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Suzuki K, Akiyama M, Kondo Y, Saito S, Kikuchi J, Hanaoka H, Kaneko Y. Re-emphasising the importance of catheter-based angiography to differentiate polyarteritis nodosa from cutaneous arteritis: Two case reports. Mod Rheumatol Case Rep 2023; 8:133-136. [PMID: 37947049 DOI: 10.1093/mrcr/rxad064] [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: 08/29/2023] [Revised: 10/14/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis with a poor prognosis, characterised by inflammation and necrosis of medium-sized arteries. PAN patients can present with a wide range of systemic manifestations, whereas cutaneous arteritis (CA) is a restricted manifestation to skin of the disease with a more favourable prognosis. Thus, differentiation between PAN and CA is crucial. Here, we present two cases that were initially diagnosed as CA due to the limited presence of systemic symptoms, but were finally diagnosed as PAN through catheter-based angiography. Although contrast-enhanced computed tomography and computed tomographic angiography are increasingly used to diagnose PAN, neither case had any abnormal findings on these examinations. Our cases therefore underscore that catheter-based angiography is critical for differentiation between PAN and CA, even in cases with limited systemic symptoms.
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Affiliation(s)
- Koji Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Kondo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Berardi E, Antonica G, Procaccio A, Marziliano D, Susca N, Leone P, Sabbà C, Racanelli V, Prete M. Cutaneous polyarteritis nodosa and pulmonary arterial hypertension: An unexpected liaison. A case report. Medicine (Baltimore) 2023; 102:e36563. [PMID: 38115264 PMCID: PMC10727645 DOI: 10.1097/md.0000000000036563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Cutaneous polyarteritis nodosa (cPAN) is a form of medium-sized vessel necrotizing vasculitis. It is a rare, skin-limited variant of polyarteritis nodosa, characterized by dermal and subcutaneous tissue involvement. The most common findings in cPAN include digital gangrene, livedo reticularis, and tender subcutaneous nodules. However, while limited to the skin, cPAN results in significant morbidity and mortality due to the accompanying skin ischemia and necrosis, such that patients are vulnerable to superinfection. Here, we describe a unique presentation of cPAN associated with pulmonary arterial hypertension (PAH). METHODS A 78-year-old female presented with digital ischemia and leg ulcers associated with PAH. Skin biopsy showed necrotizing fibrinoid necrosis of the small- and middle-sized vessels of the dermis. A diagnosis of cPAN and PAH was made. The patient was treated with glucocorticoids, vasodilators, and cyclophosphamide. RESULTS She died due to severe sepsis complications. CONCLUSION To date, this is the first case report describing the association between cPAN and PAH. In this case, PAH is a complication of the cutaneous vasculitides suggesting that vasculopathy could play a role in the pathophysiology of PAH. However, the underlying pathophysiological mechanisms still have to be firmly established.
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Affiliation(s)
- Elsa Berardi
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Gianfranco Antonica
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Annagrazia Procaccio
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Donatello Marziliano
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Nicola Susca
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Patrizia Leone
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Carlo Sabbà
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Vito Racanelli
- Centre for Medical Sciences, University of Trento and Internal Medicine Unit, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy
| | - Marcella Prete
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
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Feng H, Li S, Jie Y. Leucocytoclastic Vasculitis Presenting as Bilateral Ulcerative Keratitis: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231204358. [PMID: 37808226 PMCID: PMC10559690 DOI: 10.1177/11795476231204358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023]
Abstract
Introduction Small artery disease caused by neutrophils and immune-mediated is known as leucocytoclastic vasculitis (LCV). Clinically, it manifests as palpable, asymptomatic purpuric papules on the limbs. Ocular manifestation is rare. Here, we describe a case of peripheral ulcerative keratitis (PUK) associated with LCV. Case presentation A 59-year-old man was referred to the hospital with blurred vision due to corneal perforation in his left eye. He complained of itchy nodules on his hands and lower legs for 15 years and the skin biopsy of the back of his hand revealed LCV 6 years ago, which suggested erythema elevatum diutinum. The patient was under treatment with anti-inflammatory and immunosuppressive drugs and physical features of LCV seen in him included erythema on his hands and legs. After receiving conjunctival flap covering surgery, the corneal perforation was resolved. Conjunctival flaps covered cornea that limited his vision to hand motion. Six months later, he was referred to our clinic again because of pain, redness, photophobia, and tearing in the right eye, presenting with PUK. Necrotic tissue was removed during surgery, which also included a conjunctival flap covering procedure. Following surgery, the symptoms were reduced, and the postoperative eye condition remained stable. Conclusion To our knowledge, it is the first case of PUK secondary to LCV which was diagnosed 6 years ago. This case demonstrates that PUK associated with LCV can be successfully treated by surgical interventions.
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Affiliation(s)
| | | | - Ying Jie
- Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing Tongren Eye Center, Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Uehara H, Okuyama M, Oe Y, Yoshimura T, Gunji T. Cutaneous Arteritis Presenting With Chronic Limb-Threatening Ischemia. Circ J 2023; 87:1407. [PMID: 37648456 DOI: 10.1253/circj.cj-23-0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Hiroki Uehara
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital
| | - Masaki Okuyama
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital
| | - Yutaro Oe
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital
| | | | - Takahiro Gunji
- Department of Cardiovascular Medicine, Kin-ikyo Chuo Hospital
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Fujimoto M, Miyake T, Kaku Y, Hirata M, Kabashima K, Haga H. Cutaneous arteritis with intimal fibrin ring and immature myeloid cell infiltrate: lymphocytic thrombophilic arteritis or histiocytoid polyarteritis nodosa? Virchows Arch 2023:10.1007/s00428-023-03531-8. [PMID: 36964280 DOI: 10.1007/s00428-023-03531-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/26/2023]
Abstract
The ongoing debate on whether lymphocytic thrombophilic arteritis (LTA) is a separate disease or a type of polyarteritis nodosa (PAN) has yet to be settled. In this study, we analyzed the nature of infiltrating cells in LTA to resolve this controversy. Skin biopsies from five female patients (mean age 29.4 years, age range 16-45 years) diagnosed with LTA were immunostained for CD3, CD20, CD68, lysozyme, myeloid cell nuclear differentiation antigen, myeloperoxidase, and PU.1. Immunohistochemistry revealed that the majority of mononuclear cells in all five cases were not lymphocytes but myelomonocytic cells. Given that the infiltrating cells are of the myelomonocyte lineage including immature myeloid cells, PAN was deemed the more appropriate diagnosis for the five cases rather than LTA. Whether PAN with immature myeloid cells (histiocytoid PAN) is the same disease as conventional PAN with mature neutrophils requires further investigation.
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Affiliation(s)
- Masakazu Fujimoto
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Toshiya Miyake
- Department of Dermatology, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yo Kaku
- Department of Dermatology, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Masahiro Hirata
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Kenji Kabashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Hanberg JS, Miloslavsky EM. Steroid sparing in vasculitis: Myth or reality? Best Pract Res Clin Rheumatol 2023; 37:101843. [PMID: 37355346 DOI: 10.1016/j.berh.2023.101843] [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: 03/29/2023] [Revised: 05/13/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023]
Abstract
Glucocorticoids are the cornerstone of therapy for all forms of vasculitis. However, glucocorticoid treatment carries with it the risk of glucocorticoid toxicity. Recent research efforts in vasculitis have emphasized investigation into strategies that reduce glucocorticoid exposure. These strategies include the adoption of rapid-acting steroid-sparing agents, reduced-dose glucocorticoid induction regimens, the early introduction of steroid-sparing agents for maintenance therapy, and the extension of maintenance therapy to minimize glucocorticoid exposure associated with disease relapse. These are critical advances to move us toward the goal of glucocorticoid-free treatment of vasculitis. The evidence supporting each of these strategies and directions for future research are explored.
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Affiliation(s)
| | - Eli M Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Elston DM. Letter from the Editor: Management of cutaneous polyarteritis nodosa. J Am Acad Dermatol 2022; 87:1273-1274. [PMID: 35643240 DOI: 10.1016/j.jaad.2022.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Dirk M Elston
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Liang I, Hamid M, Sebaratnam D, Manolios N. The spectrum of cutaneous polyarteritis nodosa. A case report of two contrasting cases and review of the literature. Clin Case Rep 2022; 10:e6659. [PMCID: PMC9701887 DOI: 10.1002/ccr3.6659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ian Liang
- Department of Rheumatology Westmead Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Mariya Hamid
- Department of Rheumatology Westmead Hospital Sydney New South Wales Australia
| | - Deshan Sebaratnam
- Department of Dermatology Liverpool Hospital Sydney New South Wales Australia
- Faculty of Medicine University of New South Wales Sydney New South Wales Australia
| | - Nicholas Manolios
- Department of Rheumatology Westmead Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
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Cole C, Amber KT. Off-Label Uses of Rituximab in Dermatology. CURRENT DERMATOLOGY REPORTS 2022; 11:209-220. [PMID: 36217351 PMCID: PMC9534735 DOI: 10.1007/s13671-022-00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review Rituximab has transformed the treatment of B-cell malignancies and rheumatoid arthritis in the past 2 decades. More recently, this anti-CD20 monoclonal antibody has seen increasing usage in the field of dermatology. This review highlights the evidence supporting its use in several important dermatologic conditions. Recent Findings Key recent findings include the 2018 FDA approval of rituximab for the treatment of moderate-to-severe pemphigus. Summary Data from randomized controlled trials have demonstrated the efficacy of rituximab in pemphigus, ANCA-associated vasculitis, and cryoglobulinemic vasculitis. More limited data suggests its use in recalcitrant cases of diseases such as pemphigoid, epidermolysis bullosa acquisita, and dermatomyositis. There is scarce evidence and mixed results for rituximab when studied in cutaneous polyarteritis nodosa and cutaneous lupus erythematosus.
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Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL USA
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Abstract
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that preferentially affects medium-sized vessels. The idiopathic form has become rare. Its treatment relies on corticosteroid therapy and is combined with cyclophosphamide infusions for severe forms. Secondary PANs were mainly associated with hepatitis B virus infection; they were treated with plasma exchange and antivirals in combination with short-term corticosteroid therapy. Other secondary forms of PAN are now becoming more common, such as those due to blood disorders. More recently, a monogenic form linked to adenosine deaminase-2 mutations has been identified. It requires treatment with TNF inhibitors to decrease the occurrence of ischemic central nervous system complications, which make it serious. Once remission is obtained, relapses are typically rare during PAN and affect 28% of idiopathic PANs, within an average of 26 months from the diagnosis. The prognosis has improved considerably, with 5- and 10-year survival rates of 83% and 74%.
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Affiliation(s)
- Xavier Puéchal
- Centre de Référence des Maladies Systémiques Auto-immunes rares d'Île de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Institut Cochin, Inserm U1016, CNRS UMR 8104, Paris, France.
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