Serial high-resolution computed tomography imaging in patients with Wegener granulomatosis: differentiation between active inflammatory and chronic fibrotic lesions

Advances in Therapies and Imaging for Systemic Vasculitis

Vasculitis is a systemic disease characterized by immune-mediated injury of blood vessels. Current treatments for vasculitis, such as glucocorticoids and alkylating agents, are associated with significant side effects. Furthermore, the management of both small and large vessel vasculitis is challenging because of a lack of robust markers of disease activity. Recent research has advanced our understanding of the pathogenesis of both small and large vessel vasculitis, and this has led to the development of novel biologic therapies capable of targeting key cytokine and cellular effectors of the inflammatory cascade. In parallel, a diverse range of imaging modalities with the potential to monitor vessel inflammation are emerging. Continued expansion of combined structural and molecular imaging using positron emission tomography with computed tomography or magnetic resonance imaging may soon provide reliable longitudinal tracking of vascular inflammation. In addition, the emergence of radiotracers able to assess macrophage activation and immune checkpoint activity represents an exciting new frontier in imaging vascular inflammation. In the near future, these advances will allow more precise imaging of disease activity enabling clinicians to offer more targeted and individualized patient management.

[Imaging techniques for the evaluation of systemic manifestations of vasculitis]

Vasculitides create a local inflammatory process in the vessel wall, which determines the different organic manifestations according to vessel size and location. Imaging techniques play a key role in the characterization and detection of large and medium size vessel vasculitides. Imaging is able to detect the vessel wall edema and to monitor the therapeutic response. In small vessel vasculitis, imaging can indirectly analyse the organic and/or systemic manifestations, because at present, none of the imaging techniques has the necessary spatial resolution to directly visualize small vessels.

Atypical bronchial thickening and ulceration: a rare radiological finding in Wegener's granulomatosis

We report the case of a 55-year-old male patient who presented with non-specific pulmonary symptoms (cough, haemoptysis, fever up to 39 degrees C, night sweats and weight loss). After empirical antibiotic therapy prescribed by his primary care physician, the patient showed no improvement in symptoms. Laboratory findings were: elevated C-reactive protein and C-ANCA, leukocytosis and thrombocytosis, and anaemia. Chest radiography showed disseminated nodules bilaterally. On multidetector-row computed tomography (MDCT), the bronchial walls showed a significant thickening and extensive peribronchiolar consolidations. Bronchoscopy revealed diffuse erythema of the tracheobronchial mucosa with diffusely scattered white plaques. Histopathology described a multifocal ulcerative bronchitis with underlying chronic bronchitis. These findings in combination with the laboratory data lead to the diagnosis of Wegener's granulomatosis. Consequently, we started with an immunosuppressive therapy. Chest radiography after 10 days showed marked resolution of the infiltrates. Within 1 month, the patient became asymptomatic.

Imaging studies in the diagnosis and management of vasculitis

The term vasculitis encompasses a number of distinct clinicopathologic disease entities. Final diagnosis should be supported by histologic study in most cases. However, different imaging modalities offer the potential for an early visualization of inflammatory vascular abnormalities, provide some diagnostic clues, and allow for an adequate assessment of therapeutic response. This review discusses recent advances in imaging techniques and refinements in vascular imaging methods, as well as a brief mention of research modalities that are increasingly used in studies of pathogenesis or in the assessment of disease progression.

Outpatient assessment of systemic vasculitis

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.