarely the sole clinical sign of systemic necrotizing vasculitis, and its association with other typical manifestations is often suggestive of the diagnosis of vasculitis. Herein are summarized recent advances that have clarified but not yet fully elucidated the pathogenesis of peripheral neuropathy in systemic vasculitides, together with the latest clinical findings and therapeutic strategies.
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Affiliation(s)
- Christian Pagnoux
- Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris V, Paris, France.
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Stegeman CA, Kallenberg CG. Clinical aspects of primary vasculitis. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 2001; 23:231-51. [PMID: 11591100 DOI: 10.1007/s002810100079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- C A Stegeman
- Department of Internal Medicine/Division of Nephrology, University Hospital Groningen, Faculty of Medical Sciences, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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Appenzeller S, Kobayashi E, Costallat LT, Zanardi VD, Ribeiro Neto JM, Damasceno BP, Cendes F. Magnetic resonance imaging in the evaluation of patients with aseptic meningoencephalitis and connective tissue disorders. ARQUIVOS DE NEURO-PSIQUIATRIA 2000; 58:45-51. [PMID: 10770865 DOI: 10.1590/s0004-282x2000000100007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the role of magnetic resonance imaging (MRI) in the evaluation of patients with chronic and recurrent aseptic meningitis. METHOD A retrospective study of five patients with aseptic meningoencefalitis diagnosed by clinical and CSF findings. CT scans showed without no relevant findings. RESULTS MRI showed small multifocal lesions hyperintense on T2 weighted images and FLAIR, with mild or no gadolinium enhancement, mainly in periventricular and subcortical regions. Meningoencephalitis preceded the diagnosis of the underlying disease in four patients (Behçet's disease or systemic lupus erythematosus). After the introduction of adequate treatment for the rheumatic disease, they did not present further symptoms of aseptic meningoencephalitis. CONCLUSION Aseptic meningoencephalitis can be an early presentation of an autoimmune disease. It is important to emphasize the role of MRI in the diagnosis and follow-up of these patients.
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Affiliation(s)
- S Appenzeller
- Departamento de Neurologia, Faculdade de Ciências Médicas (FCM), Universidade Estadual de Campinas (UNICAMP)
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García-Porrúa C, González-Gay MA. Comparative clinical and epidemiological study of hypersensitivity vasculitis versus Henoch-Schönlein purpura in adults. Semin Arthritis Rheum 1999; 28:404-12. [PMID: 10406408 DOI: 10.1016/s0049-0172(99)80006-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the incidence and clinical features of adults with hypersensitivity vasculitis (HV) and Henoch-SchOnlein purpura (HSP) in a well-defined population. METHODS Retrospective study of an unselected population of adult patients (>20 years) with biopsy-proven cutaneous vasculitis diagnosed as having HV or HSP who presented at a primary hospital between 1988 and 1997. Patients with cutaneous vasculitis secondary to collagen vascular diseases, neoplasia, severe infections, and those with other well-defined clinical entities were excluded. Patients were classified as having either HV or HSP according to the criteria proposed by Michel et al (J Rheumatol 1992;19:721-28). RESULTS Fifty-six adults (35 men/21 women), were classified as having HV and 27 adults as having HSP (19 men/8 women). The annual incidence rate for HV was 29.7/million and 14.3/million for HSP. At the onset of the disease, adults with HSP were younger than those with HV (46+/-18 years versus 59+/-18 years in HV; P = .005). Precipitating events were found in 50% of HV and in 30% of HSP patients. A history of drug therapy before the onset of vasculitis was found in 46% of HV and in 26% of HSP (P = .074). At disease onset, skin lesions were the most common manifestation in both groups. During the disease course, adults with HSP had joint manifestations more commonly (59% in HSP v25% in HV; P < .003) and more gastrointestinal (82% v 5% in HV; P < .001) and renal complications (48% v 5% in HV; P < .001). HSP subjects required more aggressive therapy consisting of steroids (P < .001) or cytotoxic agents (P < .001). After 37+/-28 (median, 31) months, complete recovery was observed in 98% of adults with HV. After 40+/-27 (median, 36) months, complete recovery was observed in only 67% of adults with HSP (P < .001). Renal insufficiency was observed in 8% of adults with HSP. CONCLUSIONS In adults, HV and HSP as defined by these criteria, behave as two well-differentiated diseases. HV has a milder course and lack of severe complications, and HSP a higher risk of gastrointestinal and renal complications.
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Abstract
Polyarteritis nodosa (PAN), first described by Küssmaul and Maier, is a well-known form of necrotizing angiitis whose manifestations are weight loss, fever, asthenia, peripheral neuropathy, renal involvement, musculoskeletal and cutaneous manifestations, hypertension, gastrointestinal tract involvement, and cardiac failure. Recently individualized from PAN, microscopic polyangiitis (MPA) is a systemic vasculitis of small-size vessels whose clinical manifestations are very similar to those of PAN, but it is characterized by the presence of rapidly progressive glomerulonephritis (RPGN), which is nearly constant, and pulmonary involvement usually absent in PAN. Churg Strauss syndrome (CSS) is a disorder characterized by hypereosinophilia and systemic vasculitis similar to that of PAN and occurring in individuals with asthma and allergic rhinitis. Considering the etiologies of PAN, primary and secondary vasculitides can also be distinguished because PAN can be the consequence of hepatitis B virus (HBV) infection and sometimes of other etiologic agents. The prognosis of systemic vasculitides has been transformed by corticosteroids that are, except in HBV-related PAN, the basic treatment. Immunosuppressive drugs, especially cyclophophamide, have also contributed to improving the prognosis, but their precise role in the management of these vasculitides is still being elucidated.
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Affiliation(s)
- F Lhote
- Hôpital Delafontaine, Saint-Denis, France
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Linardaki G, Skopouli FN, Koufos C, Moutsopoulos HM. Subclinical multisystemic autoimmunity presenting as a progressive myelopathy. Lupus 1997; 6:675-7. [PMID: 9364427 DOI: 10.1177/096120339700600809] [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: 02/05/2023]
Abstract
Autoimmunity can manifest clinically in many ways; however, despite the various efforts to classify autoimmune disorders into specific disease entities, the borders between these disorders remain, in many cases, unclear. In this report we describe a young woman with subclinical Sjögren's syndrome and biliary cirrhosis, who presents clinically with symptoms exclusively from the central nervous system. This neurological syndrome is consistent with a progressive myelopathy. Although the patient has a serologically and histologically confirmed multisystemic autoimmune disorder, she fulfills none of the classification criteria for the diagnosis of a specific connective tissue disease.
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Affiliation(s)
- G Linardaki
- Department of Pathophysiology, Laiko General Hospital, School of Medicine, National University of Athens, Greece
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Guillevin L, Lhote F, Gherardi R. Polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: clinical aspects, neurologic manifestations, and treatment. Neurol Clin 1997; 15:865-86. [PMID: 9367969 DOI: 10.1016/s0733-8619(05)70352-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Polyarteritis nodosa (PAN), microscopic polyangiitis (MPA), and Churg-Strauss syndrome (CSS) all have neurologic symptoms and share characteristics and outcomes. Clinical aspects, neurologic manifestations, and treatment of these three diseases are examined in this article.
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Affiliation(s)
- L Guillevin
- Service de Medecine Interne, Hopital Avicenne, Faculté de Medecine Paris-Nord, Bobigny, France
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Abstract
Necrotizing vasculitis of the type in polyarteritis nodosa is a treatable cause of neuropathy. The diagnosis must be confirmed histologically by demonstration of characteristic arterial lesions in nerve and muscle biopsy specimens. Ischemic neuropathy which results from occlusion of nerve arteries in polyarteritis nodosa also occurs as a consequence of inflammatory arterial lesions in other connective tissue disorders, in some infectious neuropathies and in patients with malignant lymphomas. Patients with vasculitic neuropathy may also present with isolated peripheral neuropathy.
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Affiliation(s)
- G Said
- Service de Neurologie, Hopital de Bicetre, Universite Paris Sud, Paris, France
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Lhote F, Guillevin L. POLYARTERITIS NODOSA, MICROSCOPIC POLYANGIITIS, AND CHURG-STRAUSS SYNDROME. Rheum Dis Clin North Am 1995. [DOI: 10.1016/s0889-857x(21)00479-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lie JT. Nomenclature and classification of vasculitis: plus ça change, plus c'est la même chose. ARTHRITIS AND RHEUMATISM 1994; 37:181-6. [PMID: 8129772 DOI: 10.1002/art.1780370205] [Citation(s) in RCA: 150] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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