Diagnostic value of contrast-enhanced ultrasound in the activity of idiopathic retroperitoneal fibrosis: a retrospective study

OBJECTIVES

To explore the diagnostic value of contrast-enhanced ultrasound (CEUS) in the disease activity of idiopathic retroperitoneal fibrosis (IRPF).

METHODS

This retrospective study included 148 CEUS examinations from 63 patients with IRPF treated in our hospital from April 2016 to September 2021. They were divided into two groups: IRPF active group (69 examinations) and inactive group (79 examinations). Uni- and multivariable analyses were used to identify independent risk factors for IRPF activity. Receiver operating characteristic (ROC) curves were drawn to establish different diagnostic models to evaluate the diagnostic value of IRPF activity. The z test was used to compare the differences of the area under the curves (AUCs). The value of CEUS in evaluating the variation of disease activity over time was also investigated between repeat patient studies.

RESULTS

Univariate and multivariate logistic regression analyses revealed the thickness [odds ratio (OR) = 14.125, 95% confidence interval (CI) = 3.017-66.123] was the most significant independent risk factor for IRPF activity (P < 0.01). The best diagnostic model was model 3, which was established by CEUS score combined with thickness. The AUC was 0.944 (95%CI = 0.912-0.977), and the sensitivity and specificity were 89.86% and 86.08%, respectively. The diagnostic performance was not significantly improved after combining clinical symptom (back pain) and laboratory indicators [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]. Compared with before treatment, the CEUS score and thickness were significantly decreased after treatment (x2 = 14.580, P < 0.001 and z = 4.708, P < 0.001, respectively).

CONCLUSION

CEUS has good diagnostic value for IRPF disease activity. Key points • Thickness and contrast-enhanced ultrasound score were significantly higher in the active group than those in inactive group (P < 0.001). • With thickness of 4 mm and contrast-enhanced ultrasound 2 score as optimal cut-off values, the sensitivity and specificity were 89.86%, 81.01% and 52.17%, 100.00%, respectively. • During follow-up, when the disease progressed, the change of CEUS score was earlier than the change of thickness.

Ultrasonography and contrast-enhanced ultrasound for activity assessment in 115 patients with carotid involvement of Takayasu arteritis

OBJECTIVES

To evaluate the efficacy of ultrasound and contrast-enhanced ultrasound (CEUS) in disease activity assessment of Takayasu arteritis (TA) with carotid involvement.

METHODS

This is a cohort study of 115 patients of TA with carotid involvement. We investigated correlations between clinical data, sonographic features, and CEUS enhancement at the site most prominent lesion of each patient. Disease activity was assessed by the National Institute of Health Kerr criteria. Sonographic findings were compared with follow-up examinations. CEUS was repeated after a 3-7 months interval in 35 patients to evaluate change of CEUS enhancement after treatment.

RESULTS

Extensiveness of CEUS enhancement at most prominent carotid lesions had significant correlations with disease activity by the Kerr criteria (P < .001). The specificity of extensive enhancement for indicating active disease was 95%, while sensitivity was 67%. Patients with active disease showed greater arterial wall thickness and more prominent reduction of arterial wall thickness after treatment. Most of the patients (68%) with subsided active disease after treatment featured decrease of CEUS enhancement.

CONCLUSIONS

Extensiveness of enhancement by CEUS and arterial wall thickness by ultrasonography may be useful markers for initial and follow-up assessment of disease activity of TA with common carotid artery involvement.

A patient with Takayasu arteritis presenting with malignant hypertension: a case report

Background

Takayasu arteritis (TA) is a rare large-vessel vasculitis primarily affecting the aorta and its proximal branches. The manifestation of TA is variable, ranging from asymptomatic cases to severe organ dysfunction secondary to vascular damage, which often delays diagnosis.

Case summary

Here, we present a 37-year-old male patient suffering from visual impairment and malignant hypertension. Emergency fundoscopy showed large left subretinal bleeding and bilateral signs of hypertensive retinopathy. Echocardiographic and magnetic resonance imaging showed mildly reduced left ventricular ejection fraction and signs of hypertensive cardiomyopathy. Evaluation for secondary causes of arterial hypertension did not reveal an underlying disease, and the patient was discharged with optimal medical therapy. He was re-admitted after 11 days with fever of unknown origin, fatigue, and elevated inflammatory markers. The diagnosis of TA was finally established using ¹⁸F-fluorodeoxyglucose positron emission computed tomography scan and sonography of carotid and subclavian arteries. Anti-inflammatory combination therapy for active, severe TA with ophthalmologic involvement was initiated using high-dose glucocorticoids and the tumour necrosis factor alpha inhibitor adalimumab to minimize drug-related risks. The patient was scheduled for multidisciplinary follow-up appointments, including specialist consultation in rheumatology, angiology, cardiology, diabetology, and ophthalmology.

Discussion

This case highlights the diversity of initial symptoms, the challenges of TA diagnosis, and the importance of comprehensive evaluation for rare secondary causes of arterial hypertension. Individualized acute and long-term care necessitates multidisciplinary management of immunosuppressive therapy, secondary organ involvement, and concomitant diseases.

Cytokines, growth factors and proteases in medium and large vessel vasculitis

Giant cell arteritis and Takayasu arteritis are autoimmune vasculitides that cause aneurysm formation and tissue infarction. Extravascular inflammation consists of an intense acute phase response. Deeper understanding of pathogenic events in the vessel wall has highlighted the loss of tissue protective mechanisms, the intrusion of immune cells into "forbidden territory", and the autonomy of self-renewing vasculitic infiltrates. Adventitial vasa vasora critically control vessel wall access and drive differentiation of tissue-invasive T cells. Selected T cells establish tissue residency and build autonomous, self-sufficient inflammatory lesions. Pathogenic effector T cells intrude and survive due to failed immune checkpoint inhibition. Vasculitis-sustaining T cells and macrophages provide a broad portfolio of effector functions, involving heterogeneous populations of pro-inflammatory T cells and diverse macrophage subsets that ultimately induce wall capillarization and intimal hyperplasia. Redirecting diagnostic and therapeutic strategies from control of extravascular inflammatory markers to suppression of vascular inflammation will improve disease management.

Contrast-enhanced Ultrasonography for Monitoring Arterial Inflammation in Takayasu Arteritis

OBJECTIVE

To evaluate the utility of contrast-enhanced ultrasound (CEUS) compared with 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) in assessing vessel inflammation of Takayasu arteritis (TA).

METHODS

This is a retrospective analysis of 71 patients with TA who had undergone carotid CEUS. Twenty-two of 71 patients underwent FDG-PET after CEUS. Clinical disease activity was assessed by Kerr criteria and the Indian Takayasu Clinical Activity Score 2010 (ITAS2010). We investigated the correlation between carotid vascularization on CEUS and clinical data. The consistency of carotid CEUS and PET data has been analyzed for TA disease activity.

RESULTS

There was a statistically significant correlation between the results of CEUS and ITAS2010 (p = 0.004) or Kerr criteria (p < 0.001). According to ITAS2010, thirty-four of 71 patients with TA were clinically inactive. Assessment of 34 TA patients with clinically inactive disease yielded 11 CEUS scans that showed active lesions (visual grade ≥ 2) in the left or right carotid artery. In 22 cases that underwent CEUS and FDG-PET, 12 were active and 10 were inactive on the basis of ITAS2010. Moreover, bilateral carotid CEUS vascularization score positively correlated with vascular FDG uptake in these patients with TA (p = 0.004). When vascular inflammation was defined as FDG uptake with visual grade ≥ 2, carotid CEUS showed sensitivity of 100% and specificity of 80%.

CONCLUSION

For TA patients with clinically inactive disease, CEUS could help clinicians to identify active lesions in the carotid vascular region. Carotid CEUS may be a rapid and cost-effective imaging tool in the followup of patients with TA.

Investigations in systemic vasculitis - The role of imaging

Imaging plays an increasing role for confirming a suspected diagnosis of giant cell arteritis (GCA) or Takayasu arteritis (TAK). Ultrasound, magnetic resonance imaging (MRI), and computed tomography demonstrate a homogeneous, most commonly concentric, arterial wall thickening. 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) displays increased FDG uptake of inflamed artery walls delineating increased metabolism. Ultrasound and MRI are recommended to be the initial imaging modalities in cranial GCA and TAK, respectively. Extracranial disease can be confirmed by all four modalities, particularly by PET in case of inflammation of unknown origin. If the diagnosis remains uncertain, additional investigations including biopsy and/or additional imaging are recommended. Imaging should be performed by a trained specialist using appropriate operational procedures and settings with appropriate equipment. Further research is necessary on the role of imaging for disease monitoring. This review will discuss advantages and disadvantages of imaging modalities in the diagnosis of vasculitis.