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Alexander G, Moore SA, Lenert PS. Eosinophilic granulomatosis with polyangiitis and its association with montelukast: a case-based review. Clin Rheumatol 2024; 43:2153-2165. [PMID: 38720163 DOI: 10.1007/s10067-024-07000-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/17/2024] [Accepted: 05/05/2024] [Indexed: 05/24/2024]
Abstract
The association between the use of certain medications (including sulfonamides, hydralazine, and procainamide) and the occurrence of drug-induced lupus or hepatitis is well established. More recently, cases of immune-related adverse events ranging from inflammatory polyarthritis to necrotizing myositis in patients taking checkpoint inhibitors have been reported. However, data linking drugs to systemic vasculitis are scarce and at times debatable. Propylthiouracil, hydralazine, and minocycline have been associated with rare cases of ANCA-associated syndromes, including life-threatening pulmonary-renal syndromes and systemic polyarteritis nodosa-like diseases. Eosinophilic granulomatosis with polyangiitis (EGPA) has been reported in patients taking leukotriene inhibitors. Since the link between the use of leukotriene inhibitors and occurrence of EGPA remains highly controversial, we performed a literature review for cases of EGPA in patients taking montelukast without prior history of oral corticosteroid use. We found 24 cases, along with our own two cases described, making 26 cases in total. The mean age was 43 and a majority (18/26) were female. In majority of cases EGPA-like disease never relapsed after they were taken off leukotriene inhibitors suggesting a clear causal relationship between the use of these drugs and occurrence of eosinophil-rich systemic EGPA.
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Affiliation(s)
- Grace Alexander
- Department of Internal Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Steven A Moore
- Department of Pathology, University of Hospitals & Clinics, Iowa City, IA, USA
| | - Petar S Lenert
- Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
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2
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Schroeder JW, Folci M, Losappio LM, Chevallard M, Sinico RA, Mirone C, De Luca F, Nichelatti M, Pastorello EA. Anti-Neutrophil Cytoplasmic Antibodies Positivity and Anti-Leukotrienes in Eosinophilic Granulomatosis with Polyangiitis: A Retrospective Monocentric Study on 134 Italian Patients. Int Arch Allergy Immunol 2019; 180:64-71. [PMID: 31189169 DOI: 10.1159/000500544] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis associated with asthma, anti-neutrophil cytoplasmic antibodies (ANCA) positivity, and tissue eosinophilia. OBJECTIVE To describe the presenting clinical features, significant biochemical alterations, and also potential pathogenic factors in adult patients diagnosed in our Center over a period of >20 years. METHOD A retrospective study of EGPA patients diagnosed from 1994 to 2019 at ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan (Italy), which was performed according to the 1990 American College of Rheumatology criteria and Chapel Hill Consensus Conference definition. A dataset was compiled, registering demographic and clinical features, biochemical analysis at onset, and also the therapies received 3 months prior to EGPA diagnose. Statistical analyses were subsequently conducted dividing patients in 2 groups based on ANCA positivity and comparing them. RESULTS Two groups were clearly identified by ANCA serology and specific organ involvement in accordance with literature reports; however, our data underline for the first time the association between anti-leukotriene receptor antagonists (LTRAs) and ANCA positivity. The group of previously treated patients presents an OR of 6.42 to be ANCA positive. This finding could be attributed to an imbalanced stimulation of leukotriene receptors, inducing both mast cells activation and an increased neutrophil extracellular traps release from neutrophils. CONCLUSION Despite the limitations of this retrospective study, the association between LTRAs and ANCA antibodies elucidates the mechanism by which innate immunity is directly involved in tolerance breakdown and autoantibodies production. Validation of our results with targeted studies could clarify the differences between ANCA-positive and ANCA-negative patients with important consequences on the use of some drug classes in the treatment of EGPA and asthmatic subjects.
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Affiliation(s)
- Jan Walter Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Marco Folci
- Department of Internal Medicine, Division of Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy
| | - Laura Michelina Losappio
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Michel Chevallard
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy.,DISCCO, University of Study of Milan, Milan, Italy
| | - Renato Alberto Sinico
- Department of Medicine and Surgery, Nephrology Unit, University of Milano-Bicocca, Monza, Italy
| | - Corrado Mirone
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Fabrizio De Luca
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Michele Nichelatti
- Service of Biostatistics, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Elide Anna Pastorello
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy, .,DISCCO, University of Study of Milan, Milan, Italy,
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3
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Calapai G, Casciaro M, Miroddi M, Calapai F, Navarra M, Gangemi S. Montelukast-induced adverse drug reactions: a review of case reports in the literature. Pharmacology 2014; 94:60-70. [PMID: 25196099 DOI: 10.1159/000366164] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/27/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Montelukast, a leucotriene receptor antagonist, binds the cysteinyl leucotriene type 1 receptor. Montelukast is commonly prescribed to asthma patients as add-on therapy to inhaled corticosteroids. Several clinical trials emphasized that montelukast can be considered a safe drug. However, recent evidence reconsidered the benefit/risk ratio of the use of montelukast for both paediatric and adult patients. SUMMARY The present review analyzed the previous published case reports regarding montelukast-induced adverse drug reactions (ADRs). They included agitation, anxiety, depression, sleep disturbance, hallucinations, suicidal thinking and suicidality, tremor, dizziness, drowsiness, neuropathies and seizures. The immune system can be involved, in particular, cases of Churg-Strauss syndrome have been published. Furthermore, it can induce hypersensitivity reactions, including anaphylaxis and eosinophilic infiltration. In addition, hepatobiliary, pancreatic and uropoietic disorders have been observed. Some of these cases are characterized by severe prognosis (i.e. neurological deficit and fatal hepatotoxicity). Key Message: The use of montelukast can be burdened by several ADRs, of which physicians should be aware in their clinical practice. A better understanding of the mechanisms causing ADRs after using montelukast could help researchers and clinicians in defining a risk-reduction strategy aimed to lessen montelukast toxicity. More accurate epidemiological studies, in order to discover risk factors favouring montelukast-associated ADRs, are demanded.
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Affiliation(s)
- Gioacchino Calapai
- School and Division of Allergology and Clinical Immunology, University of Messina, Messina, Italy
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4
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Scott JP, Peters-Golden M. Antileukotriene agents for the treatment of lung disease. Am J Respir Crit Care Med 2013; 188:538-44. [PMID: 23822826 DOI: 10.1164/rccm.201301-0023pp] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Leukotrienes (LTs) C4, D4, and E4, collectively termed cysteinyl LTs (cysLTs), are lipid mediators formed by the 5-lipoxygenase (5-LO) pathway of arachidonic acid metabolism. Originally recognized for their potent bronchoconstrictor actions, they were subsequently determined also to promote inflammation, microvascular permeability, and mucus secretion. These actions that are so central to asthma pathophysiology are mediated to a significant extent by ligation of the cysLT receptor 1 (CysLT1). Antagonism of CysLT1 and inhibition of 5-LO have both been shown to have clinical use in the management of asthma, but substantial interindividual heterogeneity is observed in the response to these agents. In this article, we review the biologic actions of LTs, their biosynthetic pathways and cognate receptors, the pharmacology of available anti-LT agents, and the clinical evidence for the use of anti-LT agents as monotherapy and combination therapy in asthma. We also consider heterogeneity of response, the possible roles of cysLT receptors other than CysLT1, the role of another class of LT, LTB4, and the potential role of LTs in lung diseases other than asthma.
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Affiliation(s)
- Jacob P Scott
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, USA
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5
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Bassetto F, Scarpa C, Vindigni V, Doria A. The periprosthetic capsule and connective tissue diseases: a piece in the puzzle of autoimmune/autoinflammatory syndrome induced by adjuvants. Exp Biol Med (Maywood) 2012; 237:1117-22. [DOI: 10.1258/ebm.2012.012151] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Breast prostheses have been criticized for being responsible for triggering systemic autoimmune disease. The presence of breast implants causes a natural foreign body reaction characterized by the infiltration of macrophages and T-cells. Using PubMed, Medline and eMedicine, we performed a systematic literature review on the stages of periprosthetic capsule formation and cells involved in order to understand which immunological pathways could be responsible for giving rise to, and the development of, connective tissue disease such as systemic sclerosis. We focused on the relationship between tissue growth factor- β, interleukin (IL)-1, IL-6 and T helper 17 or T regulatory cells, as well as on their effects on the different steps of capsular tissue formation. A disturbance in the modulation of these key cytokines may be responsible, in susceptible individuals, for a perpetuation of the inflammatory reaction which can locally lead to capsular contracture and at the systemic level may contribute to triggering autoimmune diseases.
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Affiliation(s)
- Franco Bassetto
- Plastic Surgery Clinic, Padua University, Via Giustininani, 2
| | - Carlotta Scarpa
- Plastic Surgery Clinic, Padua University, Via Giustininani, 2
| | | | - Andrea Doria
- Division of Rheumatology, Department of Medicine, Padua University, 35100 Padua, Italy
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6
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Anar C, Ünsal I, Ozanturk ME, Halilçolar H, Yucel N. A case of Churg-Strauss syndrome treated with montelukast. Med Princ Pract 2012; 21:186-9. [PMID: 22025058 DOI: 10.1159/000331901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 05/31/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report a case of Churg-Strauss syndrome who had asthma and allergic rhinitis treated with montelukast. CLINICAL PRESENTATION AND INTERVENTION A nonsmoking 59-year-old woman presented with fever, hemoptysis and dyspnea. Past medical history included allergic rhinitis and asthma which were diagnosed 18 years ago. The asthma was treated successfully with inhaled salmeterol and beclamethasone. She also received montelukast (10 mg/day) for 3 years. Although her chest X-ray was normal a week earlier, she had widespread bilateral pulmonary infiltrates on admission. She had leukocytosis (12.5 × 10(9)/l) with eosinophilia (15.6%). Her total IgE count was 550 U/ml. Testing for protoplasmic-staining antineutrophil cytoplasmic antibodies was positive. Bronchoalveolar lavage could not be performed due to bronchospasm and severe hypoxemia; however, mucosal biopsies were obtained, which revealed eosinophil leukocytes in the lumen and walls of small vessels. She was diagnosed to have Churg-Strauss syndrome and had remarkable clinical improvement on day 5 with high-dose of oral prednisolone (50 mg/day). Radiological improvement was detected at the end of the second week. CONCLUSION This case shows the importance of being aware that leukotriene receptor antagonists could cause Churg-Strauss syndrome, in spite of the uncertainty about its mechanism.
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Affiliation(s)
- Ceyda Anar
- Division of Pulmonary Medicine, Dr. Suat Seren Chest Disease and Surgery Training and Research Hospital, Izmir, Turkey.
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7
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McCabe C, Jones Q, Nikolopoulou A, Wathen C, Luqmani R. Pulmonary-renal syndromes: an update for respiratory physicians. Respir Med 2011; 105:1413-21. [PMID: 21684732 DOI: 10.1016/j.rmed.2011.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/01/2011] [Accepted: 05/24/2011] [Indexed: 12/14/2022]
Abstract
Pulmonary-renal syndromes are a group of disorders characterised by necrotising glomerulonephritis and pulmonary haemorrhage. Small vessel systemic vasculitis is the most common cause of pulmonary-renal syndromes presenting to respiratory physicians. Rarer causes include systemic lupus erythematosus and connective tissue diseases though severe pneumonia or cardiac failure may mimic their presentation. Some forms of small vessel vasculitides have a predilection for the pulmonary and renal vascular beds and if left untreated can result in fulminant organ failure. Whilst the aetiology of these syndromes remains unclear, much is known about the disease mechanisms including the pathogenic role of autoantibodies, immune-complex mediated inflammation and microangiopathic in-situ thrombosis. Despite established treatments achieving successful remission induction, patient tolerability and side effect profiles have limited their use which has led to searches for more targeted treatments. Consequently newer biological therapies have gained wider acceptance despite little being known about their long term safety and efficacy. The European Vasculitis Study Group (EUVAS) have recently formulated guidelines to provide consensus on diagnosis and management in this area and work to define survival rates in these conditions with longer term follow-up studies is ongoing. This review summarises the current aetiopathogenesis thought to underlie these complex diseases, the diagnostic definitions and classification criteria currently in use and the evidence base for modern therapies. Though unusual for respiratory specialists to coordinate overall management of these patients, an update on their current management is regarded as important to their practice given the recently changing trends in treatments.
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Affiliation(s)
- Colm McCabe
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.
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8
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Javelle E, Gasperini G, Mercier J, Luciano L, Sagui E, Soulier M, Kerebel S, Lebougeant P, Molinier S, Guisset M, Coton T, Morand JJ. A 78-year-old woman with an acute eosinophilic gastroenteritis. Clin Res Hepatol Gastroenterol 2011; 35:755-8. [PMID: 21820380 DOI: 10.1016/j.clinre.2011.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 06/22/2011] [Accepted: 06/24/2011] [Indexed: 02/04/2023]
Abstract
Eosinophil accumulation in the gastrointestinal tract is a common feature of numerous disorders including mainly parasitic infection, drug-induced allergic reactions, inflammatory bowel disease, and various connective tissue disorders. Digestive tissue eosinophilia requires thorough searching for secondary causes that may be specifically treated with antibiotics, dietary and drug elimination or immunosuppressive therapy. Frequency, prognosis and therapeutic implications must guide the diagnostic course. An acute eosinophilic gastroenteritis in a 78-year-old asthmatic woman receiving celecoxib is reported. She presented later with neurologic and cutaneous features and was finally treated by methylprednisolone and cyclophosphamide. The diagnostic approach leading to a Churg-Strauss syndrome (CSS) assertion is described. We discuss the pathogenesis, the management and the potential enhancing role of celecoxib in CSS gastrointestinal involvement.
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Affiliation(s)
- Emilie Javelle
- Department of Internal Medicine and Infectious diseases, Laveran Military Teaching Hospital, 4, boulevard Laveran, BP 60149, 13384 Marseille cedex 13, France.
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9
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A case of montelukast-induced churg-strauss syndrome associated with liver dysfunction. Case Reports Hepatol 2011; 2011:412524. [PMID: 25954543 PMCID: PMC4412211 DOI: 10.1155/2011/412524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 06/02/2011] [Indexed: 01/03/2023] Open
Abstract
A 64-year-old woman was admitted to hospital due to protracted diarrhea and liver dysfunction. The patient was diagnosed as Churg-Strauss syndrome (CSS) due to asthma, paranasal sinusitis, hypereosinophilia, and polyneuropathy. There was a history of taking montelukast, a leukotriene receptor antagonist (LTRA), which is thought to have some relationship with CSS. The liver biopsy specimen showed eosinophilic infiltration and centrolobular fatty change. In this paper, we review the relationship between LTRA and CSS. Several lines of evidence suggest that leukotriene plays an important role in maintaining neural tissues. We also review the potential relationship between centrolobular fatty change and pivoxil-containing antibiotics, which was prescribed for sinusitis before admission. Carnitine deficiency induced by pivoxil-containing agents may cause impaired fatty acid oxidation in mitochondria.
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10
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 652] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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11
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Alobid I, Cardelús S, Picado C, Mullol J. Antileukotrienes in rhinosinusitis and nasal polyposis. Expert Rev Clin Immunol 2010; 4:331-7. [PMID: 20476923 DOI: 10.1586/1744666x.4.3.331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nasal polyposis is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite different hypotheses of its cause, remains poorly understood. The management of nasal polyposis has been the topic of countless frequent controversial debates for many decades. International guidelines generally suggest that first-line treatment should be based on a medical approach with mainly nasal and oral corticosteroids. Surgical procedures are often viewed as adjunctive to medical therapy. Given that antileukotrienes are currently indicated in the treatment of asthma and allergic rhinitis and there exists an increased leukotriene production in nasal polyps, antileukotrienes, especially montelukast, may represent a potential effective therapy for chronic rhinosinusitis, including nasal polyps.
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Affiliation(s)
- Isam Alobid
- Rhinology Unit and Smell Clinic, Department of Otorhinolaryngology, Hospital Clínic i Universitari, c/ Villarroel, 170, Barcelona 08036, Catalunya, Spain
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12
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Szwarc D, Veillon F, Moser T, Averous G, De Blay F, Riehm S. [Churg-Strauss syndrome under omalizumab treatment: a rare visceral manifestation]. ACTA ACUST UNITED AC 2010; 90:1737-9. [PMID: 19953062 DOI: 10.1016/s0221-0363(09)73273-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D Szwarc
- Service de Radiologie, Hôpital de Hautepierre, Strasbourg Cedex, France.
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13
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Kaliterna DM, Perković D, Radić M. Churg-Strauss syndrome associated with montelukast therapy. J Asthma 2009; 46:604-5. [PMID: 19657903 DOI: 10.1080/02770900903006273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Churg-Strauss syndrome is a rare form of eosinophilic vasculitis associated with asthma. Several cases of eosinophilic conditions including Churg-Strauss syndrome have recently been reported in asthmatic patients being treated with antileukotriene receptor antagonists. However, whether these drugs have a direct pathogenic role remains controversial. We describe two patients who developed Churg-Strauss syndrome after starting treatment with montelukast.
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14
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El-Gamal Y. Churg-strauss syndrome in the pediatric age group. World Allergy Organ J 2008; 1:34-40. [PMID: 23283308 PMCID: PMC3650976 DOI: 10.1097/wox.0b013e3181626fde] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 11/16/2007] [Indexed: 12/15/2022] Open
Abstract
The rate of reporting of childhood Churg-Strauss syndrome (CSS) has increased lately because of either increased awareness to the disease or a real increase in incidence. It is defined as one of the antineutrophil cytoplasmic antibody-associated vasculitides, but the antineutrophil cytoplasmic antibody positivity is less reported in pediatric cases. The cause of CSS remains unknown. Several lines of evidence suggest genetic predisposition, which may entail inherited tendency to dysregulation of the cellular immune system. With the addition of leukotriene receptor antagonists to the treatment regimen of asthma, an association to CSS was presumed. However, the nature of this relationship remains to be elucidated. In addition, some environmental factors seem to provoke transient effects that resemble the disease. Patients' symptoms are defined by various degrees of eosinophilic inflammation and necrotizing vasculitis, which may affect any organ. Three clinical stages have been described in the clinical evolution of CSS: prodromal phase involving allergic rhinitis and asthma (usually without family history of atopy), a second phase that involves peripheral eosinophilia and eosinophilic tissue infiltration, and the hallmark of the final phase is systemic vasculitis. Pulmonary disease is a central feature of pediatric CSS, but other manifestations include skin lesions, testicular pain, hypertension, seizures, and nephropathy. More subtle presentations in children include cervical lymphadenopathy, acute abdominal pain, deep venous thrombosis, oral ulceration, multiple colonic ulcers, chorea, bilateral optic neuropathy, and retinal artery occlusions. Churg-Strauss syndrome patients usually respond well to corticosteroid therapy. Several trials reported additional benefit from cyclophosphamide, azathioprine, and methotrexate, whereas the therapeutic effects of etanercept, plasma exchange, and intravenous immunoglobulin therapy are controversial. The relapse rate is approximately 25% to 30%, but corticosteroids have significantly increased survival, which now approaches greater than 75% at 5 years. However, there is limited information about survival or long-term outcome in childhood.
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Affiliation(s)
- Yehia El-Gamal
- The Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt. 98 Mohamed Farid St, Cairo 11111, Egypt
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15
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Incecik F, Onlen Y, Sangun O, Akoglu S. Probable montelukast-induced hepatotoxicity in a pediatric patient: case report. Ann Saudi Med 2007; 27:462-3. [PMID: 18059126 PMCID: PMC6074176 DOI: 10.5144/0256-4947.2007.462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Faruk Incecik
- Department of Pediatrics, Cukurova University Medical Faculty, Adana, Turkey
| | - Yusuf Onlen
- Department of Infectious Diseases and Clinical Microbiology, Mustafa Kemal University Medical Faculty, Antakya, Hatay, Turkey
| | - Ozlem Sangun
- Department of Pediatrics, Mustafa Kemal University Medical Faculty, Antakya, Hatay, Turkey
| | - Sabahat Akoglu
- Department of Chest Diseases, Mustafa Kemal University Medical Faculty, Antakya, Hatay, Turkey
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16
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Guilpain P, Pagnoux C, Lhote F, Mouthon L, Guillevin L. [Antileukotrienes and Churg-Strauss syndrome]. Presse Med 2007; 36:890-4. [PMID: 17383148 DOI: 10.1016/j.lpm.2007.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Accepted: 01/24/2007] [Indexed: 11/29/2022] Open
Abstract
Churg-Strauss syndrome is a systemic necrotizing vasculitis involving small and medium-sized vessels. Classic features include asthma and hypereosinophilia. Antineutrophil cytoplasm antibodies (ANCA) are detected in about 40% of patients. Churg-Strauss syndrome has been reported in patients receiving leukotriene modifiers for asthma, in particular, leukotriene receptor antagonists (LTRA) (montelukast, zafirlukast or pranlukast). Clinical manifestations cases do not differ in these cases from those in Churg-Strauss syndrome without antileukotriene exposure. It is increasingly less likely that LTRA is the direct cause of this syndrome in those patients, although this hypothesis has not been completely ruled out. In many patients, LTRA treatment is prescribed because of worsening asthma, which is an early sign of Churg-Strauss syndrome. LTRA for asthma patients should be prescribed with great care, especially in cases of atypical or rapidly aggravated asthma. The onset of Churg-Strauss syndrome in patients treated with LTRA usually requires that they stop this treatment. Prescription of LTRA In patients with Churg-Strauss syndrome should be discussed with specialists.
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Affiliation(s)
- Philippe Guilpain
- Service de médecine interne, AP-HP, Hôpital Cochin, Université Paris V, Paris, France
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17
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Watanabe T, Iinuma Y, Naito SI, Nitta K. Eosinophilic tumor in a patient with bronchial asthma receiving pranlukast. Eur J Pediatr 2007; 166:183-4. [PMID: 16915372 DOI: 10.1007/s00431-006-0226-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 06/21/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Toru Watanabe
- Department of Pediatrics, Niigata City General Hospital, 2-6-1 Shichikuyama, 950-8739 Niigata, Japan.
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18
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Cuchacovich R, Justiniano M, Espinoza LR. Churg-Strauss syndrome associated with leukotriene receptor antagonists (LTRA). Clin Rheumatol 2007; 26:1769-71. [PMID: 17256102 DOI: 10.1007/s10067-006-0510-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Accepted: 11/27/2006] [Indexed: 10/23/2022]
Abstract
Churg-Strauss syndrome (CSS) is a rare vasculitic disorder that generally occurs in patients with bronchial asthma. CSS is being increasingly recognized in asthmatic patients treated with leukotriene receptor antagonists. However, the nature of this relationship remains to be elucidated. The present report describes three asthmatic patients who developed clinical manifestations highly suggestive of CSS, although one patient lacked the presence of eosinophilia. The patient, however, exhibited biopsy-proven cutaneous necrotizing vasculitis, which improved after withdrawal of montelukast. The second patient presented with systemic constitutional signs including fever, malaise, arthralgias, clinical jaundice, peripheral blood eosinophilia, and biopsy-proven eosinophilic hepatitis. The third patient also had circulating eosinophilia, scleritis, and arthritis. All patients improved after discontinuation of the leukotriene receptor antagonist (montelukast).
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Affiliation(s)
- R Cuchacovich
- Division of Rheumatology, Department of Internal Medicine, LSU Health Sciences Center, 2020 Gravier Street, 7th Floor, Box E-20, New Orleans, LA 70115, USA
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Cohen P, Pagnoux C, Mahr A, Arène JP, Mouthon L, Le Guern V, André MH, Gayraud M, Jayne D, Blöckmans D, Cordier JF, Guillevin L. Churg-Strauss syndrome with poor-prognosis factors: A prospective multicenter trial comparing glucocorticoids and six or twelve cyclophosphamide pulses in forty-eight patients. ACTA ACUST UNITED AC 2007; 57:686-93. [PMID: 17471546 DOI: 10.1002/art.22679] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare long and short durations of adjunctive cyclophosphamide for the treatment of severe Churg-Strauss syndrome (CSS). METHODS In this prospective multicenter therapeutic trial, 48 patients with CSS with at least 1 poor-prognosis factor at baseline were treated with glucocorticoids and either 12 or 6 intravenous cyclophosphamide pulses. RESULTS At 8 years, complete remission rates and severe side effects of therapy were comparable for both groups. The overall difference in relapses was not significant between the 12-pulse and the 6-pulse regimens (P = 0.07), but when considering only the number of mild relapses this difference became statistically significant (P < 0.02). Although the total number of inclusions was not reached, the study was stopped prematurely in response to the superiority of the 12-pulse regimen. CONCLUSION We concluded that 12 cyclophosphamide pulses were better able to control severe CSS than a 6-pulse regimen. The optimal duration of therapy remains to be determined.
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Affiliation(s)
- Pascal Cohen
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université René Descartes Paris, Recherche Clinique et Thérapeutique, Paris, France
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20
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Obase Y, Matsuse H, Shimoda T, Haahtela T, Kohno S. Pathogenesis and management of aspirin-intolerant asthma. ACTA ACUST UNITED AC 2005; 4:325-36. [PMID: 16137190 DOI: 10.2165/00151829-200504050-00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In 2-23% of adults with asthma, and rarely in children with asthma, aspirin (acetylsalicylic acid) and non-steroidal anti-inflammatory drugs (NSAIDs) cause asthma exacerbations. Within 3 hours of ingestion of aspirin/NSAIDs, individuals with aspirin-intolerant asthma (AIA) develop bronchoconstriction, often accompanied by rhinorrhea, conjunctival irritation, and scarlet flush. In severe cases, a single therapeutic dose of aspirin/NSAIDs can provoke violent bronchospasm, loss of consciousness, and respiratory arrest. In order to diagnose AIA, oral, inhaled, nasal or intravenous aspirin challenge tests are performed in facilities where experienced physicians are present and emergency treatment is available. The exact differences in the pathogenesis of AIA and other types of asthma are not fully understood. The interference of aspirin/NSAIDs with arachidonic acid metabolism in the lungs plays an important role in the mechanism of AIA; inhibition of cyclo-oxygenase is accompanied by overproduction of cysteinyl leukotrienes (cys-LTs). It has been proposed that overproduction of cys-LTs, together with removal by aspirin/NSAIDs of the 'brake' imposed by the bronchodilator prostaglandin E2, may cause an asthma attack in patients with AIA. Development of a suitable animal model to investigate the pathogenesis of AIA would help to clarify this question. Although it is still controversial whether leukotriene modifiers are more effective in patients with AIA compared with other types of asthma, because LT plays an important role in the pathogenesis of AIA, leukotriene modifiers are the preferred medication for the long-term control of AIA. Add-on efficacy of leukotriene modifiers has been confirmed in patients with AIA already treated with inhaled corticosteroids. However, this does not mean that aspirin/NSAIDs can be safely taken by aspirin-sensitive patients treated with leukotriene modifiers. To prevent attacks of AIA, sensitive patients should avoid the use of aspirin/NSAIDs or use selective cyclo-oxygenase 2 inhibitors when required. When patients with AIA need aspirin for specific situations they should receive aspirin desensitization therapy or treatment with selective cyclo-oxygenase 2 inhibitors.
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Affiliation(s)
- Yasushi Obase
- Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland.
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Riccioni G, Di Ilio C, D'Orazio N. An update of the leukotriene modulators for the treatment of asthma. Expert Opin Investig Drugs 2005; 13:763-76. [PMID: 15212617 DOI: 10.1517/13543784.13.7.763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bronchial asthma is a chronic inflammatory airway disease involving many cells and mediators. Chronic inflammation constitutes an important predisposing condition for airway remodelling with secondary irreversible airflow obstruction. Current approaches for asthma treatment involve many classes of drugs, adequate patient education for their correct use, environmental exposure control and daily monitoring of pulmonary function. Unfortunately, the use of multiple therapies complicates treatment regimens, thus leading to a reduced compliance to therapy. Available evidence from randomised clinical trials and real-word experience derived from managing patients with asthma justifies a broader role for leukotriene receptor antagonist drugs in asthma management than that recommended in the National Asthma Education and Prevention Programme and National Health Lung and Blood Institute Treatment Guidelines. While a low dose of inhaled corticosteroids remains the reference drug as a controller in mild-to-moderate persistent asthma, oral therapy with an leukotriene-receptor antagonist drug represents a good option providing the clinical efficacy requested in common clinical practice. For this reason the recent Global Initiative for Asthma Guidelines allocate this drug to the second and third steps of asthma treatment.
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Affiliation(s)
- Graziano Riccioni
- G D'Annunzio University, Department of Biomedical Science, Via dei Vestini 66013, 66100 Chieti, Italy.
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22
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Abstract
A síndrome de Churg-Strauss caracteriza-se por asma, eosinofilia e graus variados de vasculite sistêmica. As formas mais graves com acometimento cardíaco, gastrintestinal, sistema nervoso central e renal requerem ciclofosfamida para seu tratamento.
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Beduneau G, Berard H, Dominique S, Picard C, Calvet P, Nouvet G. [Churg-Strauss syndrome relapse when antileucotriene in taggered]. Rev Med Interne 2005; 26:832-5. [PMID: 15993988 DOI: 10.1016/j.revmed.2005.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Accepted: 05/02/2005] [Indexed: 10/25/2022]
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McDanel DL, Muller BA. The linkage between Churg-Strauss syndrome and leukotriene receptor antagonists: fact or fiction? Ther Clin Risk Manag 2005; 1:125-40. [PMID: 18360552 PMCID: PMC1661620 DOI: 10.2147/tcrm.1.2.125.62913] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Epidemiologic evidence has shown that the worldwide prevalence of asthma is increasing. The leukotriene receptor antagonists (LTRAs) represent a new class of therapy for asthma. They have been developed in the last decade and play a pivotal steroid-sparing role in treating the inflammatory component of asthma. Consequently, reports of Churg-Strauss syndrome (CSS), a rare form of systemic vasculitis, have been recognized as a potential side effect in individuals with moderate to severe asthma on LTRA therapy. The serious nature of this disorder is worthy of prompt recognition by clinicians and aggressive therapy to avoid the subsequent longstanding effects of vasculitis. To validate the postulated linkage between the LTRAs and CSS, this review comprehensively evaluates reported cases in the literature and supports a pathophysiological relationship between the LTRAs and the development of CSS.
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Affiliation(s)
- Deanna L McDanel
- Departments of Pharmaceutical Care University of Iowa Hospitals and ClinicsIowa City, IA, USA
| | - Barbara A Muller
- Internal Medicine, University of Iowa Hospitals and ClinicsIowa City, IA, USA
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Hamad AM, Sutcliffe AM, Knox AJ. Aspirin-induced asthma: clinical aspects, pathogenesis and management. Drugs 2005; 64:2417-32. [PMID: 15482000 DOI: 10.2165/00003495-200464210-00004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Aspirin (acetylsalicylic acid)-induced asthma (AIA) consists of the clinical triad of asthma, chronic rhinosinusitis with nasal polyps, and precipitation of asthma and rhinitis attacks in response to aspirin and other NSAIDs. The prevalence of the syndrome in the adult asthmatic populations is approximately 4-10%. Respiratory disease in these patients may be aggressive and refractory to treatment. The aetiology of AIA is complex and not fully understood, but most evidence points towards an abnormality of arachidonic acid (AA) metabolism. Cyclo-oxygenase (COX), the rate-limiting enzyme in AA metabolism, exists as two main isoforms. COX-1 is the constitutive enzyme responsible for synthesis of protective prostanoids, whereas COX-2 is induced under inflammatory conditions. A number of theories regarding its pathogenesis have been proposed. The shunting hypothesis proposes that inhibition of COX-1 shunts AA metabolism away from production of protective prostanoids and towards cysteinyl leukotriene (cys-LT) biosynthesis, resulting in bronchoconstriction and increased mucus production. The COX-2 hypothesis proposes that aspirin causes a structural change in COX-2 that results in the generation of products of the lipoxygenase pathway. It is speculated that this may result in the formation of mediators that cause respiratory reactions in AIA. Related studies provide evidence for abnormal regulation of the lipoxygenase pathway, demonstrating elevated levels of cys-LTs in urine, sputum and peripheral blood, before and following aspirin challenge in AIA patients. These studies suggest that cys-LTs are continually and aggressively synthesised before exposure to aspirin and, during aspirin-induced reactions, acceleration of synthesis occurs. A genetic polymorphism of the LTC4S gene has been identified consisting of an A to C transversion 444 nucleotides upstream of the first codon, conferring a relative risk of AIA of 3.89. Furthermore, carriers of the C444 allele demonstrate a dramatic rise in urinary LTE(4) following aspirin provocation, and respond better to the cys-LT antagonist pranlukast than A444 homozygotes.AIA patients have an aggressive form of disease, and treatment should include combination therapy with inhaled corticosteroids, beta(2)-adrenoceptor agonists and LT modifiers. Furthermore, recently developed inhibitors of COX-2 may be safer in patients with AIA.
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Affiliation(s)
- Ahmed M Hamad
- Department of Respiratory Medicine, Al-Mansourah University, Al-Dakahlia, Egypt
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DuMouchel W, Smith ET, Beasley R, Nelson H, Yang X, Fram D, Almenoff JS. Association of asthma therapy and Churg-Strauss syndrome: an analysis of postmarketing surveillance data. Clin Ther 2004; 26:1092-1104. [PMID: 15336474 DOI: 10.1016/s0149-2918(04)90181-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Churg-Strauss syndrome (CSS), also known as allergic granulomatous angiitis (AGA), is a rare vasculitis that occurs in patients with bronchial asthma. The nature of the association of CSS with various asthma therapies is unclear. OBJECTIVE This study investigated the associations of different multidrug asthma therapy regimens and the reporting of AGA (the preferred code for CSS in the coding dictionary for the Adverse Event Reporting System [AERS]) by applying an iterative method of disproportionally analysis to th AERS database maintained by the US Food and Drug Administration. METHODS The public-release version of the AERS database was used to identify reports of AGA in patients receiving asthma therapy. Reporting of AGA was examined using iterative disproportionality methods in patients receiving > or =1 of the following drug classes: inhaled corticosteroid (ICS), leukotriene receptor antagonist (LTRA), short-acting beta(2)-agonist (SABA), or long-acting beta(2)-agonist (LABA). The Bayesian data-mining algorithm known as the multi-item gamma poisson shrinker was used to determine the relative reporting rates by calculation of the empirical Bayes geometric mean (EBGM) and its 90% CI (EB05 = lower limit and EB95 = upper limit) for each drug. Subset analyses were performed for each drug with different medication combinations to differentiate the relative reporting of AGA for each. RESULTS A strong association was found between LTRA use and AGA (EBGM = 104.0, EB05 = 95.0, EB95 = 113.8) that persisted with all combinations of therapy studied. AGA was also associated with the ICS, SABA and LABA classes (EBGM values of 27.8, 14.6 and 40.4, respectively). However, the latter associations were mostly dependent on the presence of concurrent LTRA and, to a lesser extemt, oral corticosteroid therapy and became negligible (ie, EB05 < 2) for patients who were not receiving these concurrent treatments. CONCLUSIONS Differences based on relative reporting were observed in the patterns of association of AGA with LTRA, ICS, and beta(2)-agonist therapies. A strong association between LTRA use and AGA was present regardless of the use of other asthma drugs.
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Cantrell FL, Farson-Collier M. The benign clinical course following a large pediatric montelukast ingestion. ACTA ACUST UNITED AC 2004; 42:333-4. [PMID: 15362605 DOI: 10.1081/clt-120037436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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De Nardo D, De Sanctis G, Biancone L, Khalil J, Kroegler B, De Risi E, Franconi G, Capria A, Fontana L. Churg-Strauss Syndrome Development during Asthma Therapy with Leukotriene Receptor Antagonists: Just a Coincidental Association? EUR J INFLAMM 2004. [DOI: 10.1177/1721727x0400200307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A report on our clinical experience based on 3 male patients who developed Churg-Strauss syndrome (CSS) after standard oral montelukast use. All patients affected by moderate asthma and chronic hyperplastic rhinosinusitis were treated with inhaled corticosteroids and ß2 agonists. Systemic corticosteroid treatment consisted in oral daily prednisone in case 1, in short courses of oral betamethasone in case 2, and in remote and isolated administrations of oral betamethasone and intramuscular methylprednisolone in case 3. Because of the improvement of the asthma symptoms after montelukast use, patient 1 decided to take half the dose of prednisone for 10 days and patient 2 decided to discontinue systemic and inhaled corticosteroids for 45 days. Overt CSS was heralded by vasculitic skin lesions and developed in each patient with severe organ damage, consisting in renal, myocardial and gastrointestinal involvement. Remission was obtained by standard CSS therapy after montelukast withdrawal. According to the unmasking hypothesis, antileukotriene treatment, by enabling the reduction in systemic corticosteroid therapy in case 1 and its discontinuation in case 2, might have only permitted the precipitation of the vasculitis. However antileukotriene-associated CSS reportedly occurred in systemic corticosteroid-naïve patients and relapsed in one patient after antileukotriene treatment. These observations lend support to the concept that the precipitation of the vasculitic phase may be associated with leukotriene modifier deleterious effects. In conclusion there is not enough evidence to prove that antileukotriene treatment plays a direct causative role in the pathogenesis of CSS. Further clinical and experimental research is required to clarify the antileukotriene associated CSS controversy.
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Affiliation(s)
| | | | - L. Biancone
- Cattedra di Gastroenterologia, Department of Internal Medicine, Tor Vergata University of Rome, Italy
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Abstract
For most patients who have suspected drug-induced eosinophilic lung disease, the history provides a presumptive diagnosis that can be confirmed by pulmonary findings and eosinophilia after cessation of the drug. As new drugs are developed and released for clinical use, many will result in eosinophilic lung disease in susceptible patients. Therefore, development of pulmonary abnormalities in conjunction with blood or lung eosinophilia after prescription ofa newly released medication should raise the possibility of drug-induced lung disease, even if that medication has not yet been reported to cause eosinophilic lung disease. In all patients, the diagnosis requires exclusion of other causes of eosinophilic lung disease by history, and, if necessary, laboratory testing or lung biopsy.
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Affiliation(s)
- James N Allen
- Division of Pulmonary and Critical Care Medicine, The Ohio State University, 201 Heart Lung Institute Building, 473 West 12th Avenue, Columbus, OH 43210, USA.
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Moraes TJ, Selvadurai H. Management of exercise-induced bronchospasm in children: the role of leukotriene antagonists. ACTA ACUST UNITED AC 2004; 3:9-15. [PMID: 15174889 DOI: 10.2165/00151829-200403010-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This review assesses the evidence on the efficacy of leukotriene antagonists in the management of exercise-induced bronchospasm (EIB) in children. Only two randomized, double-blind, placebo-controlled, crossover studies have examined the effect of leukotriene antagonists in EIB in a pediatric setting. All other studies, including those comparing leukotriene antagonists with other agents such as beta(2)-adrenoceptor agonists (beta(2)-agonists) and inhaled corticosteroids, primarily involve adult patients. In children, not receiving other asthma medication, leukotriene antagonists can offer statistically significant protection from EIB compared with placebo. However, protection is not complete, as a significant proportion of children will continue to experience a >15% reduction in FEV(1). None of the studies involved children treated concurrently with other asthma medications; therefore, comments on additive therapy cannot be made. Despite evidence from only a few studies, leukotriene antagonists are seen to be well tolerated, efficacious, and of benefit to some children. In addition, current management for EIB with short-acting beta(2)-agonists is less than ideal. It is therefore concluded that in children with EIB, leukotriene antagonists are indicated on a trial basis with individualized therapy and follow-up to evaluate treatment response.
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Affiliation(s)
- Theo J Moraes
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Otani Y, Anzai S, Shibuya H, Fujiwara S, Takayasu S, Asada Y, Terashi H, Takuma M, Yokoyama S. Churg-Strauss syndrome (CSS) manifested as necrosis of fingers and toes and liver infarction. J Dermatol 2004; 30:810-5. [PMID: 14684939 DOI: 10.1111/j.1346-8138.2003.tb00483.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2003] [Accepted: 07/01/2003] [Indexed: 12/17/2022]
Abstract
We report a case of Churg-Strauss syndrome (CSS) with necrosis of the fingers and toes and liver infarction. A 59-year-old man with asthma suddenly noticed that his fingers and toes felt unusually cold. This condition worsened progressively, and some digits became necrotic within several weeks. Laboratory studies revealed hypereosinophilia and an extremely elevated serum level of IgE. Digital subtraction angiography of the extremities revealed extensive irregular narrowing of small and medium-sized arteries in the extremities. Abdominal computed tomography (CT) revealed an area of low density at the periphery of the right lobe of the liver. Angiography revealed irregular narrowing of small arteries that corresponded to the ischemic area. A nerve conduction study suggested sensory nerve neuropathy. The preceding asthma, acute onset of digital necrosis, liver infarction, neuropathy, and hypereosinophilia strongly suggested a diagnosis of CSS. The patient was treated with 40 mg of prednisolone and 120 micro g of intravenous prostaglandin E1 daily, and all the digits that had turned black and necrotic were amputated. After the amputation, the dose of prednisolone was gradually reduced, and no new lesions appeared on the skin or in the liver. The rare possible complications of CSS, including necrosis of digits and liver infarction, should not be ignored.
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Affiliation(s)
- Yuichiro Otani
- Department of Anatomy, Biology, and Medicine (Dermatology), Oita Medical University, Oita, Japan
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Kobayashi S, Ishizuka S, Tamura N, Takaya M, Kaneda K, Hashimoto H. Churg-Strauss syndrome (CSS) in a patient receiving pranlukast. Clin Rheumatol 2003; 22:491-2. [PMID: 14677037 DOI: 10.1007/s10067-003-0791-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2003] [Accepted: 08/11/2003] [Indexed: 11/30/2022]
Abstract
Pranlukast is a cysteinyl leukotriene receptor I antagonist (LTRAs) approved for treatment of asthma in Japan since 1995. Compared to other LTRAs, such as zafilukast and montelukast, only few cases with Churg-Strauss syndrome (CSS) have been reported in association with treatment with pranlukast. We describe a 17-year-old Japanese male patient who developed CSS with a 13 month history of mild asthma receiving pranlukast for 11 months without systemic and/or inhaled corticosteroid administration prior to development of CSS. From the aspect of temporal relationship between treatment with pranlukast and development of CSS, a direct induction of CSS by pranlukast is suggested in our case.
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Affiliation(s)
- Shigeto Kobayashi
- Department of Rheumatology and Internal Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, 113-8421 Tokyo, Japan.
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Choi IS, Koh YI, Joo JY, Lee SH, Bae WG. Churg-Strauss syndrome may be induced by leukotriene modifiers in severe asthma. Ann Allergy Asthma Immunol 2003; 91:98. [PMID: 12877461 DOI: 10.1016/s1081-1206(10)62071-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Granulomatous vasculitis is a subset of systemic necrotizing vasculitis and has granulomatous inflammation as the main histopathologic feature. Etiopathogenesis remains poorly understood, although recent advances suggest an important role for certain pro-inflammatory cytokines, such as tumor necrosis factor-alpha. They are a heterogeneous group of clinical disorders with protean manifestations. Serologic abnormalities are present, and the presence of granular cytoplasmic staining-antineutrophil cytoplasmic antibodies is most important and is particularly useful for the diagnosis of active Wegener's granulomatosis. Corticosteroids and cyclophosphamide remain very useful in the treatment of most of these disorders.
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Affiliation(s)
- Javier Marquez
- Section of Rheumatology, Department of Medicine, Louisiana State University, New Orleans 70112, USA
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Masi AT, Hamilos DL. Leukotriene antagonists: bystanders or causes of Churg-Strauss syndrome? Semin Arthritis Rheum 2002; 31:211-7. [PMID: 11836654 DOI: 10.1053/sarh.2002.30439] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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