VASCULITIS ASSOCIATED WITH CONNECTIVE TISSUE DISORDERS

Vasculitis in Juvenile-Onset Systemic Lupus Erythematosus

Juvenile-onset systemic lupus erythematosus (JSLE) is a rare, heterogeneous multisystem autoimmune disease that can affect any organ, and present with diverse clinical and serological manifestations. Vasculitis can be a feature of JSLE. It more commonly presents as cutaneous vasculitis than visceral vasculitis, which can affect the central nervous system, peripheral nervous system, lungs, gut, kidneys, heart, and large vessels. The incidence and prevalence of vasculitis in JSLE has not been well described to date. Symptoms of vasculitis can be non-specific and overlap with other features of JSLE, requiring careful consideration for the diagnosis to be achieved and promptly treated. Biopsies are often required to make a definitive diagnosis and differentiate JSLE related vasculitis from other manifestations of JSLE, vasculopathies, and JSLE related antiphospholipid syndrome. Visceral vasculitis can be life threatening, and its presence at the time of JSLE diagnosis is associated with permanent organ damage, which further highlights the importance of prompt recognition and treatment. This review will focus on the presentation, diagnosis, management and outcomes of vasculitis in JSLE, highlighting gaps in the current evidence base.

Anti-tubulin-α-1C autoantibody in systemic lupus erythematosus: a novel indicator of disease activity and vasculitis manifestations

A variety of autoantibodies has been involved in the pathogenesis of systemic lupus erythematosus (SLE), some of which are well known and applied as disease biomarkers. This study aimed to determine the prevalence of a novel autoantibody, anti-tubulin-α-1C, in patients with SLE and investigate its clinical significance. Anti-tubulin-α-1C autoantibody levels were determined by enzyme-linked immunosorbent assay (ELISA) in 128 SLE patients, 38 primary Sjögren's syndrome (pSS) patients, and 106 healthy controls (HCs).White blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), IgM, IgG, C3, C4, RF, ANA, dsDNA, Sm, AnuA, aCL, anti-SSA, and anti-SSB were measured by standard laboratory techniques. SLE Disease Activity Index (SLEDAI) was evaluated accordingly. Anti-tubulin-α-1C antibody levels were significantly increased in SLE patients. Elevated anti-tubulin-α-1C were correlated with higher levels of SLEDAI, increased titers of anti-Sm antibody, and decreased titers of anti-dsDNA antibody and significantly associated with cutaneous and mucosal vasculitis and milder renal involvement. Anti-tubulin-α-1C may become a novel biomarker indicative of active vasculitis in SLE and could be applied in future clinical practice.

Acute ischemia after revision hallux valgus surgery leading to amputation

Acute arterial insufficiency after revision hallux valgus surgery is a rare complication. The identification of surgical candidates who are at risk of vascular complications is of utmost importance. The patient-reported symptoms and physical findings combined with noninvasive vascular studies are generally reliable to assess the vascular status but can fail to identify patients with atypical disease patterns. We present the case of a patient with normal pulses who underwent revision hallux valgus surgery, leading to gangrene of the hallux that required transmetatarsal amputation. We reviewed the vascular evaluation methods and causes of acute ischemia after surgery, including vasculitis.

Juvenile idiopathic arthritis-its rare presentation

The authors report a case of systemic onset juvenile idiopathic arthritis who presented with fever, excruciating neck pain and stiffness followed by respiratory difficulty after few days of onset of illness. The unusual features of the case were: cervical spondylitis without any peripheral joint involvement, myocarditis leading to congestive cardiac failure, though pericarditis being the common cardiovascular manifestation of SOJIA was also associated.

Follistatin-like protein 1 is elevated in systemic autoimmune diseases and correlated with disease activity in patients with rheumatoid arthritis

Introduction

Follistatin-like protein 1 (FSTL1) is a proinflammation mediator implicated in arthritis in rodent animal models. The present study is aimed at assessing FSTL1 levels in systemic autoimmune diseases and correlating them with disease activity in patients with rheumatoid arthritis (RA).

Methods

Serum FSTL1 levels from 487 patients with systemic autoimmune diseases and 69 healthy individuals were measured by enzyme-linked immunosorbent assay (ELISA). FSTL1 expression in synovial fluid (SF) and synovial tissues (STs) was determined by ELISA, immunohistochemistry, real-time polymerase chain reaction (RT-PCR) and western blot analysis in RA patients and trauma controls. FSTL1 levels in fibroblast-like synoviocytes (FLSs) from RA patients were determined by real-time PCR and western blot analysis.

Results

Serum FSTL1 levels were significantly elevated in patients with RA, ulcerative colitis, systemic lupus erythematosus, Sjögren's syndrome (SS), systemic sclerosis and polymyositis/dermatomyositis. Serum FSTL1 levels in the RA and secondary SS patients were substantially higher than those in other patients. Serum FSTL1 levels were increased in early RA, rheumatoid factor (RF)- and anti-cyclic citrullinated peptide antibody (ACPA)-negative patients compared to healthy controls. Moreover, serum FSTL1 concentrations were significantly higher in long-standing RA patients than in early RA patients and in the RF- and ACPA-positive RA patients than in RF- and ACPA-negative RA patients. Elevated FSTL1 levels in the STs and SF of RA patients were also observed. FSTL1 levels in serum were markedly higher than those in SF in RA patients. The strongest FSTL1 staining was detected in the cytoplasm of synovial and capillary endothelial cells from RA synovium. Furthermore, FSTL1 was induced in FLSs by inflammatory mediators. Importantly, serum FSTL1 levels were correlated with several important biologic and clinical markers of disease activity, including erythrocyte sedimentation rate, C-reactive protein, RF, ACPA, swollen joint count, patient global visual analogue scale score and Disease Activity Score 28 in the adult RA patient population. Notably, serum FSTL1 levels were significantly diminished following successful treatment and clinical improvement.

Conclusions

Elevated FSTL1 levels reflect not only joint diseases but also inflammation and tissue degradation in systemic autoimmune diseases. Serum FSTL1 levels may thus serve as a serological inflammatory marker of disease activity in RA patients.

Juvenile idiopathic arthritis with peripheral gangrene

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disorder of the childhood and is manifested by synovitis with or without systemic features. Secondary vasculitis occurring in response to JIA is reflected clinically on different structures or systems of the body. Here is reported a rare case of systemic onset JIA (SOJIA) with vasculitis leading to peripheral gangrene.

Severe Proximal Myopathy and Mononeuritis Multiplex in Rheumatoid Arthritis

Vascular injury is considered to be a key finding in the pathogenesis of rheumatoid arthritis (RA). Manifestations are varied depending on the vessel size and the organ system involved. Vasculitis leading to symptomatic inflammatory myositis is a rare complication of RA. We describe a 62-year-old man with seropositive erosive RA of 1-year duration, who presented with severe proximal weakness and mononeuritis multiplex. His joint disease was clinically mild at the time of presentation. Creatine kinase was normal and the electromyogram did not suggest myopathy. However, muscle biopsy revealed extensive small vessel vasculitis and severe inflammatory myositis. This report emphasizes the importance of fully evaluating patients with RA who present with proximal myopathy. The myopathy in our patient was not related to active joint disease, disuse atrophy, or complication of therapy. Rheumatoid vasculitis leading to myositis is a rare and not well-recognized complication of RA for which aggressive immunosuppressive therapy is warranted.

Vasculitis in systemic lupus erythematosis

Vasculitis in connective tissue diseases is not an uncommon complication. Vasculitis complicates both rheumatoid arthritis and systemic lupus erythematosis (SLE) in about 4% of cases. Cutaneous lesions, representing small-vessel involvement, are most common; however, widespread, necrotizing visceral medium-and large-vessel involvement, mimicking primary vasculitic syndromes, may also occur. Connective tissue disease-associated vasculitis is separated from primary vasculitis syndromes in classification schemes. Granulomatous large-vessel disease does not occur in connective tissue diseases, suggesting a different pathogenesis. In most disorders, the etiology of vascular inflammation in not completely understood, but basic pathogenic mechanisms can often be distinguished. The role of immune complexes in the inflammatory manifestations of SLE is recognized, and other pathogenic factors such as antineutrophil cytoplasmic antibodies, common in other vasculitides, are infrequent. A diverse spectrum of clinical features, due to inflammatory involvement of arterial and venous vessels of all sizes, characterize several connective tissue diseases including Behçet's disease and SLE. The recognition of disease manifestations due to vasculitis in these disorders has important implications for treatment and may be critical to reduce morbidity and mortality.

Vasculitis Following Treatment of Rheumatoid Arthritis with Extracorporeal Staphylococcal Protein A Immunoadsorption Column (Prosorba)

We report a case of vasculitis after Prosorba treatment in a patient with rheumatoid arthritis. The patient is a 66-year-old white male with long standing rheumatoid arthritis and hepatitis B. He was treated with the standard regimen for Prosorba treatment. He improved and met criteria for an American College of Rheumatology (ACR) 20% response. While on therapy he developed a nonhealing ulcer. Approximately 2 weeks after treatment was completed, he developed palpable purpura and mononeuritis multiplex. Deep dermal biopsy confirmed the presence of both small and medium vessel vasculitis. Nerve conductions studies were consistent with neuropathic conduction delays. He was treated with 1mg/kg/day of oral prednisone. Prosorba has been reported to cause leukocytoclastic vasculitis during treatment, but has not been noted to involve medium sized vessels. This patient's history and presentation are most consistent with rheumatoid arthritis associated vasculitis, though the Prosorba treatment cannot be ruled out as a cause or a contributing factor. Importantly, although Prosorba treated his synovitis, it did not prevent concomitant vasculitis.

Vasculitis in the connective tissue diseases

Vasculitides in the setting of connective tissue diseases are generally thought to be infrequent and relatively little is written about them. They are, however, important both because they may pose diagnostic and therapeutic challenges and affect prognosis. In each of the connective tissue diseases, vasculitis can present in various clinical and pathologic forms adding to their diagnostic and therapeutic difficulties. This article reviews recent information on the frequency, characteristics, and possible pathogenic mechanisms of the vasculitides occurring in patients with the main connective tissue diseases.

Henoch-Schönlein purpura as clinical presentation of a myelodysplastic syndrome

Small-vessel vasculitis may be a paraneoplastic syndrome. It may be associated with haematologic malignancies and less frequently with solid tumors. We describe a patient with myelodysplastic syndrome presenting as Henoch-Schönlein Purpura. To our knowledge this association has not previously reported.

Vasculitis associated with connective tissue disease

Vasculitis, one of the clinical features shared by connective tissue diseases, should be considered when signs and symptoms are observed that may result from tissue ischaemia due to damaged vessels. The lesions seem to result from specific and non-specific immunopathogenic mechanisms targeted at the vascular endothelium. Because of the therapeutic implications it is the physician's responsibility to document its presence and the extent of organ involvement. Prompt institution of immunosuppressive drugs may be lifesaving. On the other hand there are some forms of vasculitis accompanying connective tissue disease which are entirely benign. Patients with infarctions of extremities and progressive functional disturbances of the central nervous system or internal organs because of vasculitis should be treated with high dosages of corticosteroids in combination with cytostatic drugs. Remissions are frequently obtained within three to six months of initiation of treatment and can be maintained with a less aggressive treatment regimen.

Behçet-type vasculopathy in a patient without the diagnostic features of Behçet's disease

Behçet's disease is a multisystem inflammatory disorder which may involve the vascular system. The vasculopathy of Behçet's disease is distinctive among the vasculitides in that it involves both arteries and veins, and vessels of all sizes. Most published diagnostic criteria for Behçet's disease include the classic triad of orogenital ulceration and ocular inflammation. In this report, we describe a patient who had a vasculopathy fitting the Behçet's disease type, but who lacked the other characteristic or diagnostic features of Behçet's disease. This case illustrates an unusual presentation and natural history of a complex vasculitic disease.