Leucocytoclastic vasculitis: an update for the clinician

Mixed cryoglobulinaemia vasculitis secondary to marginal zone lymphoma in a patient with end-stage renal failure on haemodialysis

Cryoglobulinaemia vasculitis can present with a variety of symptoms and there is limited data on the incidence and presentation of cryoglobulinaemia vasculitis in haemodialysis patients. We report a case of a 63-year-old male who had a series of presentations with rash, visual changes, abdominal pain, weight loss, fevers and digital ischaemia. This is on a background of a congenital single kidney with end-stage renal failure secondary to diabetes and hypertension, receiving haemodialysis for nearly 5 years. He initially experienced a leukocytoclastic vasculitis rash confirmed on skin biopsy, followed by multiple hospital presentations for undifferentiated abdominal pain and fever of unknown source. Jejunal biopsy revealed intestinal vasculitis. His peripheral blood flow cytometry and bone marrow biopsy were consistent with marginal zone lymphoma (indolent subtype, IgM kappa clone). Further testing revealed a type II cryoglobulinaemia consisting of an IgM kappa monoclonal band with polyclonal IgG (cryocrit 5%). A diagnosis of cryoglobulinaemia vasculitis was established and he was treated with pulsed methylprednisolone and rituximab therapy. However, after receiving three doses of rituximab the patient developed a presumed vasculitis-associated pulmonary haemorrhage for which he received treatment with five sessions of plasma exchange. His symptoms resolved and cryocrit reduced to < 1% after his final dose of rituximab. The clinical features of cryoglobulinaemia may be difficult to detect in chronic haemodialysis patients and vigilance is required.

Association between choroidal thickness and interstitial lung disease in patients with rheumatoid arthritis: A cross-sectional study

Objectives

This study aimed to evaluate choroidal thickness (CT) in patients with rheumatoid arthritis (RA) and healthy controls and to determine its relationship with RA-associated interstitial lung disease (RA-ILD).

Patients and methods

A total of 63 patients with RA and 36 age- and sex-matched healthy controls were recruited in the cross-sectional study. Serological findings, Disease Activity Score-28, disease duration, and medical treatment of patients were recorded. Patients with RA were subdivided into two groups: patients with RA-ILD (Group 1) and patients with RA but without ILD (RA-noILD; Group 2). CTs were measured using enhanced depth imaging optical coherence tomography. CT was measured at five points: the subfoveal region, 750 μm nasal and temporal to the fovea, 1500 μm nasal and temporal to the fovea. Patients with RA-ILD were evaluated with delta high-resolution computed tomography (ΔHRCT) and pulmonary function test to determine the severity of interstitial lung disease.

Results

Four of 63 RA patients were excluded due to comorbidities. Thus, 59 RA patients, 20 in the RA-ILD group and 39 in the RA-noILD group, were included in the analyses. The RA groups were similar in terms of clinical characteristics and laboratory findings. There were statistically significant differences between Group 1, Group 2 and healthy controls (Group 3) compared to all CT values (p<0.05). The mean CT measured at 750 μm and 1500 μm nasal to the fovea was lowest in the RA-ILD group, followed by the RA-noILD and healthy groups (p<0.05). CT measurements did not correlate with the pulmonary function test and ΔHRCT.

Conclusion

RA-ILD patients had a thinner CT measured at nasal points. However, there was no association between CT measurements and the severity of ILD.

Choroidal, retinal, and optic nerve changes in rheumatoid arthritis and primary sjogren's syndrome patients: comparıson with each other and healthy subjects

PURPOSE

The present study aims to evaluate the optic nerve, macula, and choroidal changes in both rheumatoid arthritis (RA) and primary Sjögren's syndrome (SjS) patients, and to compare these findings with age-matched healthy volunteers.

METHODS

This study included 46 RA patients, 33 primary SjS patients, and 37 age-matched healthy volunteers. All of the patients underwent a thorough ophthalmological examination, during which measurements of the retinal nerve fiber layer (RNFL), ganglion cell layer(GCL), and subfoveal choroidal thickness (CT) were taken using OCT (optical coherence tomography). The measurements taken from the right eye of each patient were used to compare among the groups.

RESULTS

RNFL thickness in superior quadrant was found to be statistically significantly thinner in the eyes with RA when compared to the control group (p = 0.022). In the nasal quadrant, the RNFL thickness was significantly thinner in patients with primary SjS compared to healthy individuals (p = 0.036). Also, the temporal quadrant RNFL was significantly thinner in RA patients than in the primary SjS patients (p = 0.033). GCL thickness was observed to be thinner in all quadrants of both RA and primary SjS groups compared to the control group. However, the difference was not found to be statistically significant. Subfoveal CT was observed to be thicker in RA and SjS groups compared to the control group, but this difference was also not statistically significant.

CONCLUSION

Systemic autoimmune diseases like RA and primary SjS can lead to a decrease in RNLF and GCL thickness, which can impair visual acuity even in the absence of ocular symptoms. Therefore, monitoring changes in the optic nerve, retina, and choroid layer are crucial in these patients.

A Case of Successful Direct Oral Anticoagulant Use for the Treatment of Warfarin-Induced Vasculitis in a Patient With Left Ventricular Thrombus

Cutaneous small vessel leukocytoclastic vasculitis (LCV) is isolated to the dependent areas of the skin. LCV can be induced by pharmaceutical drugs, and management requires abrupt discontinuation of the offending drug. Warfarin is a rare medication to cause LCV, with sparse literature to date. Here, we present a case of warfarin-induced LCV, complicated by a patient's comorbid left ventricular thrombus, and successful treatment with discontinuation of warfarin and replacement with a direct oral anticoagulant (apixaban).

Danggui Sini decoction treatment of refractory allergic cutaneous vasculitis: A case report

BACKGROUND

Allergic cutaneous vasculitis (ACV) is a difficult disease to treat. At present, there is no effective treatment for this condition. Traditionally, immunosuppressants and hormones have been primarily used in its management, but the treatment effect is suboptimal, and it has several side effects.

CASE SUMMARY

We present the case of a 19-year-old woman who presented at our hospital with a four-year history of symmetric skin lesions mainly affecting her lower extremities. She had previously undergone treatment with prednisolone acetate, cetirizine hydrochloride, and loratadine tablets but had not experienced any relief in her condition. Thereafter, she was treated with oral traditional Chinese medicine. Her skin damage gradually improved within two months of treatment initiation. After six months, the skin ulcers had completely subsided. No evidence of skin ulcer recurrence was observed during the subsequent follow-up. This report presents the first case of a female patient who received oral Danggui Sini decoction for the treatment of ACV.

CONCLUSION

Danggui Sini decoction may be a promising oral treatment for ACV patients.

A Review of the Mechanism of Vascular Endothelial Injury in Immunoglobulin A Vasculitis

Immunoglobulin A (IgA) vasculitis (IgAV), also known as Henoch-Schönlein purpura, is the most common form of childhood vasculitis. It is characterized by cutaneous hemorrhage, resulting from red blood cell leakage into the skin or mucosae, possibly caused by damage to small blood vessels. These acute symptoms usually disappear without treatment. Endothelial cells are distributed on the inner surfaces of blood vessels and lymphatic vessels, and have important functions in metabolism and endocrine function, as well as being the primary targets of external stimuli and endogenous immune activity. Injury to endothelial cells is a feature of IgA vasculitis. Endothelial cell damage may be related to the deposition of immune complexes, the activation of complement, inflammatory factors, and chemokines, oxidative stress, hemodynamics, and coagulation factors. Both epigenetic mechanisms and genetic diversity provide a genetic background for endothelial cell injury. Here, research on the role of endothelial cells in allergic IgA vasculitis is reviewed.

Constrictive Pericarditis: An Unusual Presentation of Rheumatoid Vasculitis

We describe a case of rheumatoid vasculitis with an atypical presentation of constrictive pericarditis. A 51-year-old man who was previously admitted for diffuse lymphadenopathy, presented with chest pain and a lower extremity rash. Extensive workup including multimodality imaging, serology tests, and biopsy, resulted in the diagnosis of rheumatoid vasculitis.

Scurvy and Tinea Corporis Simulating Leukocytoclastic Vasculitis

ABSTRACT

Leukocytoclastic vasculitis (LCV) is a small vessel inflammatory condition considered to be caused by circulating immune complexes and often occurs after an acute infection or exposure to a new medication, although it may be associated with an underlying systemic disease or be idiopathic in nature. It is important to determine the etiology, identify the extent of the disease for early intervention and appropriate management, and treat and/or eliminate the underlying cause. Here, we report cases of scurvy and tinea corporis that presented with histopathologic features of LCV and had significant clinical improvement with treatment of the underlying etiologies. These cases emphasize that histopathologic features of early evolving LCV may be seen in other settings including scurvy and tinea corporis. Appropriate treatment of the underlying condition is important for optimized patient management.

Top 10 acral skin manifestations associated with COVID-19: A scoping review

COVID‐19‐associated cutaneous manifestations are one of the most important and relatively common extra‐respiratory presentations of SARS‐COV‐2 infection. The exact identification and classification of these lesions can facilitate the accurate diagnosis and treatment. There are several case reports and small case series which describe cutaneous lesions in hands and feet. Currently, there is no scoping review about acral skin manifestations associated with COVID‐19. This paper covers the COVID‐related acral skin manifestations in 10 entities including acral papulo‐vesicular eruption, acral urticarial lesion, acral non‐inflammatory purpura and necrosis, acro‐ischemia associated COVID‐19, acral vasculitis, chilblain‐like lesion (COVID Toe), acral erythema multiform (EM) like lesion, hand and foot skin lesions associated with multisystem inflammatory syndrome in children (MISC), acral peeling conditions and red half‐moon nail sign. Future studies should focus on exact investigation of etiologies of these lesions including role of immune senescence, environment, gender, immunogenetics and relation of these lesion with major organ involvements.

Tofacitinib Treatment of Refractory Cutaneous Leukocytoclastic Vasculitis: A Case Report

Introduction

To date, there is no treatment with proven efficacy for cutaneous leukocytoclastic vasculitis (CLV). Several reports have suggested that CLV responds favorably to corticosteroids, colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), azathioprine, and hydroxychloroquine (HCQ). To the best of our knowledge, the oral small molecule Janus kinase inhibitor, tofacitinib, plays an important role in the treatment of autoimmune and inflammatory diseases. Therefore, tofacitinib may be a prospective therapy in patients with CLV.

Case Presentation

A 29-year-old woman presented to our hospital with a 5-year history of symmetric skin lesions mainly affecting both lower extremities. The results for anti-neutrophil cytoplasmic antibodies (ANCA), anti-extracted nuclear antigens (ENA) autoantibodies, anti-double-stranded deoxyribonucleic acid (dsDNA) antibodies, and antinuclear antibodies (ANA) were all negative. The definite diagnosis of CLV was determined by a skin biopsy. However, the patient exhibited a poor response to prednisone, HCQ, methotrexate, colchicine, azathioprine, and tripterygium wilfordii polyglycoside tablets (TGTs) treatments. She was then treated with oral tofacitinib (5 mg twice daily) and oral prednisone (25 mg daily).

Outcomes

Her skin lesions gradually improved over a period of 4 weeks. Two months later, the skin ulcers completely resolved. No evidence of recurrence of skin ulcers was observed during a 6-month follow-up.

Conclusion

We present the first case of a female patient receiving short-term tofacitinib therapy for refractory CLV. Tofacitinib may be a promising oral alternative for patients with CLV. However, its efficacy and safety require further appraisal through clinical trials.

Autologous platelet-rich plasma in the treatment of refractory wounds in cutaneous leukocytoclastic vasculitis complicated with hypertension (grade 2 moderate risk): A case report

INTRODUCTION

Cutaneous leukocytoclastic vasculitis is an inflammatory variant of vasculitis with a variety of causes that only affects the skin. Its pathological manifestations include neutrophil infiltration and nuclear fragmentation. Clinically, it is characterised by a pleomorphic rash, including erythema, purpuric skin lesions, reticulocytosis, necrosis and ulceration. Once formed, local ulcerations are very difficult to heal.

CASE PRESENTATION

A 46-year-old female was diagnosed with cutaneous leukocytoclastic vasculitis. The patient's legs exhibited ulcers with a black eschar on the surface. The largest wound was 4.5 × 4.0 cm and the deepest wound was 1.7 × 1.8 × 1.0 cm. The ulcers had been present for 6 months and did not exhibit signs of healing. Treatment was commenced with platelet-rich plasma, and the wounds healed within 1 month.

CONCLUSION

Topical application of autologous platelet-rich plasma gel exerts beneficial effects in cutaneous leukocytoclastic vasculitis with regard to wound size reduction, and it induces granulation tissue formation. Platelet-rich plasma may represent a safe and cost-effective treatment for managing cutaneous wound healing to reduce the length of the recovery period.

Leucocytoclastic vasculitis in a patient with COVID-19 with positive SARS-CoV-2 PCR in skin biopsy

Main skin manifestations of COVID-19 have been recently classified. However, little is known about cutaneous histopathological patterns and the presence of SARS-CoV-2 in these skin lesions. We present a healthy 29-year-old man who developed a leucocytoclastic vasculitis for COVID-19 with positive SARS-CoV-2 PCR in skin biopsy.

Leukocytoclastic vasculitis associated with sorafenib treatment for hepatocellular carcinoma

Small-vessel vasculitis is an uncommon diagnosis associated with many causes, including certain medication. Characteristic findings are immune complex deposition, vessel wall damage, and erythrocyte extravasation. We present a case of a 77-year-old man with advanced hepatocellular carcinoma who was treated with sorafenib. Twenty days post introduction to sorafenib, the patient experienced high fever and painful purpura on the lower limbs. The results of the skin biopsy confirmed the diagnosis. More extensive diagnostics was undertaken, which excluded other possible causes of vasculitis and infectious disease. Following a full recovery, after the steroid treatment was completed, sorafenib has been continued until the progression of the carcinoma. This is the second described case of hepatocellular carcinoma associated with sorafenib treatment and leukocytoclastic vasculitis. Sorafenib is a potential cause of vasculitis, and clinicians should bear in mind to differentiate it from hand-foot skin reaction, which is a common side effect of multikinase inhibitors. The result of our assessment is important considering that vasculitis requires more specific diagnostic procedures, treatment, and often drug discontinuation.

Development of Central Nervous System Vasculitis in a Patient with Waldenstrom Macroglobulinemia: A Rare Presentation with Poor Prognosis

Waldenstrom macroglobulinemia (WM) is a rare lymphoproliferative disorder characterized by the presence of monoclonal immunoglobulin M in serum. WM may present with neurologic complications involving the peripheral and central nervous systems (CNS) though CNS complications associated with WM are rare. We present a case of a 72-year-old male with an 18-month history of WM who experienced neurologic and constitutional symptoms indicative of WM progression over a three-week period while on rituximab maintenance therapy. The patient’s symptoms were initially attributed to rituximab-induced asthenia though his clinical condition did not improve with rituximab discontinuation. Due to progressively worsening neurologic symptoms, the patient was re-evaluated and found to have multiple cerebral infarcts and increased serum cryoglobulin levels indicative of cryoglobulinema. The patient was promptly initiated on a combination regimen of high dose steroids, intravenous immunoglobulin (IVIG), and plasmapheresis but had a poor response. Brain biopsy revealed necrotizing vasculitis with dense intra- and peri-vascular CD3 positive T-cell infiltrates with mural necrosis. This is a unique case of WM complicated by type 1 cryoglobulinemia associated with CNS vasculitis that was unresponsive to active rituximab therapy; this case illustrates a poor prognosis of patients with CNS involvement in WM.

Retinal vasculitis associated with cutaneous leukocytoclastic vasculitis

INTRODUCTION

To report a case of retinal vasculitis associated with cutaneous leukocytoclastic vasculitis.

METHODS

Retrospective chart review.

RESULTS

A 28-year-old man, who initially presented with occlusive retinal vasculitis and vitreous hemorrhage in right eye that resolved with sectoral photocoagulation. Laboratory investigations for tuberculosis, sarcoidosis, syphilis and sickle cell disease were negative. Past history included recent diagnosis of Enterobacter epididymo-orchitis and multiple red nodules on skin of forearm. Fourteen months later, he developed active retinal vasculitis in right eye and recurrent nodules on forearm. Skin biopsy revealed neutrophilic infiltrates in and around dermal vessels with destruction of vessel walls leading to scattered neutrophils, lymphocytes and histiocytes between collagen bundles, suggestive of leukocytoclastic vasculitis. Both skin and ocular lesions resolved with oral corticosteroid and methotrexate therapy and did not recur over a six-year period.

CONCLUSION

We have reported the first case of clinically manifest retinal vasculitis, associated with a common form of cutaneous vasculitis.

Leukocytoclastic vasculitis complicating cisplatin + radiation treatment for laryngeal cancer: a case report

BACKGROUND

Leukocytoclastic vasculitis is typically mediated by deposition of immune complexes and is related to many causes, including medication. To the best of our knowledge, leukocytoclastic vasculitis related to cisplatin has not yet been described in the scientific literature.

CASE PRESENTATION

We report a rare case of leukocytoclastic vasculitis after the first cycle of high-dose cisplatin chemotherapy in a patient with larynx carcinoma. A 48-year-old Caucasian man with larynx carcinoma received a high-dose of cisplatin monochemotherapy (100 mg/m² every 21 days), along with 70 Gy of radiotherapy divided into 35 sessions, as a therapeutic schedule. Twelve days after the first chemotherapy administration and after 8 sessions of radiotherapy (total of 16 Gy), the patient presented with acute onset of palpable purpura in the lower limbs. The patient was hospitalized for 10 days, and during this period, he underwent several examinations to rule out infectious, autoimmune, and neoplastic disorders. A skin biopsy showed leukocytoclastic vasculitis with a positive pattern for IgM and C3, as detected through direct immunofluorescence. Twenty-five days after cisplatin administration, the chemotherapy regimen was changed to carboplatin AUC 5, and the episodes of purpura ceased, reinforcing the hypothesis of an adverse reaction to cisplatin.

CONCLUSIONS

Cisplatin can induce leukocytoclastic vasculitis and clinicians should be aware of this potential effect for better case management and diagnosis.

Evaluation of retrobulbar blood flow and choroidal thickness in patients with rheumatoid arthritis

PURPOSE

To evaluate whether retrobulbar blood flow and choroidal thickness (CT) are affected in patients with rheumatoid arthritis (RA), and the relationship between these values.

METHODS

We evaluated 40 eyes of 20 RA patients and 40 eyes of 20 healthy controls. The enhanced depth imaging optical coherence tomography, color Doppler imaging, was held. Statistical analysis was performed.

RESULTS

Peak systolic velocity (PSV) of ophthalmic (OA) and central retinal artery (CRA) were significantly higher in RA. No significant difference was observed when end-diastolic velocity (EDV) of OA and CRA was compared between the groups. The resistivity index (RI) of OA and CRA was higher in RA. Perifoveal/subfoveal CT was lower in RA. Negative correlation was detected between the RI of OA and the perifoveal CT, and a positive correlation was detected between RI of CRA and CT.

CONCLUSIONS

Ocular hemodynamics is effected by RA and can exaggerate ocular complications of various vascular diseases such as diabetes mellitus, hypertension, retinal vascular occlusions.

Demographic characteristics, aetiology, and assessment of treatment options in leukocytoclastic vasculitis

Introduction

Vasculitides are a heterogeneous group of diseases characterized by inflammation of the blood vessel walls. Etiological factors include infections, drugs, connective tissue diseases, and malignancies.

Aim

To examine the demographic characteristics, etiological factors, and treatment options in 75 patients with leukocytoclastic vasculitis.

Material and methods

The study included 75 patients diagnosed with leukocytoclastic vasculitis at our clinic. The patients’ medical records were reviewed to determine their age, sex, presence of systemic symptoms, possible etiological factors, laboratory results, types of cutaneous lesions, locations of the lesions, treatment options, and disease course.

Results

There were 43 women and 32 men. Cutaneous lesions affected only the lower limbs in 60 of the 75 patients (80%) and usually presented as palpable purpura (64%, n = 48). Arthralgia (26.7%, n = 20) was the most frequent extracutaneous symptom. Of the patients with secondary vasculitis, the most common causes were infections and drugs. The mean age of the patients with Henoch-Schönlein purpura was 26.8 years. There was no significant association between age and renal, gastrointestinal, or joint involvement.

Conclusions

The most common form of vasculitis in our study was cutaneous leukocytoclastic vasculitis. In most of the patients it appeared to be idiopathic. Among drugs, antibiotics were the most common etiological factor. In 4 patients, the cutaneous leukocytoclastic vasculitis behaved like the paraneoplastic syndrome.

Rare Case of Metformin-Induced Leukocytoclastic Vasculitis

Objective:

To report a case of leukocytoclastic vasculitis (LV) related to metformin.

Case Summary:

A 33-year-old woman developed palpable purpura on her lower limbs after starting self-medication with metformin 850 mg/day for weight loss. Drug-induced vasculitis was suspected, metformin was stopped, and the rash improved significantly. One month later, the woman again took metformin. Similar cutaneous lesions recurred, and skin biopsy showed LV, which was managed by discontinuing metformin and applying topical antiseptics. The patient had no further episodes of skin rash over a follow-up period of 3 months.

Discussion:

Metformin has widespread use throughout the world. It has a variety of metabolic and vascular effects. Our patient developed a rash within a few days of metformin administration. Resolution of skin manifestations within several days after withdrawal of the drug and their recurrence when the drug was reintroduced were consistent with a pathogenic role of metformin. Other known causes of vasculitis were excluded in a reasonable way. According to the Naranjo probability scale, the vasculitis experienced by our patient was probably due to metformin.

Conclusions:

Clinicians should be aware of the ability of metformin to induce cutaneous LV.

Warfarin-induced leukocytoclastic vasculitis and proteinuria

Warfarin is typically prescribed for patients with thromboembolic diseases and atrial fibrillation. In addition to the complications of bleeding, allergic skin reaction is one of its rare adverse effects. We herein report a case of a 79 year old male patient with leukocytoclastic vasculitis and proteinuria secondary to warfarin. The warfarin was discontinued and oral prednisone therapy was initiated. The cutaneous lesions and the proteinuria resolved thereafter.

Leukocytoclastic vasculitis and acute allergic interstitial nephritis following ceftriaxone exposure

Leukocytoclastic vasculitis (LCV), also known as hypersensitivity vasculitis is a small vessel inflammatory disease which mainly involves the postcapillary venules. A 17-year-old girl developed palpable purpura over lower limbs and acute allergic interstitial nephritis 5 days after exposure to ceftriaxone. Skin biopsy from the lesion over lower limbs confirmed the diagnosis of LCV. Discontinuation of drug and treatment with steroid resulted in resolution of skin lesions and normalization of kidney functions. Beta-lactams are commonly used antibiotics in various types of infection in day-to-day practice. LCV, a rare complication of ceftriaxone should be kept in mind while using this drug.

Leukocytoclastic vasculitis in a patient with ankylosing spondylitis

A 26-year-old male patient presented to our rheumatology clinic with pain, swelling and limitation of movement in his right ankle, and also purpuric skin lesions in the lower extremity pretibial region. He was asked questions, and he said that he had been having chronic low back pain and morning stiffness for the last few years. His physical examination revealed that he had arthritis in his right ankle, purpuric skin lesions in pretibial regions of both legs, and bilateral FABERE/FADIR positivity. The sacroiliac joint imaging and MRI revealed bilateral sacroiliitis findings, and the lateral heel imaging revealed enthesitis. HLA-B27 was positive. Skin biopsy from lower skin lesions was reported to be consistent with leukocytoclastic vasculitis. Based on clinical, laboratory, radiological, and pathological examinations, the patient was diagnosed with ankylosing spondylitis and leukocytoclastic vasculitis. Administration of corticosteroid, salazopyrin, and nonsteroid anti-inflammatory medications was started. Notable clinical and laboratory regression was observed during his checks 3 months later.

Type-I complex regional pain syndrome of umbilical port site: An unforeseen complication of laparoscopic surgery

Many complications have been observed after laparoscopic surgery. Persisting pain in the umbilical port site is due to infection, hernia, endometriosis, metastasis, etc. There is no case report due to neuralgic complex regional pain syndrome, and we have dealt a case which is described with relevant literature review and etiopathogenesis.

Unexpected cure from cutaneous leukocytoclastic vasculitis in a patient treated with N-butyldeoxynojirimycin (miglustat) for Gaucher disease

Cutaneous leukocytoclastic vasculitis (CLV) is a necrotizing inflammation of the small vessels in the dermis. We report the case of a Swedish man with an untreated N370S/L444P Gaucher disease who developed CLV at the age of 79 years. The patient has been treated for CLV with topical and oral corticosteroids, moisturizing agents, and periodically with antibiotics for 3 years without improvement. Administration of miglustat (N-butyldeoxynojirimycin; Zavesca®) because of progress of Gaucher disease resulted in a prompt and durable cure of the CLV.

Investigation of the change in CD4⁺ T cell subset in children with Henoch-Schonlein purpura

Helper T (Th) cells comprising Th1, Th2, Th17, and Treg are involved in the pathogenesis of various vascular inflammations, and information about Th cells in Henoch-Schonlein purpura (HSP) is still controversial. The aim of our study was to investigate the changes in CD4(+) T cell subsets and their roles in the pathogenesis of HSP. Thirty children with diagnosis of HSP and thirty age-matched healthy controls were enrolled in this study. Real-time PCR was used to evaluate the mRNA expression levels of transcriptional factors and cytokines of CD4(+) T cells. Proportions of Th1, Th2, Th17, and Treg cells in peripheral blood were detected by flow cytometry. Plasma cytokine concentrations were measured by ELISA. The proportions of Th2 and Th17 cells increased significantly in children with acute HSP (P < 0.05), while there were no significant differences between HSP and healthy controls regarding the proportions of Treg cells and Th1 cells (P > 0.05). mRNA levels of transcriptional factors and cytokines of Th2 and Th17 cells were significantly up-regulated (P < 0.05), while the differences were not significant as to those of Th1 and Treg cells (P > 0.05). Plasma concentrations of IL-17A, IL-4, and IL-6 in patients with HSP were found to be much higher than those of the control group (P < 0.05), and no differences between IFN-γ, IL-12, and TGF-β were detected between the two groups (P > 0.05). Presence of higher proportions of Th2 and Th17 cells in patients with HSP could be closely correlated with aberrant creation of antibody and development of vessel vasculitis. The changes in cytokine milieu in peripheral blood may play an important role in the derangement of CD4(+) T cell subset.

Imaging of pulmonary vasculitis

The presence of pulmonary vasculitis can be suggested by a clinical presentation that includes diffuse pulmonary hemorrhage, acute glomerulonephritis, chronic refractory sinusitis or rhinorrhea, imaging findings of nodules or cavities, mononeuritis multiplex, multisystemic disease, and palpable purpura. Serologic tests, including the use of cytoplasmic antineutrophil cytoplasmic antibody (ANCA) and perinuclear ANCA, are performed for the differential diagnosis of the diseases. A positive cytoplasmic ANCA test result is specific enough to make a diagnosis of ANCA-associated granulomatous vasculitis if the clinical features are typical. Perinuclear ANCA positivity raises the possibility of Churg-Strauss syndrome or microscopic polyangiitis. Imaging findings of pulmonary vasculitis are diverse and often poorly specific. The use of a pattern-based approach to the imaging findings may help narrow the differential diagnosis of various pulmonary vasculitides. Integration of clinical, laboratory, and imaging findings is mandatory for making a reasonably specific diagnosis.

Intravenous dexamethasone followed by oral prednisolone versus oral prednisolone in the treatment of childhood Henoch-Schönlein purpura

The aim of this study was to evaluate the effectiveness of intravenous corticosteroid therapy when Henoch-Schönlein purpura (HSP) patients are unable to tolerate oral medications due to abdominal pain. We retrospectively analyzed 111 children with a diagnosis of HSP (mean age 6.9 ± 2.3 years, male:female = 54:57) from the years 2000 to 2007. They were divided into two groups: 49 patients received only oral prednisolone (PL group) and 62 patients received oral prednisolone after intravenous dexamethasone (Dexa + PL group). Palpable purpura was seen in all 111 patients (100%), abdominal pain in 55 (50%), and arthralgia in 65 (59%). Dexa + PL group had significantly longer duration of fasting than PL group (0.7 ± 1.2 vs. 0.02 ± 0.1 days, P < 0.01) due to more severe and frequent abdominal pain (68 vs. 27%, P < 0.01). Intravenous dexamethasone resulted in the rapid resolution of abdominal pain or arthralgia in all patients without major complications. However, the development of nephritis (21% in PL group versus 32% in Dexa + PL group, P = 0.098), the number of relapse (4 vs. 11%, P = 0.167), and persistent nephritis at last follow-up (12 vs. 16%, P = 0.563) were not different between the two groups despite more severe symptoms in Dexa + PL group. Intravenous dexamethasone followed by oral prednisolone may be a useful and effective therapeutic strategy in HSP children who cannot tolerate oral medications due to severe abdominal pain.

Ulcerative colitis associated with leukocytoclastic vasculitis of the skin

Ulcerative colitis may be associated with a number of skin lesions such as erythema nodosum and pyoderma gangrenosum. We here describe an unusual case of a 33-year-old-caucasian male with ulcerative colitis and skin lesions diagnosed as leukocytoclastic vasculitis. An initial treatment with oral deflazacort led to little benefit, while treatment with oral mesalazine caused remission of the skin and intestinal manifestations in 2 weeks.

Vascular disease in rheumatoid arthritis: from subclinical lesions to cardiovascular risk

Rheumatoid arthritis (RA) is one of the most prevalent and complex inflammatory diseases affecting primarily the joints, but also associating several extra-articular features. The vascular disease in RA encompasses a large spectrum of lesions, from rheumatoid vasculitis to atherosclerotic lesions. During the last years the importance of the vascular disease related to atherosclerosis in terms of cardiovascular morbidity and global mortality became evident in RA. The inflammatory hypothesis of atherosclerosis in RA implies that mediators originating from the inflamed synovial tissue or from the liver may have systemic vascular consequences, leading to endothelial dysfunction and structural abnormalities of the vessels. Hence, the global management of patients with RA must include the improvement of cardiovascular risk in parallel with the management of joint disease.

Henoch-Schönlein purpura: a long-term prospective study in Greek children

OBJECTIVE

Henoch-Schönlein purpura is a common vasculitis of childhood. The present study, comprising 74 children enrolled during a 9-year period, aimed to delineate the clinical spectrum and the long term follow-up of the disease.

METHODS

Patients were diagnosed strictly on the criteria established by the American College of Rheumatology. The diagnosis was further strengthened by a skin biopsy performed in more than half of cases (42/74), which revealed leukocytoclastic vasculitis in all patients, whereas IgA deposits were found in 37/42 children.

RESULTS

There was a predominance of boys (41 males), and the mean age of study population was 5.2 +/- 2.54 years. Palpable purpura was identified in 73/74 children, whereas transient arthritis manifested in 68/74 children. Gastrointestinal blood loss was elicited in 30 children, 11 of whom had also renal involvement. The latter was seen in 19/74 (25.7%) children, and in the long term follow-up (extended to 2004, from 4-12 years, mean duration 7.3 years), 2 children remained with persistent occult hematuria. Relapses occurred in 49 children (66%), and half of them experienced more than 1 recurrence. Arthritis was less common in the relapsed episodes, and this difference was statistically significant (P < 0.001). Relapses tended to be more common in children with renal involvement and colicky abdominal pain without however reaching statistical significance.

CONCLUSION

Despite common relapses, this disease is benign in the long term even if severe renal involvement can occur during its active period. Recurrences often differ to some extent from the initial episode with arthritis being less common with relapses.

Cutaneous leukocytoclastic vasculitis and myelodysplastic syndrome with little or no evidence of associated autoimmune disorders-a case report and a brief review of the literature

Cutaneous leukocytoclastic vasculitis (CLV) is a necrotizing inflammatory disease of the small vessels in the dermis. Approximately 50% of cases with CLV are primary or idiopathic and the remainder may be associated with various diseases. Less than 1% CLV occurs in association with malignancies including leukemia, lymphoma, and myelodysplastic syndrome (MDS). The pathogenetic mechanism of CLV remains speculative and is generally believed to be related to autoimmune processes. We report here a 77-year-old white woman who presented with contemporaneous occurrence of CLV and MDS (WHO subtype RAEB-2). Autoantibodies and immune-complexes were not detected either in the serum or by direct immunofluorescense in the skin biopsy. The clinical course of MDS remained steady, but the cutaneous lesion resolved within 2 weeks with minimal or no specific therapy except corticosteroids. We suggest that absence of autoimmune phenomena and immune-complex in the skin lesions of CLV may be a hallmark of good prognosis.

Leukocytoclastic vasculitis with severe cardiac involvement in an infant: a case report

Severe visceral involvement in leukocytoclastic vasculitis is rare. We report here the case of a 2-month-old male infant with leukocytoclastic vasculitis who initially presented with fever and skin purpura. Endomyocarditis with mitral valve regurgitation, multiple hepatic infarction, and pulmonary hemorrhage developed later. The patient was successfully managed with an aggressive treatment of high frequency oscillation ventilation and extracorporeal membrane oxygenation together with corticosteroid and azathioprine therapy for 3 months. Valvuloplasty was also performed due to irreversible damage of the mitral valve, although long-term oral anticongestive medications were also needed.

Vasculite cutânea de pequenos vasos: etiologia, patogênese, classificação e critérios diagnósticos - Parte I

Vasculite é a inflamação da parede dos vasos. Pode variar em gravidade desde doença autolimitada de um único órgão até doença grave com risco de morte por falência de múltiplos órgãos. Existem várias causas, embora só se apresente por poucos padrões histológicos de inflamação vascular. Vasos de qualquer tipo e em qualquer órgão podem ser afetados, resultando em ampla variedade de sinais e sintomas. Diferentes vasculites com apresentações clínicas indistinguíveis têm evolução e tratamento muito diferentes. Essa condição representa desafio para o médico, incluindo classificação, diagnóstico, exames laboratoriais pertinentes, tratamento e seguimento adequado. Neste artigo são revistos a classificação, a etiologia, a patogênese e os critérios diagnósticos das vasculites cutâneas.

Systemic rheumatoid vasculitis: a review

OBJECTIVES

To review the most recent information on the incidence, clinical course, pathology, pathogenesis, diagnosis, and treatment of rheumatoid vasculitis (RV), including the still scanty data on the use of biologics.

METHODS

PubMed and MEDLINE databases (1950-2006) were searched for the key words "vasculitis" and "rheumatoid arthritis"; and "rheumatoid arthritis" and "extra-articular manifestations." All relevant articles in English and French were reviewed. Additional words used in follow-up research include "anti-TNF," "rituximab," "IL-1 receptor antagonists," and "CTLA-4 Ig," all in conjunction with "vasculitis." Pertinent secondary references were also retrieved.

RESULTS

RV is an inflammatory condition of the small- and medium-sized vessels that affects a subset of patients with established rheumatoid arthritis (RA) (approximately 1 to approximately 5%). It has a vast array of clinical manifestations with a predilection for the skin (peripheral gangrene, deep cutaneous ulcers) and the peripheral nervous system (mononeuritis multiplex). Because of the lack of specific signs and symptoms, the diagnosis relies on the exclusion of other causes of similar lesions (diabetes, atherosclerosis, drug reactions, infection, neoplasias) and, ideally, on the histopathological demonstration of necrotizing vasculitis. Despite the availability of a host of promising new drugs for the treatment of RA, no clinical trials have tested their efficacy in RV; therefore, its management remains largely empirical.

CONCLUSIONS

Although RV has apparently been decreasing over the last 2 decades, possibly as a consequence of the more energetic approach to the management of RA currently used, it remains an important complication of RA that needs to be promptly recognized and treated.

Predictive factors for nephritis, relapse, and significant proteinuria in childhood Henoch-Schönlein purpura

OBJECTIVE

To identify predictive factors for nephritis, relapse, and significant proteinuria in childhood Henoch-Schönlein purpura (HSP).

METHODS

Two hundred and six consecutive patients with HSP (93 female, 113 male), followed up at a single centre between 1996 and 2001, were analysed retrospectively. They were regularly monitored for clinical and laboratory parameters for renal sequelae and relapse.

RESULTS

Nephritis was seen in 78 patients (38%), relapse in 52 (25%), and significant proteinuria in 39 (19%). In univariate analysis, an older age at onset (>10 years), persistent purpura, severe bowel angina, and relapse were identified as factors associated with nephritis and significant proteinuria. Relapse-related factors were an older age, persistent purpura, severe bowel angina, and leucocytosis. Logistic regression analysis showed that nephritis was significantly associated with an older age, persistent purpura, and relapse, and significant proteinuria was closely related to severe bowel angina and relapse.

CONCLUSION

We identified some predictors for nephritis, relapse, and significant proteinuria in childhood HSP, and close attention should be paid to those patients with the risk factors, such as an older age at onset, persistent purpura, severe bowel angina, and relapse.

Henoch-Schönlein purpura nephritis with nephrotic-range proteinuria: histological regression possibly associated with cyclosporin A and steroid treatment

OBJECTIVE

To clarify the therapeutic role of cyclosporin A (CyA) for patients with Henoch-Schönlein purpura nephritis (HSPN) showing nephrotic-range proteinuria.

METHODS

The clinical and histological findings of eight children (7.7+/-3.8 years), who were treated with CyA and prednisolone, were evaluated retrospectively. All underwent a renal biopsy before therapy, and six of the eight patients received a follow-up biopsy after therapy.

RESULTS

The histological grade of the International Study of Kidney Disease in Children (ISKDC) was improved in all six patients who received a follow-up biopsy (pre-therapy, four grade IIIa and two grade IIIb; post-therapy, one grade I and five grade II) and it was statistically significant (p = 0.031). The activity index was significantly decreased after therapy (8.3+/-1.6 vs. 3.5+/-1.5, p = 0.031), and the chronicity index (0.5+/-0.5 vs. 0.7+/-1.0) and tubulointerstitial (TI) scores (1.5+/-1.3 vs. 0.8+/-1.6) did not change. There was a reduction in proteinuria from 3.2+/-2.3 to 0.1+/-0.1 g/m2/day (p = 0.008) and renal function remained normal in all patients after therapy. However, one patient showed CyA-induced nephrotoxicity at a second biopsy. After an average follow-up period of 3.8 years, six patients showed normal urine and renal function, and two showed minor urinary abnormalities.

CONCLUSION

This study suggests that CyA therapy is effective in reducing proteinuria, which is a known risk factor for the development of renal insufficiency in HSPN and may regress the renal pathology in patients with nephrotic-range proteinuria.

Gallbladder vasculitis associated with cutaneous leucocytoclastic vasculitis

A 72-year-old woman presented with a 1-week history of a painful, purpuric, pruritic rash on her legs, buttocks and arms. Skin biopsy revealed histological features typical of leucocytoclastic vasculitis. She was admitted, her usual medications were withheld, and she was commenced on ibuprofen and loratadine. The patient had undergone a laparoscopic cholecystectomy 2 months prior to her rash appearing. She had been having upper abdominal pain for 2 years and, following a more severe acute episode, an abdominal ultrasound scan had revealed a solitary cholelithiasis. Histology of the gallbladder revealed acute fibrinoid vasculitis in two small arteries, on a background of chronic cholecystitis. A mild postoperative wound infection was treated with a short course of cephalexin and no other investigations were conducted. As an inpatient, the patient's rash improved, but she progressed to develop systemic vasculitis and acute renal failure. Renal biopsy showed focal necrotizing glomerulonephritis, consistent with vasculitis. She was subsequently commenced on cyclophosphamide 100 mg daily, prednisolone 50 mg daily and one prophylactic trimethoprim/sulphamethoxazole (160 mg/800 mg) tablet 3 days/week. Following discharge, the patient's cutaneous vasculitis eventually resolved and renal function gradually improved. Her prednisolone was gradually reduced to 7 mg daily and cyclophosphamide was weaned, then substituted with azathioprine 100 mg daily.

The prototypic tissue pentraxin PTX3, in contrast to the short pentraxin serum amyloid P, inhibits phagocytosis of late apoptotic neutrophils by macrophages

OBJECTIVE

Phagocytosis of apoptotic cells can be facilitated by complement components and short pentraxins, such as serum amyloid P (SAP). In contrast, the long pentraxin PTX3 was shown to inhibit phagocytosis of apoptotic Jurkat cells by dendritic cells and to bind late apoptotic polymorphonuclear leukocytes (PMNs). Recently, levels of the pentraxin PTX3 were shown to parallel disease activity in small-vessel vasculitis, which is often characterized by leukocytoclasia, a persistence of leukocyte remnants in the vessel wall. We undertook this study to test our hypothesis that PTX3 inhibits phagocytosis of late apoptotic PMNs by macrophages, thereby leading to their accumulation in the vessel wall.

METHODS

Macrophages were allowed to phagocytose late apoptotic or secondary necrotic PMNs that were incubated with or without PTX3 for 30 minutes prior to phagocytosis. Phagocytosis was allowed to occur in the presence of 30% normal human serum with or without SAP and with or without depletion of complement. To discriminate between an inhibitory effect of PTX3 on binding and the internalization of apoptotic PMNs into macrophages, internalization was blocked by cytochalasin B.

RESULTS

SAP and complement were both necessary for effective in vitro phagocytosis. In contrast, PTX3 inhibited phagocytosis in a dose-dependent manner, from 11% inhibition at 6.25 microg/ml to almost complete inhibition at 100 microg/ml. Furthermore, PTX3 partly affected binding of apoptotic PMNs to macrophages.

CONCLUSION

PTX3, in contrast to SAP and complement, inhibits phagocytosis of late apoptotic PMNs by monocyte-derived macrophages in a dose-dependent manner. Therefore, PTX3 can play a role in the development of leukocytoclasia by affecting the clearance of apoptotic PMNs, thereby inducing their accumulation in the vessel wall.