1
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Eckstein A, Welkoborsky HJ. [Interdisciplinary Management of Orbital Diseases]. Laryngorhinootologie 2024; 103:S43-S99. [PMID: 38697143 DOI: 10.1055/a-2216-8879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.
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Affiliation(s)
| | - H-J Welkoborsky
- Univ. Klinik für Augenheilkunde Universitätsmedizin Essen, Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, Klinikum Nordstadt der KRH
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2
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Falde SD, Fussner LA, Tazelaar HD, O'Brien EK, Lamprecht P, Konig MF, Specks U. Proteinase 3-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e314-e327. [PMID: 38574742 DOI: 10.1016/s2665-9913(24)00035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024]
Abstract
Proteinase 3 (PR3)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is one of two major ANCA-associated vasculitis variants and is pathogenically linked to granulomatosis with polyangiitis (GPA). GPA is characterised by necrotising granulomatous inflammation that preferentially affects the respiratory tract. The small vessel vasculitis features of GPA are shared with microscopic polyangiitis. Necrotising granulomatous inflammation of GPA can lead to PR3-ANCA and small vessel vasculitis via activation of neutrophils and monocytes. B cells are central to the pathogenesis of PR3-ANCA-associated vasculitis. They are targeted successfully by remission induction and maintenance therapy with rituximab. Relapses of PR3-ANCA-associated vasculitis and toxicities associated with current standard therapy contribute substantially to remaining mortality and damage-associated morbidity. More effective and less toxic treatments are sought to address this unmet need. Advances with cellular and novel antigen-specific immunotherapies hold promise for application in autoimmune disease, including PR3-ANCA-associated vasculitis. This Series paper describes the inter-related histopathological and clinical features, pathophysiology, as well as current and future targeted treatments for PR3-ANCA-associated vasculitis.
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Affiliation(s)
- Samuel D Falde
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Henry D Tazelaar
- Department of Anatomic Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maximilian F Konig
- Division of Rheumatology, Department of Medicine & Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
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3
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Li Z, Zhang Q, Wang X, Shi F. Granulomatosis with polyangiitis presenting headache: A case report and review of literature. Medicine (Baltimore) 2024; 103:e36972. [PMID: 38215096 PMCID: PMC10783307 DOI: 10.1097/md.0000000000036972] [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: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024] Open
Abstract
RATIONALE Central nervous system involvement is a rare manifestation of active-phaselocalized Granulomatosis with polyangiitis (GPA). In hypertrophic dura meningitis, GPA with headache is typical. In this case, cerebral magnetic resonance (MR) enhancement revealed no meningeal thickening, to our knowledge, this manifestation had not been found previously. PATIENT CONCERNS The patient presented to the Rheumatology and Immunology Clinic with severe headache and hearing loss, and central nervous system granulomatosis with polyangiitis was confirmed after a series of examinations. The patient had no significant effect after treatment with cyclophosphamide (CTX), but after the use of rituximab, the headache and hearing loss were significantly improved, and laboratory indicators returned to normal levels. DIAGNOSIS We comprehensively screened for craniocerebral infection and malignant tumors, diagnosed central nervous system granulomatosis with polyangiitis. INTERVENTIONS We gave sequential treatment of rituximab. OUTCOMES All indicators are mostly back to normal when the patient was monitored at the outpatient clinic. LESSONS GPA and severe headache are more prevalent in hypertrophic dura meningitis, but the patient early headache could not be explained by hypertrophic dura meningitis or localized granulomatous lesions that invaded the central nervous system. Patients with severe headaches likely have vascular inflammation and local bone destruction at the base of the skull.
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Affiliation(s)
- Zhao Li
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Qiushuang Zhang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xuebin Wang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Fang Shi
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
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4
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Sorin B, Iudici M, Guerry MJ, Samson M, Bielefeld P, Maillet T, Nouvier M, Karras A, Meyer L, Lavigne C, Régent A, Durel CA, Fabre M, Charles P, Raimbourg Q, Lanteri A, Pugnet G, Rivière F, Pineton de Chambrun M, Cacoub P, Le Guenno G, Jourdain P, Mekinian A, Paule R, Dion J, Legendre P, Cohen P, Guillevin L, Puéchal X, Terrier B. Induction failure in granulomatosis with polyangiitis: a nationwide case-control study of risk factors and outcomes. Rheumatology (Oxford) 2023; 62:3662-3671. [PMID: 36847447 DOI: 10.1093/rheumatology/kead098] [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: 11/22/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE To identify characteristics of granulomatosis with polyangiitis (GPA) associated with induction failure, describe salvage therapies and their efficacy. METHODS We conducted a nationwide retrospective case-control study of GPA with induction failure between 2006 and 2021. Each patient with induction failure was randomly paired to three controls matched for age, sex and induction treatment. RESULTS We included 51 patients with GPA and induction failure (29 men and 22 women). At induction therapy, median age was 49 years. Twenty-seven patients received intravenous cyclophosphamide (ivCYC) and 24 rituximab (RTX) as induction therapy. Patients with ivCYC induction failure more frequently had PR3-ANCA (93% vs 70%, P = 0.02), relapsing disease (41% vs 7%, P < 0.001) and orbital mass (15% vs 0%, P < 0.01) compared with controls. Patients with disease progression despite RTX induction therapy more frequently had renal involvement (67% vs 25%, P = 0.02) with renal failure (serum creatinine >100 µmol/l in 42% vs 8%, P = 0.02) compared with controls. After salvage therapy, remission was achieved at 6 months in 35 (69%) patients. The most frequent salvage therapy was switching from ivCYC to RTX (or vice versa), showing an efficacy in 21/29 (72%). Remission was achieved in nine (50%) patients with inappropriate response to ivCYC, while in patients with progression after RTX induction, remission was achieved in four (100%) who received ivCYC (with or without immunomodulatory therapy), but only in three (50%) after adding immunomodulatory therapy alone. CONCLUSION In patients with induction failure, characteristics of GPA, salvage therapies and their efficacy vary according to induction therapy and failure modality.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Michele Iudici
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Division of Rheumatology, Department of Internal Medicine and Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Mary-Jane Guerry
- Department of Nephrology, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Philip Bielefeld
- Department of Nephrology and Systemic Diseases, Hôpital François Mitterrand, Dijon, France
| | - Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Mathilde Nouvier
- Department of Nephrology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Lara Meyer
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Lavigne
- Department of Internal Medicine-Clinical Immunology, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marc Fabre
- Department of Internal Medicine, Centre Hospitalier Pierre Oudot, Bourgouin, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Quentin Raimbourg
- Department of Nephrology, Hôpital Bichat Claude Bernard, Paris, France
| | - Aurélia Lanteri
- Department of Internal Medicine-Infectious Diseases, Centre Hospitalier d'Antibes, Antibes, France
| | - Grégory Pugnet
- Department of Internal Medicine and Clinical Immunology, Hôpital Rangueil, Toulouse, France
| | - Frédéric Rivière
- Department of Pneumology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | | | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital d'Estaing, Clermont-Ferrand, France
| | - Pierre Jourdain
- Department of Nephrology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Arsène Mekinian
- Department of Internal Medicine, Hôpital Saint-Antoine, Paris, France
| | - Romain Paule
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Department of Clinical Immunology, Centre Hospitalier du Mans, Le Mans, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
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5
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Baca V, Barragán-García AA, García-Vega D, Vázquez-Lara Y, Siordia-Reyes G, Yañez-Gutierrez L. Limited granulomatosis with polyangiitis in children with idiopathic orbital inflammation: a case series and literature review. Rheumatol Int 2023:10.1007/s00296-023-05366-7. [PMID: 37322355 DOI: 10.1007/s00296-023-05366-7] [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: 04/16/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
Idiopathic orbital inflammation (IOI) is a diagnosis of exclusion, but the exclusion of other inflammatory diseases of the orbit is broad and relies on clinician experience, response to corticosteroid, or biopsy. This study aimed to investigate the presence of granulomatosis with polyangiitis (GPA) in patients initially diagnosed as IOI and describe its clinicopathological features, ANCA status, treatment, and outcome. We performed a retrospective case series study of children diagnosed with limited GPA (L-GPA) in patients with IOI. A systematic review of the literature was performed in children with GPA and orbital mass. Eleven of 13 (85%) patients with IOI had L-GPA. Two additional patients with orbital mass and L-GPA were included in this analysis. The median age was 10 years, and 75% were female. Twelve cases were ANCA positive and 77% were MPO-pANCA positive. Most patients had a poor response to treatment and had a high relapse rate. Based on literature review, 28 cases were found. Most (78.6%) were female with a median age of 9 years. Three patients were misdiagnosed as IOI. Patients with L-GPA more frequently had MPO-pANCA positivity (35%) than children with systemic GPA (18%) and were less often PR3-cANCA positive than patients with systemic GPA (18% vs. 46%). L-GPA accounts for a high prevalence of children diagnosed as IOI. The high prevalence of MPO-pANCA observed in our study may be related to L-GPA rather than with the orbital mass. Long-term follow-up, orbital biopsy, and serial ANCA testing are necessary to exclude GPA in patients with IOI.
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Affiliation(s)
- Vicente Baca
- Department of Rheumatology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Av. Cuauhtémoc # 330, Col. Doctores, CP 06720, Mexico City, Mexico.
| | - Alejandro A Barragán-García
- Department of Rheumatology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Av. Cuauhtémoc # 330, Col. Doctores, CP 06720, Mexico City, Mexico
- Department of Pediatrics, Hospital Gabriel Mancera IMSS, Mexico City, Mexico
| | - Daphne García-Vega
- Department of Ophthalmology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Yolanda Vázquez-Lara
- Department of Ophthalmology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Georgina Siordia-Reyes
- Department of Pathology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Lucelli Yañez-Gutierrez
- Department of Congenital Heart Diseases, Hospital de Cardiología Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
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Dammacco R, Biswas J, Mohanan-Earatt A, Lisch W, Zito FA, Rubini G, Manno C, Cicco S, Alessio G, Dammacco F. The eye is a common site of granulomatosis with polyangiitis. A collaborative study. BMC Ophthalmol 2023; 23:26. [PMID: 36653761 PMCID: PMC9850589 DOI: 10.1186/s12886-022-02743-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/16/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%). METHODS Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination. RESULTS The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined. CONCLUSIONS The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.
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Affiliation(s)
- Rosanna Dammacco
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Jyotirmay Biswas
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Amanda Mohanan-Earatt
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Walter Lisch
- grid.5802.f0000 0001 1941 7111Department of Ophthalmology, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Giuseppe Rubini
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, University of Bari Medical School, Bari, Italy
| | - Carlo Manno
- grid.7644.10000 0001 0120 3326Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplant Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Sebastiano Cicco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Giovanni Alessio
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Franco Dammacco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rheumatic diseases characterized by small-to-medium vessel vasculitis. Three different entities can be distinguished: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). While lung and renal involvement are typical manifestations of both GPA and MPA, EGPA usually shows paranasal sinus and lung involvement as well as a history of bronchial asthma. Furthermore, EGPA is frequently associated with cardiac disease and peripheral neuropathy. Cyclophosphamide or rituximab, combined with glucocorticoids, are used to induce remission of severe disease. Maintenance therapy options include rituximab as the first-line treatment, as well as methotrexate or azathioprine plus low-dose glucocorticoids.
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Affiliation(s)
- Marco L. Krasselt
- Medizinische Klinik III – Endokrinologie, Nephrologie und Rheumatologie, Bereich Rheumatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103 Leipzig, Deutschland
| | - Julia U. Holle
- Rheumazentrum Schleswig-Holstein Mitte, Kuhberg 5a–7, 24534 Neumünster, Deutschland
- Rheumazentrum Schleswig-Holstein Mitte, Sophienblatt 13–17, 24103 Kiel, Deutschland
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8
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Wu SY, Chang LS, Lee YC, Pan YJ, Chou YF, Chang FL, Lu YH, Chen N. Acute Vision Loss as the Initial Manifestation of Granulomatosis with Polyangiitis Involving the Orbital Apex. Diagnostics (Basel) 2022; 12:diagnostics12071540. [PMID: 35885446 PMCID: PMC9317403 DOI: 10.3390/diagnostics12071540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 12/03/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disease consisting of necrotizing granulomatosis of the respiratory tract, necrotizing vasculitis, and necrotizing glomerulonephritis. It is under the category of ANCA-associated vasculitis, which involves small vessels. The nose, sinus, and ear were the most affected sites besides lung and kidney in localized form. They might precede other disease manifestations before progressing to the systemic form. Our patient presented with an intractable headache, followed by acute vision loss. His symptoms deteriorated regardless of antibiotic treatment for paranasal sinusitis. The sequential CT/MRI images showed the inflammatory raid of the orbital apex and cavernous sinus within days. The sinus biopsy and elevated PR3-anti-neutrophil cytoplasmic antibody led us to the diagnosis of GPA. Fortunately, the patient’s vision improved gradually after steroid and immunosuppressant treatment.
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Affiliation(s)
- Shang-Yen Wu
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
| | - Ling-Shuo Chang
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
| | - Yuan-Chieh Lee
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
- Department of Ophthalmology and Visual Science, Tzu Chi University, Hualien 970, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
| | - Yu-Jen Pan
- Division of Allergy, Immunology & Rheumatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yu-Fu Chou
- Department of Otolaryngology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
| | - Fang-Ling Chang
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
| | - Yu-Hsuan Lu
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
| | - Nancy Chen
- Department of Ophthalmology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan; (S.-Y.W.); (L.-S.C.); (Y.-C.L.); (F.-L.C.); (Y.-H.L.)
- Correspondence: ; Tel.: +886-3-8561825
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9
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Padoan R, Campaniello D, Gatto M, Schiavon F, Doria A. Current clinical and therapeutic approach to tumour-like mass lesions in granulomatosis with polyangiitis. Autoimmun Rev 2021; 21:103018. [PMID: 34902605 DOI: 10.1016/j.autrev.2021.103018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disorder classified among the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and characterized by a triad of upper and lower respiratory tract disease, systemic vasculitis involving small-to-medium vessels and renal manifestations. Mass lesions, also described as inflammatory lesions, pseudotumor or tumour-like masses, are uncommon manifestations of GPA and are often called granuloma since histology examination shows granulomatous inflammation and rarely vasculitis. Masses could represent a localized manifestation of GPA or develop as part of a systemic disease. Unusual clinical presentation together with nonspecific radiological and histological features may delay the correct diagnosis leading to disease progression and organ damage. Diagnosis of GPA in such cases may be challenging and malignancy or infections must be considered as alternative diagnostic options. Here we reviewed all the different sites where mass lesions were reported in GPA, focusing on atypical localization, and summarized current therapeutic options and their different outcomes. We retrieved and discussed the cases reported since 2010, bearing in mind the advances in the therapeutic management of AAV patients in the last decade, namely biological therapy such as rituximab. Despite treatment regimens with glucocorticoids and immunosuppressive agents, mass lesions have a refractory course in a high proportion of patients. Invasive surgical procedures may be considered only when drug therapy fails.
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Affiliation(s)
- Roberto Padoan
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Debora Campaniello
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Franco Schiavon
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy.
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10
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Sorin B, Samson M, Durel CA, Diot E, Guichard I, Grados A, Limal N, Régent A, Cohen P, Dion J, Legendre P, Le Guern V, Mouthon L, Guillevin L, Terrier B. Rituximab plus methotrexate combination as a salvage therapy in persistently active granulomatosis with polyangiitis. Rheumatology (Oxford) 2021; 61:2619-2624. [PMID: 34698818 DOI: 10.1093/rheumatology/keab791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/20/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the efficacy and safety of rituximab and methotrexate (RTX/MTX) combination therapy in ANCA-associated vasculitides (AAV). METHODS A retrospective French nationwide study was conducted in patients with AAV who received RTX/MTX combination therapy for persistently active disease. RESULTS Seventeen patients were included. All patients had granulomatosis with polyangiitis (GPA), with positive ANCA in 76% mainly with PR3-ANCA specificity. Sixteen (94%) were still active after rituximab and 11 (65%) after cyclophosphamide (oral and/or intravenous). Patients had experienced a median of 3 (2-4) flares. Manifestations requiring RTX/MTX combination therapy were subglottic or bronchial stenosis in 6 patients (35%), orbital mass in 6 (35%), disabling ENT involvement in 2 (12%), and epiduritis and pachymeningitis in 1 case each (6%). Median follow-up with combination was 11 months (11-26 months). At 6 months, global response was achieved in 15 patients (88%), including partial response in 11 (65%) and complete response in 4 (24%). At last evaluation, global response was achieved in 16 patients (94%). Seven patients (41%) experienced severe adverse events (grade 3 or 4), including infections in 4 (24%) and hepatitis in 2 (12%). Combination therapy was withdrawn in 4 patients (24%) but never for safety concerns. In contrast, MTX dose was decreased in 2 patients (12%) because of adverse events. One patient died of an unknown cause. CONCLUSION RTX/MTX combination therapy could be an effective salvage therapy to treat persistently active GPA with granulomatous manifestations, with an acceptable safety profile.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Maxime Samson
- Department of Internal Medicine and clinical immunology, Dijon University Hospital, Dijon, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
| | - Elisabeth Diot
- Department of Internal Medicine, Hôpital Bretonneau, Tours, France
| | - Isabelle Guichard
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, France
| | - Aurélie Grados
- Department of Internal Medicine, Centre Hospitalier de Niort, France
| | - Nicolas Limal
- Department of Internal Medicine, Hôpital Henri Mondor, Créteil, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | | | - Luc Mouthon
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
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11
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Bilateral Orbital Apex Syndrome Due to Granulomatosis with Polyangiitis. Can J Neurol Sci 2021; 49:426-427. [PMID: 33988103 DOI: 10.1017/cjn.2021.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Abstract
This article provides an overview of rare orbital diseases. Congenital
malformations, inflammatory diseases, benign and malignant neoplasias are
described. Although it represents a relatively small area of the body the
orbit contains multiple different tissues. Therefore, a great variety of
diseases can be found within the orbital space. That is the reason, why both
the completeness and the level of detail in the description of particular
diseases must be somewhat limited. Nevertheless, clinical manifestations,
important aspects of diagnosis, treatment strategies, and, when specific
data are available, the prognosis are described. The authors tried to
highlight the most characteristic aspects of the different diseases to
describe their relevant aspects in spite of the brevity of the
subsections.
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Affiliation(s)
- Ulrich Kisser
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
| | - Jens Heichel
- Universitätsklinik und Poliklinik für Augenheilkunde, Halle/S. (Klinikdirektor: Prof. Dr. med. A. Viestenz)
| | - Alexander Glien
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
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13
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Sorin SM, Răzvan-Marian M, Daniela MM, Dan-Alexandru T. Therapy of ocular complications in ANCA+ associated vasculitis. Rom J Ophthalmol 2021; 65:10-14. [PMID: 33817427 PMCID: PMC7995502 DOI: 10.22336/rjo.2021.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ANCA+ associated vasculitis (AAV) is a group of rare diseases with potentially vision-threatening complications. Ocular and orbital complications of these diseases are caused by vasculitis of the small vessels of the eye or by granulomatous mass formation. ANCA (anti-neutrophil cytoplasmic antibodies) represent a key component of pathophysiological pathways as well as a diagnostic marker. Various manifestations are reported in literature, scleritis and episcleritis being the most common, followed by pseudotumor orbitae. In vision-threatening orbital or ocular disease, aggressive systemic treatment with a combination of high-dose glucocorticoids and either cyclophosphamide or rituximab is needed. Certain cases require locoregional surgical management to preserve ocular integrity or vision. Ocular involvement of AAV remains a challenge in clinical practice, requiring multi-specialty cooperation in order to ensure the best possible visual outcome. Abbreviations: AAV = ANCA+ associated vasculitis, ANCA = anti-neutrophil cytoplasmic antibodies, GPA = granulomatosis with polyangiitis, EGPA = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis
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14
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Al-Awqati MZ, Sokumbi O, Gold KG, Berianu F. Periorbital masses in dermatomyositis. Rheumatology (Oxford) 2020; 59:e136-e137. [DOI: 10.1093/rheumatology/keaa421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/30/2020] [Accepted: 06/17/2020] [Indexed: 11/14/2022] Open
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15
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ANCA-associated vasculitides: Recommendations of the French Vasculitis Study Group on the use of immunosuppressants and biotherapies for remission induction and maintenance. Presse Med 2020; 49:104031. [PMID: 32645418 DOI: 10.1016/j.lpm.2020.104031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/21/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of vasculitides associated with anti-neutrophil cytoplasm antibodies (ANCA) (AAVs) has evolved dramatically in recent years, particularly since the demonstration of rituximab efficacy as remission induction and maintenance therapy for granulomatosis with polyangiitis and microscopic polyangiitis. In 2013, the French Vasculitis Study Group (FVSG) published recommendations for its use by clinicians. Since then, new data have made it possible to better specify and codify prescription of rituximab to treat AAVs. Herein, the FVSG Recommendations Committee, an expert panel comprised of physicians with extensive experience in the treatment and management of vasculitides, presents its consensus guidelines based on literature analysis, the results of prospective therapeutic trials and personal experience.
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16
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Localized Granulomatous with Polyangiitis (GPA): Varied Clinical Presentations and Update on Treatment. Curr Allergy Asthma Rep 2020; 20:56. [PMID: 32648055 DOI: 10.1007/s11882-020-00953-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Granulomatosis with polyangiitis is a primary systemic vasculitis commonly described with the typical triad of upper airway, lung, and kidney involvement. Upper and lower airway involvement is characteristic in patients with granulomatosis with polyangiitis and can sometimes represent the initial or in some instances the sole manifestation. The objective of this review is to summarize the various clinical manifestations of localized disease in GPA and their treatment. RECENT FINDINGS Sinonasal disease is seen in up to 90% of patients. Otologic and ocular involvement is also commonly seen. Laryngeal and tracheal disease although less common is associated with significant morbidity and can be therapeutically challenging. Clinicians need to be aware of these localized GPA manifestations as they may be presenting disease features in the absence of other systemic findings. Treatment of localized GPA involves both immunosuppressive and surgical interventions for specific manifestations. Collaboration between specialists including rheumatologists, otolaryngologists, and ophthalmologists is often crucial to ensure optimal outcomes for patients. This is a narrative review that provides a comprehensive overview of localized granulomatosis with polyangiitis and current treatment options.
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17
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a small to medium vessel vasculitis associated with excess morbidity and mortality. This review explores how management of AAV has evolved over the past two decades with pivotal randomized controlled trials shaping the management of induction and maintenance of remission. Contemporary AAV care is characterized by approaches that minimize the cumulative exposure to cyclophosphamide and glucocorticoids, increasingly use rituximab for remission induction and maintenance, and consider therapies with less toxicity (for example, methotrexate, mycophenolate mofetil) for manifestations of AAV that do not threaten organ function or survival. Simultaneously, improvements in outcomes, such as renal and overall survival, have been observed. Additional trials and observational studies evaluating the comparative effectiveness of agents for AAV in various patient subgroups are needed. Prospective studies are necessary to assess the effect of psychosocial interventions on patient reported outcomes in AAV. Despite the expanding array of treatments for AAV, little guidance on how to personalize AAV care is available to physicians.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - 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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18
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Berti A, Kronbichler A. Orbital masses in ANCA-associated vasculitis: an unsolved challenge? Rheumatology (Oxford) 2020; 58:1520-1522. [PMID: 31323666 DOI: 10.1093/rheumatology/kez136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alvise Berti
- Department of Rheumatology, Santa Chiara Hospital.,Centre for Integrative Biology, University of Trento, Trento, Italy
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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19
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Havuz E, GÜdÜl Havuz S. Rare Presentation of Severely Limited Granulomatosis With Polyangiitis Manifesting With Orbital Wall Destruction: Literature Review and Case Report. Arch Rheumatol 2020; 35:292-299. [PMID: 32851382 DOI: 10.46497/archrheumatol.2020.7503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/30/2019] [Indexed: 11/03/2022] Open
Abstract
Necrosis resulting from mechanical local factors can be seen in patients with granulomatosis with polyangiitis (GPA) even in remission. GPA can cause serious morbidity even when limited. An ocular prosthesis that increases inflammation and damages local circulation should be used very carefully in such patients. In this article, we report a 68-year-old male patient who was diagnosed with localized GPA 11 years ago and referred to our clinic with the complaint of displacement of an ocular prosthesis inside the nose and epistaxis. Four years ago, the left eye was enucleated because of pain and vision loss. Two months after the enucleation, the patient began to use an ocular prosthesis. Orbital medial wall destruction developed while the patient was receiving maintenance therapy that consisted of cyclophosphamide (150 mg/day) plus prednisolone (32 mg). When the ocular prosthesis was displaced in the nasal cavity, the prosthesis was first removed and the patient was clinically stabilized. Later, orbital wall reconstruction was performed at another center.
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Affiliation(s)
- Erol Havuz
- Department of Ophthalmology, University of Health Sciences, SUAM Samsun Hospital, Samsun, Turkey
| | - Seda GÜdÜl Havuz
- Department of Microbiology, Public Health Institution of Turkey, Samsun, Turkey
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20
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Ford JA, Monach PA. Disease heterogeneity in antineutrophil cytoplasmic antibody-associated vasculitis: implications for therapeutic approaches. THE LANCET. RHEUMATOLOGY 2019; 1:e247-e256. [PMID: 38229381 DOI: 10.1016/s2665-9913(19)30077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 01/18/2024]
Abstract
In recent decades, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has transformed from an almost uniformly fatal disease to a treatable form of primary systemic vasculitis. Substantial disease heterogeneity exists within ANCA-associated vasculitis and the increasing understanding of this heterogeneity has implications for guiding treatment decisions. Approaches to induction and maintenance therapy vary depending on disease severity, clinical manifestations, and patient-specific factors. In this narrative Review, we examine how disease heterogeneity in ANCA-associated vasculitis, with respect to disease severity, clinical presentations, and ANCA specificity, influences therapeutic decision making. Many questions regarding therapeutic strategies in ANCA-associated vasculitis remain unanswered, and these should guide future research in this complex group of diseases.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Paul A Monach
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, Boston, MA, USA
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21
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Gheita TA, Abd El Latif EM. Relationship of ocular presentation in granulomatosis with polyangiitis to autoantibodies and disease activity. Z Rheumatol 2019; 78:281-286. [PMID: 29926173 DOI: 10.1007/s00393-018-0495-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The aim of this study was to assess disease characteristics, autoantibodies, and disease activity in granulomatosis with polyangiitis (GPA) patients with ocular manifestations. METHODS The cohort included 46 GPA patients visiting the ophthalmology clinic. Ocular manifestations were recorded, clinical and slit lamp examinations were performed. The Birmingham Vasculitis Activity Score (BVAS) was recorded. Laboratory investigations and the antineutrophil cytoplasmic antibody (ANCA) assay were performed. RESULTS Median age of the 22 male and 24 female patients was 44.5 (32-63) years, median disease duration 6.5 (1-16) years. Ocular manifestations were present in all patients: 12 (26.1%) had proptosis; 40 (87%) had scleritis/episcleritis, with perforation in 3 (6.5%); 33 (71.7%) had keratoconjunctivitis (KC), with acute infiltrative stromal keratitis in 11, peripheral ulcerative keratitis in 15, and sclerosing keratitis in 11 patients. Uveitis was present in 11 (23.9%) and retinal changes including vasculitis, exudates, and hemorrhage were present in 7 (15.2%). Blurred vision was present in 43 (93.5%) patients and 2 (4.3%) had vision loss. Glaucoma was present in 4 (8.7%) and hypotony in 2 (4.3%) patients. Involvement was bilateral in 32 (69.6%) patients. Rheumatoid factor (RF) was positive in 56.5% and significantly associated with uveitis (p = 0.04), while antinuclear antibody (ANA) was positive in 45.7% and significantly associated with KC (p = 0.04). BVAS tended to be higher in patients with uveitis (p = 0.49). CONCLUSION Ocular involvement must be considered in all GPA patients and referral to an experienced ophthalmologist is mandatory for proper management and improved outcome of such a rare systemic disease. ANA and RF positivity may raise suspicion for KC or uveitis, respectively. There was a remarkable association between uveitis and disease activity.
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Affiliation(s)
- T A Gheita
- Rheumatology and Clinical Immunology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - E M Abd El Latif
- Ophthalmology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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22
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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23
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Cytokine profiling in anti neutrophil cytoplasmic antibody-associated vasculitis: a cross-sectional cohort study. Rheumatol Int 2019; 39:1907-1917. [PMID: 31286195 PMCID: PMC7575482 DOI: 10.1007/s00296-019-04364-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/30/2019] [Indexed: 12/29/2022]
Abstract
ANCA-associated vasculitides (AAV) are severe diseases, potentially affecting lungs, kidney, and other organs. Nevertheless, risk profiling remains difficult. Aim of the current study was to analyze serological characteristics in AAV. The principal goal was to identify diagnostic markers that potentially allow a more sophisticated risk profiling in AAV. AAV subjects were recruited and evaluated for disease activity, disease stage, medication, and laboratory findings. Serum concentrations of the following parameters were measured: IL-1β, IL-6, IL-17 A, IL-17 F, IL-21, IL-22, IL-23, TNF-α, sCD40L, IL-4, IL-10, IL-25, IL-31, IL-33, and INF-γ. A total number of 62 AAV subjects was included in the study (39 females; 23 males). Forty-five subjects were PR3+, 17 subjects showed ANCA specificity for MPO. The majority of all cytokines fell under the lower detection limit of the assay. Serum IL-10 was higher in both, AAV and SSc as compared to controls; it was also higher in early systemic AAV. Serum IL-33 was elevated in AAV and SSc; in AAV, higher levels were found in non-necrotizing GN and RTX untreated subjects. Serum CD40L was raised in AAV as well; higher concentrations were also found in PR3+ and MPO+ patients and early systemic, generalized, and refractory AAV. IL-10 may potentially serve as a marker of early systemic AAV. IL-33 may help to identify subjects with a higher risk for necrotizing GN in AAV.
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24
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Gregersen JW, Erikstrup C, Ivarsen P, Glerup R, Krarup E, Keller KK, Hansen IT, Møller BK. PR3-ANCA-associated vasculitis is associated with a specific motif in the peptide-binding cleft of HLA-DP molecules. Rheumatology (Oxford) 2019; 58:1942-1949. [DOI: 10.1093/rheumatology/kez111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 02/19/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
Objectives
This study aimed to characterize the association between HLA alleles and ANCA-associated vasculitis (AAV) in a genetically homogeneous population, and to analyse the contribution of specific HLA molecule amino acid sequences to the risk of AAV.
Methods
We included 187 Danish patients with AAV and 1070 healthy controls. All were HLA typed at two-field resolution. The association of HLA alleles to PR3- or MPO-AAV was analysed. The contribution of the dominant molecular motifs of the HLA-DPB1 molecule to the risk of AAV was investigated by association studies that included specific amino acid sequences of the hypervariable regions in exon 2.
Results
Ninety-four percent of patients with PR3-AAV were carriers of HLA-DPB1*04:01 while all patients with PR3-AAV were carriers of an HLA-DPB1*04 allele, and 85% were homozygous. This was significantly more than in the control group (P < 0.0001). The association was even stronger when HLA-DPB1*04:02 and -DPB1*23:01 were included. HLA-DPB1*04:01, -DPB1*04:02 and -DPB1*23:01 share amino acids in positions 8–9, 69, 76 and 84–87 within the hypervariable regions, but only positions 69 and 84–87 contributed significantly to the disease risk. HLA-DRB1*15 was associated with an increased risk of developing PR3-AAV, while HLA-DRB1*04, -DRB1*07 and -DQB1*03 were associated with a reduced risk of kidney involvement in PR3-AAV. MPO-AAV was only weakly associated with HLA class I alleles.
Conclusion
PR3-AAV is strongly associated with the HLA-DPB1 alleles HLA-DPB1*04:01, -DPB1*04:02 and -DPB1*23:01, which share amino acid sequences crucial for the peptide-binding groove.
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Affiliation(s)
| | | | - Per Ivarsen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | - Rie Glerup
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Ib Tønder Hansen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
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25
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Durel CA, Hot A, Trefond L, Aumaitre O, Pugnet G, Samson M, Abad S, Belot A, Blanchard-Delaunay C, Cohen P, Cohen-Aubard F, Cottin V, Crestani B, Moreuil CD, Durupt S, Garzaro M, Girszyn N, Godeau B, Hachulla E, Jamilloux Y, Jego P, Killian M, Lazaro E, Le Gallou T, Liozon E, Martin T, Papo T, Perlat A, Pillet P, Guillevin L, Terrier B. Orbital mass in ANCA-associated vasculitides: data on clinical, biological, radiological and histological presentation, therapeutic management, and outcome from 59 patients. Rheumatology (Oxford) 2019; 58:1565-1573. [DOI: 10.1093/rheumatology/kez071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Objective
Orbital mass is a rare and sight-threatening manifestation of ANCA-associated vasculitides, which remains a therapeutic challenge. We aimed to describe the presentation, therapeutic management and outcome of ANCA-associated vasculitides-related orbital mass.
Methods
We conducted a French nationwide retrospective study of patients with orbital mass in the setting of ANCA-associated vasculitides according to ACR criteria and/or Chapel Hill Consensus Conference definitions.
Results
Fifty-nine patients [33 women, median age 46 (range 7–90) years] were included. Fifty-six (95%) patients had granulomatosis with polyangiitis, two eosinophilic granulomatosis with polyangiitis and one microscopic polyangiitis. Orbital mass was unilateral in 47 (80%) cases, and seemed to develop from ENT involvement in most cases. Orbital mass biopsy was available in 32 (54%) patients, showing lymphoplasmacytic infiltration in 65%, fibrosis in 55%, granulomas in 48% and vasculitis in 36%. All patients but one received glucocorticoids as first-line therapy associated with immunosuppressive agents in 82%, mainly cyclophosphamide. Response to therapy was noted in 52% of patients treated with cyclophosphamide compared with 91% of those treated with rituximab. Twenty-seven (46%) patients required a second-line therapy because of relapse (59%) or refractory course (41%). Sequelae included visual impairment in 28%, with definitive blindness in 17%. Refractory course was associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
Conclusion
Orbital mass is associated with refractory course and high frequency of sequelae, especially blindness. Refractory course is associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
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Affiliation(s)
| | - Arnaud Hot
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon
| | - Ludovic Trefond
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Olivier Aumaitre
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Gregory Pugnet
- Department of Internal Medicine, Hôpital Purpan, Toulouse
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon
| | - Sébastien Abad
- AP-HP, Hôpital Avicennes, Department of Internal Medicine, Université Paris 13, Sorbonne, Paris Cité, Faculté de Médecine Bobigny, Paris
| | - Alexandre Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, National Referral Center for Inflammatory Rheumatism and Autoimmune Diseases, Hôpital Femme Mère Enfant, Bron
| | | | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris
| | - Fleur Cohen-Aubard
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Lyon
| | | | - Claire De Moreuil
- Department of Internal Medicine, Hôpital de la Cavale Blanche, Brest
| | - Stéphane Durupt
- Department of Internal Medicine, Centre Hospitalier Lyon Sud, Lyon
| | | | - Nicolas Girszyn
- Department of Internal Medicine, Hôpital Charles Nicolle, Rouen
| | - Bertrand Godeau
- Department of Internal Medicine, Referral Center for Adult Autoimmune Cytopenias, Hôpital Henri Mondor, Créteil
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, National Referral Center for Systemic Autoimmune Diseases North and North-West of France, Université de Lille, Lille
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Lyon
| | - Patrick Jego
- Department of Internal Medicine, Hôpital Sud, Rennes
| | - Martin Killian
- Department of Internal Medicine, Hôpital Nord, Saint-Etienne
| | - Estibaliz Lazaro
- Department of Internal Medicine, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac
| | | | - Eric Liozon
- Department of Internal Medicine, Hôpital de Limoges, Limoges
| | - Thierry Martin
- Department of Clinical Immunology, HIV, and Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases RESO, Nouvel Hôpital Civil, Strasbourg
| | - Thomas Papo
- Department of Internal Medicine, Hôpital Bichat, Paris
| | | | - Pascal Pillet
- Department of Medical Pediatrics, CHU de Bordeaux – GH Pellegrin, Bordeaux
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
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Clinical features of different orbital manifestations of granulomatosis with polyangiitis. Graefes Arch Clin Exp Ophthalmol 2018; 256:1751-1756. [DOI: 10.1007/s00417-018-4014-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022] Open
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Successful reconstruction of an ocular defect resulting from granulomatosis with polyangiitis, following treatment with rituximab. Am J Ophthalmol Case Rep 2018; 10:240-243. [PMID: 29780942 PMCID: PMC5956741 DOI: 10.1016/j.ajoc.2018.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose To report a unique case of orbital inflammatory disease which was ultimately diagnosed as granulomatosis with polyangitis (GPA) and thus successfully treated. Observation A 47 year-old man presented with a rapidly progressive necrotic soft tissue mass within the medial antero-superior aspect of the right eyelid and orbit. He also had transient retinal vasculitis in the left. Serology, histology and imaging were atypical of, but consistent with, GPA. He was thus successfully treated with intravenous rituximab followed by reconstruction of the medial eyelid. Conclusion and importance A high index of suspicion of GPA is required in orbital inflammatory disease, especially when typical diagnostic findings are absent.
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Drobysheva A, Fuller J, Pfeifer CM, Rakheja D. Orbital Granulomatosis With Polyangiitis Mimicking IgG4-Related Disease in a 12-Year-Old Male. Int J Surg Pathol 2018; 26:453-458. [PMID: 29366363 DOI: 10.1177/1066896917754252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Granulomatosis with polyangiitis is rare in children. We report a case of a 12-year-old male who presented with new symptoms of left eyelid swelling and ptosis. Magnetic resonance imaging showed an enhancing orbital mass suspicious for a neoplasm. Excisional biopsy was performed. Microscopic examination revealed fibrovascular tissue with dense collagenous fibrosis and mixed inflammatory infiltrate that included many plasma cells. Many small and medium-sized blood vessels showed granulomatous and necrotizing vasculitis with disruption of the vessel walls and fibrinoid necrosis. Immunostain for IgG highlighted the numerous plasma cells, approximately 50% of which were positive for IgG4 immunostain. A diagnosis of granulomatosis with polyangiitis was suggested, with recommendation of serologic testing for anti-neutrophil cytoplasmic antibodies. Serum anti-neutrophil cytoplasmic antibodies were borderline high with a cytoplasmic staining pattern. The patient improved with steroid and methotrexate therapy. Granulomatosis with polyangiitis can present as an orbital mass in up to 30% of children. It may be misdiagnosed as IgG4-related disease since the inflammatory background in both conditions may be rich in plasma cells with a high proportion of IgG4+ plasma cells, and accompanied by fibrosis and obliterated blood vessels. The differential diagnosis in this location should also include inflammatory pseudotumor and inflammatory myofibroblastic tumor. Knowledge of this unusual manifestation of granulomatosis with polyangiitis and its diagnostic pitfalls can facilitate early diagnosis and treatment.
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Affiliation(s)
- Anastasia Drobysheva
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Julie Fuller
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Cory M Pfeifer
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Dinesh Rakheja
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
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Ismailova DS, Grusha YO, Abramova YV, Novikov PI, Danilov SS. [Clinical manifestations of orbital lesion in granulomatosis with polyangiitis]. Vestn Oftalmol 2018; 134:178-185. [PMID: 30499515 DOI: 10.17116/oftalma2018134051178] [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] [Indexed: 06/09/2023]
Abstract
UNLABELLED One of the most common and potentially threatening manifestations of granulomatosis with polyangiitis (GPA) is orbital lesion. PURPOSE To study the clinical course and prognosis of orbital lesions of various localization in GPA patients. Material and me-thods. The study included 226 patients with GPA, 74 of them with orbital lesion. Ophthalmic examination consisted of visual acuity test, biomicroscopy, ophthalmoscopy, exophthalmometry and ocular mobility test. Visualization was done using multislice computed tomography and/or magnetic resonance tomography and/or ultrasound examination. RESULTS Among the patients of the study group, in 35.1% the lesion was limited to dacryoadenitis, in 4.0% of patients - to myositis, and 70.8% had extensive inflammatory orbital masses. Patients with orbital masses had systemic disease in 51.1%, compared to 7.7% in dacryoadenitis (p=0.00). Clinical progression in patients with orbital masses was characterized by severe exophthalmos, periorbital swelling and hyperemia. Patients with dacryoadenitis, on the contrary, had only mild symptoms. Patients with orbital masses had unfavorable prognosis. There were only three patients with myositis in the study group, so the data on them is limited; their clinical symptoms included light periorbital swelling, exophthalmos, strabismus, painful binocular diplopia and eye movement restriction. The disease was recurring in two cases. CONCLUSION Patients with orbital involvement in GPA may have different course of the disease depending on the localization of inflammation.
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Affiliation(s)
- D S Ismailova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - Y O Grusha
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, Chair of Ophthalmology, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - Yu V Abramova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, University Hospital No. 3, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - S S Danilov
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
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Ismailova DS, Novikov PI, Grusha YO, Abramova YV, Bulanov NM, Makarov EA. [The frequency of ophthalmologic manifestations of granulomatosis with polyangiitis (Wegener's) and their relationship to systemic diseases]. TERAPEVT ARKH 2017. [PMID: 28631702 DOI: 10.17116/terarkh201789569-73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To estimate the frequency of lesions in the organ of vision in granulomatosis with polyangiitis (GPA) (Wegener's) and to determine their relationship to systemic diseases. SUBJECTS AND METHODS The retrospective study enrolled 218 patients followed up at the E.M. Tareyev Clinic of Nephrology, Internal and Occupational Diseases, with a diagnosis of GPA. The frequency and association of ophthalmic manifestations with systemic involvement were statistically analyzed using PASW Statistics 18. RESULTS The organ of vision was impaired in 48.1% of the patients with GPA. The most common manifestations were orbital space-occupying lesion (22.9%), conjunctivitis/episcleritis (14.7%), dacryocystitis (6.0%), and scleritis (4.6%). Orbital space-occupying lesions occurred more frequently in the local type of the disease (p=0.0003), and, on the contrary, the involvement of the conjunctiva and eyeball was seen in patients with the systemic types of GPA (p=0.02). CONCLUSION The findings may suggest that the orbital lesion is an independent manifestation of GPA, which develops more commonly in its local type. Conjunctivitis/episcleritis is, on the contrary, more frequently seen in the active phase of the disease and generally in the involvement of other organs and systems.
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Affiliation(s)
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - Ya O Grusha
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | | | - N M Bulanov
- M.V. Lomonosov Moscow State University, Moscow, Russia
| | - E A Makarov
- M.V. Lomonosov Moscow State University, Moscow, Russia
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31
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Grusha YO, Ismailova DS, Novikov PI, Kogan EA, Abramova YV, Bulanov NM, Sherstneva LV. [Combination therapy of refractory localized granulomatosis with polyangiitis and orbital involvement]. Vestn Oftalmol 2017; 133:86-91. [PMID: 28524146 DOI: 10.17116/oftalma2017133286-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatous orbital cellulitis is one of the most common ocular manifestations of granulomatosis with polyangiitis (Wegener's). The process is often refractory to conventional immunosuppressive therapy and requires a more radical treatment approach. However, surgical experience with this type of patients is limited. There have been just a few reported cases of orbital decompression in such patients and many authors have doubted the appropriateness of the procedure, since it is associated with a high risk of potentially fatal complications. Our experience demonstrates the feasibility and effectiveness of orbital mass removal as to pain relief and exophthalmos reduction.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - D S Ismailova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - P I Novikov
- UCH #3 of I.M. Sechenov First Moscow State Medical University, 11, str.5 Rossolimo St., Moscow, Russian Federation, 119021
| | - E A Kogan
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - Yu V Abramova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021
| | - N M Bulanov
- I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - L V Sherstneva
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, 2, str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
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32
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Kogan EA, Grusha YO, Ismailova DS, Novikov PI, Abramova YV, Meshkov AD, Rizopulu EF. [Refractory form of orbital granulomatosis with polyangiitis: A clinical and morphological study]. Arkh Patol 2017; 79:56-60. [PMID: 28295009 DOI: 10.17116/patol201779156-60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orbital granulomatosis with polyangiitis (Wegener's granulomatosis, GPA), which is characterized by granulomatous inflammation with small-vessel vasculitis, can develop in local and generalized forms of the disease. The introduction of current immunosuppressive therapy regimens has improved the prognosis of the disease; however, there are immunosuppressive treatment-refractory forms of GPA, the morphology of which has been inadequately investigated. The paper describes a clinical case of refractory GPA involving the orbit, as evidenced by histological and immunohistochemical examinations. The specific feature of the case is the development of severe fibrosis with the accumulation of mainly type III collagen and the persistence of granulomatous inflammation and productive-destructive vasculitis.
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Affiliation(s)
- E A Kogan
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ya O Grusha
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Research Institute of Eye Diseases, Moscow, Russia
| | - D S Ismailova
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Research Institute of Eye Diseases, Moscow, Russia
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - A D Meshkov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - E F Rizopulu
- Research Institute of Eye Diseases, Moscow, Russia
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33
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Pachymeningitis in granulomatosis with polyangiitis: case series with earlier onset in younger patients and literature review. Clin Rheumatol 2016; 36:919-924. [DOI: 10.1007/s10067-016-3520-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/16/2016] [Indexed: 10/20/2022]
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34
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Mombaerts I, Rose GE, Garrity JA. Orbital inflammation: Biopsy first. Surv Ophthalmol 2016; 61:664-9. [DOI: 10.1016/j.survophthal.2016.03.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 12/23/2022]
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35
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Yates M, Watts RA, Bajema IM, Cid MC, Crestani B, Hauser T, Hellmich B, Holle JU, Laudien M, Little MA, Luqmani RA, Mahr A, Merkel PA, Mills J, Mooney J, Segelmark M, Tesar V, Westman K, Vaglio A, Yalçındağ N, Jayne DR, Mukhtyar C. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016; 75:1583-94. [PMID: 27338776 DOI: 10.1136/annrheumdis-2016-209133] [Citation(s) in RCA: 740] [Impact Index Per Article: 92.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/27/2016] [Indexed: 12/13/2022]
Abstract
In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.
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Affiliation(s)
- M Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK Norwich Medical School, University of East Anglia, Norwich, UK
| | - R A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK Department of Rheumatology, Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK
| | - I M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Crestani
- Assistance Publique-Hôpitaux de Paris, Department of Pulmonology, Bichat-Claude Bernard University Hospital, Paris, France
| | - T Hauser
- Immunologie-Zentrum Zürich, Zürich, Switzerland
| | - B Hellmich
- Vaskulits-Zentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Kreiskliniken Esslingen, Kirchheim-Teck, Germany
| | - J U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - M Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, Kiel, Germany
| | - M A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - R A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, Université Paris 7 René Diderot, Paris, France
| | - P A Merkel
- Division of Rheumatology and the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Mills
- Vasculitis UK, West Bank House, Winster, Matlock, UK
| | - J Mooney
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - M Segelmark
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Department of Nephrology, Linköping University, Linköping, Sweden
| | - V Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - K Westman
- Department of Nephrology, Lund University, Skåne University Hospital, Lund and Malmö, Sweden
| | - A Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - N Yalçındağ
- Department of Ophthalmology, School of Medicine, Ankara University, Ankara, Turkey
| | - D R Jayne
- Lupus and Vasculitis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - C Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
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36
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Granulomatosis with polyangiitis provoked by trauma. Can J Ophthalmol 2016; 51:e101-3. [PMID: 27316279 DOI: 10.1016/j.jcjo.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/16/2016] [Indexed: 11/20/2022]
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Kubaisi B, Abu Samra K, Foster CS. Granulomatosis with polyangiitis (Wegener's disease): An updated review of ocular disease manifestations. Intractable Rare Dis Res 2016; 5:61-9. [PMID: 27195187 PMCID: PMC4869584 DOI: 10.5582/irdr.2016.01014] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a potentially lethal systemic disorder that is characterized by necrotizing vasculitis of small arteries and veins. The respiratory system is most commonly affected in limited forms of the disease, however upper and lower respiratory system, systemic vasculitis, and necrotizing glomerulonephritis are the characteristic components of the disease triad. The peak incidence is observed at 64-75 years of age, with a prevalence of 8-10 per million depending on geographic location. In this review we focus on the ocular manifestations of the disease which occur in nearly in one third of the patients. In addition we describe the neuro-ophthalmic complications which occur in up to half of cases. We also discuss the current systemic treatment options including corticosteroids, cyclophosphamide, azathioprine, and the available biologic response modifiers including rituximab. The disease remains difficult to diagnose due to the generalized symptomatic presentation of patients with GPA. As a result, several sets of diagnostic criteria have been developed which include clinical, serological, and histopathological findings to varying extents. Early diagnosis and multi-specialty collaboration among physicians is necessary to adequately manage the disease and the potential complications that may result from drugs used in the treatment of the disease. Despite recent advances, more research is necessary to prevent the high rates of mortality from the disease itself and from therapeutic side effects.
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Affiliation(s)
- Buraa Kubaisi
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Khawla Abu Samra
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C. Stephen Foster
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Harvard Medical School, Boston, MA, USA
- Address correspondence to: Dr. C. Stephen Foster, Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, USA. E-mail:
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Orbital tumour due rhinosinusal extension in a patient with Wegener's granulomatosis. ACTA ACUST UNITED AC 2016; 91:442-5. [PMID: 27017537 DOI: 10.1016/j.oftal.2016.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/15/2016] [Accepted: 02/17/2016] [Indexed: 11/22/2022]
Abstract
CASE REPORT The case is presented of a 49 year-old woman with an orbital mass originating from the rhinosinus. She had a history of Wegener's granulomatosis, refractory to both biological and immunosuppressive therapy. Clinical examination showed proptosis, diplopia, and restriction of ocular movements. DISCUSSION Orbital mass resection was performed, due to its rapid growth, and lack of response to medical treatment.
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Keller SF, Miloslavsky EM. Corticosteroids in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis. Rheum Dis Clin North Am 2016; 42:91-101, viii. [DOI: 10.1016/j.rdc.2015.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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40
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Abstract
PURPOSE OF REVIEW To review the spectrum of lacrimal gland inflammation, with particular reference to the old condition, idiopathic dacryoadenitis, and the new, immunoglobulin G4 (IgG4)-related dacryoadenitis. RECENT FINDINGS Idiopathic dacryoadenitis remains the most common inflammatory lesion of the lacrimal gland, for which surgical treatment is successful. There is mounting evidence that the presence of IgG4-positive plasma cells in a lacrimal gland specimen is nonspecific, for being found in other inflammatory lacrimal gland lesions, even lymphoproliferative ones. To identify IgG4-related dacryoadenitis, particularly when there is no documented disease elsewhere, the criteria have been strengthened toward abundant IgG4-positive plasma cell counting. SUMMARY The gold standard of diagnosis of noninfectious lacrimal gland inflammation is tissue biopsying, which is commonly therapeutic in the case of idiopathic dacryoadenitis. Although it was initially suggested that IgG4-related dacryoadenitis is a possible cause of idiopathic dacryoadenitis, it becomes obvious that it has more resemblance to the lymphoproliferative tumors.
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Ozaki T, Maeshima K, Kiyonaga Y, Torigoe M, Imada C, Hamasaki H, Haranaka M, Ishii K, Shibata H. Large-vessel involvement in granulomatosis with polyangiitis successfully treated with rituximab: A case report and literature review. Mod Rheumatol 2015; 27:699-704. [PMID: 25736357 DOI: 10.3109/14397595.2015.1021950] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is primary necrotizing vasculitis, which predominantly affects small to medium vessels. Herein, we describe a case of a 60-year-old female with GPA who developed inflammatory wall thickening localized in the aortic arch, upper abdominal aorta, and pulmonary artery. The wall thickening in the large vessels and other GPA lesions such as lung nodules and orbital mass had failed to respond to high-dose glucocorticoids combined with cyclophosphamide; however, all were successfully treated with rituximab. Our literature review identified 24 cases of large-vessel involvement associated with GPA. Luminal stenosis, occlusion, or wall thickening were observed in 8, periaortitis in 11, and aneurysms in 5 cases. The most commonly affected vessel was the abdominal aorta (12 cases), followed by the thoracic aorta (6 cases), subclavian artery (4 cases), and internal carotid artery (4 cases). Glucocorticoids were used in 23 cases, 20 of which received combination therapy with cyclophosphamide. Surgical or endovascular therapies were performed in 10 cases with aneurysmal dilatation. This is the first case showing the potential efficacy of rituximab for refractory large-vessel involvement associated with GPA.
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Affiliation(s)
- Takashi Ozaki
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Keisuke Maeshima
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Yasuhiro Kiyonaga
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Masataka Torigoe
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Chiharu Imada
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Hajime Hamasaki
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Miwa Haranaka
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Koji Ishii
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
| | - Hirotaka Shibata
- a Department of Endocrinology , Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University , Yufu , Oita , Japan
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Grusha YO, Ismailova DS, Novikov PI, Abramova YV. [Ophthalmologic manifestation of granulomatosis with polyangiitis (Wegener's granulomatosis)]. TERAPEVT ARKH 2015; 87:111-116. [PMID: 27022660 DOI: 10.17116/terarkh20158712111-116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatosis with polyangiitis (GPA), formerly earlier known as Wegener's granulomatosis, is primary system necrotizing vasculitis of small and medium-sized vessels, which is characterized by the formation of foci of granulomatous inflammation. One of the target organs in GPA is the organ of vision. Its affection may not only reduce quality of life, but also may lead to the severest complications even to fatal outcome. The affection varies in severity from slight inflammation of the ocular superficial structures to severe involvement of all orbital and ocular structures to develop complete blindness, including bilateral one. GPA can affect any portion of the organ of vision. The changes are low specific, which makes early diagnosis and timely adequate therapy difficult. Overall all ophthalmologic manifestations can be divide into 4 groups: 1) lesions of the orbit and appendages; 2) those of the conjunctiva and fibrous tunic of the eyeball: 3) those of the retina: 4) those of the optic nerve. Orbital affection is characterized by the development of granulomas, dacryoadenitis with marked inflammatory infiltration of the surrounding tissues, including oculomotor muscles, and destruction of orbital bony walls. Nonspecific conjunctivitis and episcleritis are commonly encountered. Affection of the fibrous tunic of the eyeball is characterized by the development of necrotizing scleritis, peripheral ulcerative or stromal keratitis. The retina is rarely involved and mainly described as sporadic cases in the literature. The optic nerve is most commonly damaged due to the compression of the orbit by inflamed tissue; the lesion is more infrequently ischemic.
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Affiliation(s)
- Ya O Grusha
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - D S Ismailova
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - P I Novikov
- University Clinical Hospital Three, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - Yu V Abramova
- Research Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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Schönermarck U, Csernok E, Gross WL. Pathogenesis of anti-neutrophil cytoplasmic antibody-associated vasculitis: challenges and solutions 2014. Nephrol Dial Transplant 2014; 30 Suppl 1:i46-52. [PMID: 25540095 DOI: 10.1093/ndt/gfu398] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibodies (ANCA) with specificity for proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA) are a defining feature of ANCA-associated vasculitides (AAV). They play a pivotal role in disease pathophysiology and have strongly improved early diagnosis and treatment of these infrequent, but potentially fatal diseases. Neutrophils and their products are major players in initiating the autoimmune response and tissue destruction in vasculitic as well as granulomatous inflammation. This review highlights recent findings on old and novel players (ANCA, neutrophils, neutrophil extracellular traps, fibroblasts, immune cells and complement) and puts them into context with the current understanding of disease mechanisms in AAV.
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Affiliation(s)
- Ulf Schönermarck
- Medizinische Klinik IV, Department of Nephrology, University Hospital Munich, Munich, Germany
| | - Elena Csernok
- Klinikum Bad Bramstedt, Vasculitis Centre, Bad Bramstedt, Germany
| | - Wolfgang L Gross
- Department of Rheumatology, University Hospital Schleswig-Holstein, Luebeck, Germany
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Bitik B, Kılıç L, Küçükşahin O, Şahin K, Tufan A, Karadağ Ö, Pay S, Ateş A, Ucar M, Tutar H, Karaaslan Y, Yilmaz S, Ertenli AI, Konuk O, Turgay M, Goker B. Retro-orbital granuloma associated with granulomatosis with polyangiitis: a series of nine cases. Rheumatol Int 2014; 35:1083-92. [DOI: 10.1007/s00296-014-3179-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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Lally L, Lebovics RS, Huang WT, Spiera RF. Effectiveness of Rituximab for the Otolaryngologic Manifestations of Granulomatosis With Polyangiitis (Wegener's). Arthritis Care Res (Hoboken) 2014; 66:1403-9. [DOI: 10.1002/acr.22311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tan LT, Davagnanam I, Isa H, Taylor SR, Rose GE, Verity DH, Pusey CD, Lightman S. Clinical and Imaging Features Predictive of Orbital Granulomatosis with Polyangiitis and the Risk of Systemic Involvement. Ophthalmology 2014; 121:1304-9. [DOI: 10.1016/j.ophtha.2013.12.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/24/2013] [Accepted: 12/02/2013] [Indexed: 02/06/2023] Open
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Mueller A, Holl-Ulrich K, Gross WL. Granuloma in ANCA-associated vasculitides: another reason to distinguish between syndromes? Curr Rheumatol Rep 2014; 15:376. [PMID: 24078103 DOI: 10.1007/s11926-013-0376-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 2012 renewed Chapel Hill Consensus Conference (CHCC) officially named three clinicopathological entities, i.e. granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA), as major variants of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Recent genetic and cohort studies revealed the need for further differentiation between the entities, for example regarding differences in outcome. As well as ANCA reactivity, upper and lower airway disease were found to be differentiating factors for AAV variants, improving prognostic ability regarding relapse prediction and associated clinical features. Extravascular granulomatosis, or "granuloma", which describes both clinically relevant granulomatous manifestations and histopathologically documented granulomatous inflammation, is characteristic of localized and systemic GPA, but not MPA. This review summarizes new knowledge regarding granuloma in the head and neck region of AAV, its histomorphological equivalents in the upper and lower respiratory tract, and evidence for a granulomatous phenotype of a persistent localized GPA variant. This comprises the development of disease activity and damage scores for extravascular lesions in the ear, nose, and throat (ENT) regions, and imaging techniques. In addition, findings linking extravascular manifestations to granulomatous inflammation are described. We hypothesize that, as for ANCA, necrotizing granulomatous inflammation and its clinical manifestations are discriminators, assisting subclassification of AAV and/or GPA subphenotypes which will be useful both for designing clinical trials and for treating patients successfully.
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Affiliation(s)
- Antje Mueller
- Department of Rheumatology, University of Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany,
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