Systemic lupus erythematosus coronary vasculitis demonstrated on cardiac computed tomography

Coronary Artery Aneurysm in Kawasaki Disease: Coronary CT Angiography through the Lens of Pathophysiology and Differential Diagnosis

Kawasaki disease (KD) is an inflammatory autoimmune vasculitis affecting the coronary arteries of very young patients, which can result in coronary artery aneurysms (CAAs) with lifelong manifestations. Accurate identification and assessment of CAAs in the acute phase and sequentially during the chronic phase of KD is fundamental to the treatment plan for these patients. The differential diagnosis of CAA includes atherosclerosis, other vasculitic processes, connective tissue disorders, fistulas, mycotic aneurysms, and procedural sequelae. Understanding of the initial pathophysiology and evolutionary arterial changes is important to interpretation of imaging findings. There are multiple applicable imaging modalities, each with its own strengths, limitations, and role at various stages of the disease process. Coronary CT angiography is useful for evaluation of CAAs as it provides assessment of the entire coronary tree, CAA size, structure, wall, and lumen characteristics and visualization of other cardiothoracic vasculature. Knowledge of the natural history of KD, the spectrum of other conditions that can cause CAA, and the strengths and limitations of cardiovascular imaging are all important factors in imaging decisions and interpretation. Keywords: Pediatrics, Coronary Arteries, Angiography, Cardiac © RSNA, 2021.

Lupus Vasculitis: An Overview

Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.

Pediatric-onset systemic lupus erythematosus with coronary artery dilation: A case report

INTRODUCTION

Though pediatric-onset systemic lupus erythematosus (SLE) is at high risk of coronary artery involvement, coronary artery dilation appears to be a rare characteristic of pediatric-onset SLE. In this article, we described 1 pediatric-onset SLE patient with coronary artery dilation at the diagnosis of SLE, in order to better diagnose and manage this cardiac complication of SLE in children.

PATIENT CONCERNS

A 13-year-old boy was admitted in hospital for daily fevers with the highest temperature of 39.2°C over 10 days, with rash, non-exudative conjunctivitis, cervical adenopathy, knee, and ankle arthralgi. The result of echocardiogram implicated coronary artery dilation and aortic regurgitation. Further laboratory tests showed: Coomb's test (+), decreased C3 complement. The results of immunologic tests were only to find ANA (+) with titer 1:3200, ds-DNA (+).

DIAGNOSIS

This patient was diagnosed as SLE complicated with coronary artery dilation.

INTERVENTIONS

The patient was treated with intravenous methylprednisolone pulse therapy. He was discharged home on prednisone maintain treatment.

OUTCOMES

As soon as treatment, his temperature returned to normal, with recovery of rash, conjunctivitis, knee, and ankle arthralgi. However, the echocardiogram of this patient after 3 months also had dilation of left coronary artery (LCA) and right coronary artery (RCA).

CONCLUSIONS

Cardiac complication can occur during the entire course of SLE, suggesting that routine echocardiogram surveillance may be necessary for all SLE patients to prevent morbidity and mortality from cardiovascular events.

A case report of heart transplant for ischaemic cardiomyopathy from lupus coronary vasculitis

Background

Coronary vasculitis is a rare, life-threatening complication of systemic lupus erythematosus (SLE).

Case summary

A 23-year-old woman with SLE presented with typical angina and worsening dyspnoea on exertion. Coronary angiography revealed severe triple vessel disease with a ‘string of beads’ appearance classic for coronary vasculitis. Transthoracic echocardiogram revealed ejection fraction of 25–30% with a severely hypokinetic distal septum and distal anterior wall and an akinetic apical wall. Despite vasculitis treatment with cyclophosphamide and pulse-dose steroids, her coronary vasculitis did not improve. She was refractory to anti-anginal and guideline-directed medical therapy for heart failure and successfully underwent orthotopic heart transplant (OHT).

Discussion

This is the first reported case of OHT in the case of SLE coronary vasculitis. Chronic SLE coronary vasculitis is caused by lymphocyic infiltration leading to inflammation and fibrosis of the major epicardial coronary arteries but can be successfully managed with OHT when refractory to medical SLE and heart failure therapies. It can affect patients of all ages with SLE, emphasizing the importance of thorough history taking and clinical evaluation in young patients presenting with cardiac symptoms to establish an appropriate diagnosis and treatment plan.

Abnormalities of the Coronary Arteries in Children: Looking beyond the Origins

Coronary arterial abnormalities are uncommon findings in children that have profound clinical implications. Although anomalies of the coronary origins are well described, there are many other disease processes that affect the coronary arteries. Immune system-mediated diseases (eg, Kawasaki disease, polyarteritis nodosa, and other vasculiditides) can result in coronary arterial aneurysms, strictures, and abnormal tapering of the vessels. Because findings at imaging are an important component of diagnosis in these diseases, the radiologist's understanding of them is essential. Congenital anomalies may present at varying ages, and findings in hemodynamically significant anomalies, such as fistulas, are key for both diagnosis and preoperative planning. Pediatric heart surgery can result in wide-ranging postoperative imaging appearances of the coronary arteries and also predisposes patients to a multitude of complications affecting the heart and coronary arteries. In addition, although rare, accidental trauma can lead to injury of the coronary arteries, and awareness and detection of these conditions are important for diagnosis in the acute setting. Patients with coronary arterial conditions at presentation may range from being asymptomatic to having findings of myocardial infarction. Recognition of the imaging findings is essential to direct appropriate treatment. ^©RSNA, 2017.

Connective Tissue Disorder-Associated Vasculitis

Vasculitides secondary to connective tissue diseases are classified under the category of 'vasculitis associated with systemic disease' in the revised International Chapel Hill Consensus Conference (CHCC) nomenclature. These secondary vasculitides may affect any of the small, medium or large vessels and usually portend a poor prognosis. Any organ system can be involved and the presentation would vary depending upon that involvement. Treatment depends upon the type and severity of presentation. In this review, we describe secondary vasculitis associated with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, relapsing polychondritis, systemic sclerosis, Sjogren's syndrome and idiopathic inflammatory myositis, focusing mainly on recent advances in the past 3 years.