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Wang RX, Newman SA. Urticarial Vasculitis. Immunol Allergy Clin North Am 2024; 44:483-502. [PMID: 38937011 DOI: 10.1016/j.iac.2024.03.006] [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: 06/29/2024]
Abstract
Urticarial vasculitis is a rare autoimmune disorder characterized by persistent edematous papules and plaques on the skin that last longer than 24 hours, often accompanied by systemic symptoms such as joint pain and fever. Unlike common urticaria, this condition involves inflammation of small blood vessels, leading to more severe and long-lasting skin lesions with a tendency to leave a bruiselike appearance. Diagnosis is challenging and may require a skin biopsy. Associated with underlying autoimmune diseases, treatment involves managing symptoms with medications such as antihistamines and corticosteroids, addressing the immune system's dysfunction, and treating any concurrent autoimmune conditions.
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Affiliation(s)
- Ruth X Wang
- Department of Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 13001 East 17th Place, Aurora, CO 80045, USA
| | - Sabrina A Newman
- Department of Dermatology, University of Colorado School of Medicine, Anschutz Medical Campus, 12801 East 17th Avenue, Mail Stop 8127, Aurora, CO 80045, USA.
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2
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Bukhari S, Ghoweba M, Khan S, Ouma G. Unraveling the Diagnosis of Hypocomplementemic Urticarial Vasculitis Syndrome. Cureus 2024; 16:e57723. [PMID: 38711701 PMCID: PMC11073586 DOI: 10.7759/cureus.57723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2024] [Indexed: 05/08/2024] Open
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare condition characterized by immune complex-mediated urticarial lesions with histological features of leukocytoclastic vasculitis, low serum complement levels, and is frequently associated with systemic manifestations. Its pathophysiology is poorly understood. We present a patient who presented with abdominal pain and skin rash. Extensive work-up was performed including skin biopsy, and the presence of angioedema, oral ulcers, low complement level, leukocytic vasculitis, and persistent eosinophilia ultimately led to the diagnosis of HUVS. This case highlights the importance of recognizing and differentiating HUVS from other cutaneous diseases, which in turn helps to optimally manage these patients.
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Affiliation(s)
- Syed Bukhari
- Vascular Medicine, Cleveland Clinic, Cleveland, USA
| | | | - Syed Khan
- Vascular Medicine, Cleveland Clinic, Cleveland, USA
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3
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Webb-Robertson BJM, Nakayasu ES, Dong F, Waugh KC, Flores JE, Bramer LM, Schepmoes AA, Gao Y, Fillmore TL, Onengut-Gumuscu S, Frazer-Abel A, Rich SS, Holers VM, Metz TO, Rewers MJ. Decrease in multiple complement proteins associated with development of islet autoimmunity and type 1 diabetes. iScience 2024; 27:108769. [PMID: 38303689 PMCID: PMC10831269 DOI: 10.1016/j.isci.2023.108769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/16/2023] [Accepted: 12/18/2023] [Indexed: 02/03/2024] Open
Abstract
Type 1 diabetes (T1D) is a chronic condition caused by autoimmune destruction of the insulin-producing pancreatic β cells. While it is known that gene-environment interactions play a key role in triggering the autoimmune process leading to T1D, the pathogenic mechanism leading to the appearance of islet autoantibodies-biomarkers of autoimmunity-is poorly understood. Here we show that disruption of the complement system precedes the detection of islet autoantibodies and persists through disease onset. Our results suggest that children who exhibit islet autoimmunity and progress to clinical T1D have lower complement protein levels relative to those who do not progress within a similar time frame. Thus, the complement pathway, an understudied mechanistic and therapeutic target in T1D, merits increased attention for use as protein biomarkers of prediction and potentially prevention of T1D.
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Affiliation(s)
- Bobbie-Jo M. Webb-Robertson
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Ernesto S. Nakayasu
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Fran Dong
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kathy C. Waugh
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Javier E. Flores
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Lisa M. Bramer
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Athena A. Schepmoes
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Yuqian Gao
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Thomas L. Fillmore
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Suna Onengut-Gumuscu
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Ashley Frazer-Abel
- Divison of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - V. Michael Holers
- Divison of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Thomas O. Metz
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Marian J. Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Good SD, Rerkpichaisuth V, Fishbein MC, Ardehali A, Kermani TA. Multivalvular Cardiac Disease in a Young Woman With Hypocomplementemic Urticarial Vasculitis. Arthritis Care Res (Hoboken) 2024; 76:155-163. [PMID: 37652750 DOI: 10.1002/acr.25225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/14/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Samuel D Good
- Division of Rheumatology, University of California, Los Angeles, CA, United States
| | - Vilasinee Rerkpichaisuth
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Abbas Ardehali
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, CA, United States
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Bonnekoh H, Jelden-Thurm J, Allenova A, Chen Y, Cherrez-Ojeda I, Danilycheva I, Dorofeeva I, Jardim Criado RF, Criado PR, Gelincik Akkor A, Hawro T, Kocatürk E, Khoshkhui M, Metz M, Nasr I, Steć M, Zhao Z, Aulenbacher F, Salameh P, Altrichter S, Gonçalo M, Gimenez-Arnau A, Maurer M, Krause K, Kolkhir P. Urticarial Vasculitis Differs From Chronic Spontaneous Urticaria in Time to Diagnosis, Clinical Presentation, and Need for Anti-Inflammatory Treatment: An International Prospective UCARE Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2900-2910.e21. [PMID: 37364667 DOI: 10.1016/j.jaip.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Chronic spontaneous urticaria (CSU) and urticarial vasculitis (UV) share several clinical features including the occurrence of wheals. As of yet, the criteria for differentiating the 2 disorders are not clearly defined. OBJECTIVE Here, we aimed to identify differences, similarities, and the likelihood for specific clinical features in patients with UV versus those with CSU. METHODS Across 10 Urticaria Centers of Reference and Excellence, 106 patients with skin biopsy-confirmed UV and 126 patients with CSU were prospectively recruited to complete a questionnaire on the clinical features, course, and response to treatment of their disease. RESULTS As compared with CSU, patients with UV more often experienced postinflammatory skin hyperpigmentation, wheals of ≥24-hour duration, eye inflammation, and fever (6.9, 4.0, 3.6, and 2.4 times, respectively). Clinical features that increased the risk for UV diagnosis when present at the onset of disease included wheals of ≥24-hour duration (7.3-fold), pain of the skin (7.0-fold), postinflammatory hyperpigmentation (4.1-fold), and fatigue (3.1-fold). The diagnostic delay was markedly longer for normocomplementemic UV as compared with hypocomplementemic UV and CSU (21 vs 5 vs 6 months, respectively). Oral corticosteroids and omalizumab were the most effective treatments in patients with UV and CSU, respectively. Patients with UV showed a higher need for immunosuppressive and anti-inflammatory therapies than patients with CSU. CONCLUSIONS Long wheal duration, skin pain and hyperpigmentation, and systemic symptoms point to UV rather than CSU as the underlying disease and should prompt further diagnostic workup including a skin biopsy.
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Affiliation(s)
- Hanna Bonnekoh
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Jannis Jelden-Thurm
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Anastasiia Allenova
- Laboratory of Immune-Mediated Skin Diseases, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Medical Scientific and Educational Center of Lomonosov Moscow State University, Moscow, Russia
| | - Yudi Chen
- Department of Dermatology and Venerology, GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), National Research Center for Skin and Immune Diseases, Peking University First Hospital, Beijing, China
| | - Ivan Cherrez-Ojeda
- Department of Allergy, Universidad Espíritu Santo, Samborondon, Ecuador; Department of Allergy and Pulmonology, Respiralab Research Group, Guayaquil, Ecuador
| | - Inna Danilycheva
- National Research Center-Institute of Immunology, Federal Medical-Biological Agency of Russia, Moscow, Russia
| | - Irina Dorofeeva
- National Research Center-Institute of Immunology, Federal Medical-Biological Agency of Russia, Moscow, Russia
| | - Roberta Fachini Jardim Criado
- Alergoskin Allergy and Dermatology, Sao Paulo, Brazil; Department of Dermatology, Centro Universitário Faculdade de Medicina do ABC, Sao Paulo, Brazil
| | - Paulo Ricardo Criado
- Alergoskin Allergy and Dermatology, Sao Paulo, Brazil; Department of Dermatology, Centro Universitário Faculdade de Medicina do ABC, Sao Paulo, Brazil
| | - Asli Gelincik Akkor
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Fatih, Istanbul, Turkey
| | - Tomasz Hawro
- Institute and Comprehensive Center for Inflammation Medicine, Department of Dermatology, Allergology and Venereology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Emek Kocatürk
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
| | - Maryam Khoshkhui
- Allergy Research Center, Mashhad University of Medical Science (MUMS), Mashhad, Iran
| | - Martin Metz
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Iman Nasr
- Adult Immunology and Allergy Unit, Department of Medicine, Royal Hospital, Muscat, Oman
| | - Michał Steć
- Department of Computer Science, Chair of Embedded Systems Architectures for Signal Processing, University of Potsdam, Potsdam, Germany
| | - Zuotao Zhao
- Department of Dermatology and Venerology, GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), National Research Center for Skin and Immune Diseases, Peking University First Hospital, Beijing, China
| | - Felix Aulenbacher
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Pascale Salameh
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; School of Medicine, Lebanese American University, Byblos, Lebanon; Institut National de Santé Publique d'Épidémiologie Clinique et de Toxicologie-Liban (INSPECT-LB), Beirut, Lebanon; Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
| | - Sabine Altrichter
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Department of Dermatology and Venerology, Kepler Universitätsklinik, Linz, Austria
| | - Margarida Gonçalo
- Department of Dermatology, Centro Hospitalar e Universitário de Coimbra e Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Ana Gimenez-Arnau
- Hospital del Mar, Institut Mar d'Investigacions Mèdiques, Universitat Pompeu Fabra, Barcelona, Spain
| | - Marcus Maurer
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Karoline Krause
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Pavel Kolkhir
- GA(2)LEN Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
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Webb-Robertson BJM, Nakayasu ES, Dong F, Waugh KC, Flores J, Bramer LM, Schepmoes A, Gao Y, Fillmore T, Onengut-Gumuscu S, Frazer-Abel A, Rich SS, Holers VM, Metz TO, Rewers MJ. Decrease in multiple complement protein levels is associated with the development of islet autoimmunity and type 1 diabetes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.13.23292628. [PMID: 37502972 PMCID: PMC10370226 DOI: 10.1101/2023.07.13.23292628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Type 1 diabetes (T1D) is a chronic condition caused by autoimmune destruction of the insulin-producing pancreatic β-cells. While it is known that gene-environment interactions play a key role in triggering the autoimmune process leading to T1D, the pathogenic mechanism leading to the appearance of islet autoantibodies - biomarkers of autoimmunity - is poorly understood. Here we show that disruption of the complement system precedes the detection of islet autoantibodies and persists through disease onset. Our results suggest that children who exhibit islet autoimmunity and progress to clinical T1D have lower complement protein levels relative to those who do not progress within a similar timeframe. Thus, the complement pathway, an understudied mechanistic and therapeutic target in T1D, merits increased attention for use as protein biomarkers of prediction and potentially prevention of T1D.
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Ecclestone T, Watts RA. Classification and epidemiology of vasculitis: Emerging concepts. Best Pract Res Clin Rheumatol 2023; 37:101845. [PMID: 37468418 DOI: 10.1016/j.berh.2023.101845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023]
Abstract
The recent publication of the American College of Rheumatology (ACR)-European Alliance of Associations for Rheumatology (EULAR) classification criteria for large vessel vasculitis and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) has provided modern criteria for the classification of these conditions, which incorporate contemporary methods of investigation and diagnosis. Further validation is required in independent cohorts, especially from populations that were not well represented in the development cohort. Studies of the occurrence of large vessel vasculitis report that Takayasu arteritis is a rare disease in most populations, and giant cell arteritis is the most common vasculitis in older populations. The incidence of AAV appears to have plateaued, but the prevalence is increasing as a result of lower mortality. The new classification criteria may affect the reported incidence and prevalence, and studies will be needed to confirm this. The impact of COVID-19 on the occurrence of the vasculitides is not completely known, but there is evidence of reduced occurrence of Kawasaki disease and IgA-associated vasculitis following lockdowns with reduced transmission of possible trigger infectious agents.
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Weisnicht AM, Byrne R, Henkel EB, Harding SA, Kostelyna SP, Schady D, Lai J, Stubbs LA. Recurrent Rash in an 11-Year-Old Boy With Pericardial and Pleural Effusions. Pediatrics 2022; 150:189805. [PMID: 36305212 DOI: 10.1542/peds.2021-055524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/06/2022] Open
Abstract
An 11-year-old, previously healthy boy presented to the emergency center (EC) for acute respiratory distress in the setting of 5 months of recurrent and worsening rash with progressive fatigue, shortness of breath, chest pain, and cough. At the onset of his rash, he and his younger brothers were diagnosed with roseola. Although his brothers' symptoms resolved, the patient's rash recurred, prompting his primary care provider to prescribe amoxicillin. The rash subsequently worsened, so amoxicillin was stopped; a prednisone course was prescribed which alleviated the rash. Upon completion of the prednisone course, the rash returned more diffusely with associated symptoms of shortness of breath, chest pain, and cough. Because of these symptoms, his mother brought him to the EC, where his vitals were notable for tachypnea and tachycardia. His initial EC imaging workup was remarkable for an echocardiogram with a mild to moderate circumferential pericardial effusion, chest x-ray (CXR) with a large right pleural effusion, and chest computerized tomography significant for prominent and diffuse mediastinal and hilar lymphadenopathy with numerous enlarged axillary lymph nodes. Laboratory results were notable for elevated liver enzymes, inflammatory markers, d-dimer, and brain natriuretic peptide. Differential diagnosis remained broad, including infectious, oncologic, and rheumatologic etiologies. Our panel of experts reviews the evaluation, hospital course, and treatment of this patient presenting with an unusual rash and serositis.
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Affiliation(s)
| | | | | | | | | | | | - Jamie Lai
- Pediatric Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Leigh A Stubbs
- Pediatric Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Bonnekoh H, Jelden-Thurm J, Butze M, Krause K, Maurer M, Kolkhir P. In Urticarial Vasculitis, Long Disease Duration, High Symptom Burden, and High Need for Therapy Are Linked to Low Patient-Reported Quality of Life. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2734-2741.e7. [PMID: 35868452 DOI: 10.1016/j.jaip.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 07/03/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Urticarial vasculitis (UV) is a rare and difficult-to-treat chronic skin disease defined by long-lasting urticarial lesions and the histopathologic finding of leukocytoclastic vasculitis. As of yet, little is known about UV patients' perspective on the disease. OBJECTIVE To assess UV patients' perspective on the clinical course, treatment response, greatest challenges, and quality-of-life (QOL) impairment. METHODS A web-based questionnaire was disseminated in a Facebook group of patients with UV. Patients with UV confirmed by skin biopsy were included. RESULTS Patients with UV had a mean age of 47.3 ± 12.3 years and were mostly female (94.3%; n = 82 of 87). The median delay in diagnosis was 8.1 months (interquartile range, 2.0-46.3). Normocomplementemia and hypocomplementemia were present in 54.0% (n = 27) and 46.0% (n = 23) of 50 patients, respectively. Most patients with UV (51.8%; n = 43 of 83) reported severely decreased QOL due to their disease. Low QOL was also the most frequently reported greatest challenge for patients with UV (40.7%), followed by the long-standing course of UV with frequent relapses (14.8%). Low QOL correlated with long disease duration (r = 0.298; P = .02) and high numbers of clinical symptoms (r = 0.294; P = .007). Patients with UV with allergies, lung diseases, and chronic infections reported lower QOL. Patients with UV with low QOL were treated with analgesics, dapsone, montelukast, omalizumab, and colchicine more often than patients with UV with higher QOL (P < .05 for all). CONCLUSIONS Our results show a considerable impairment in QOL in patients with UV associated with long disease duration, high symptom burden, and a high need for therapy. Improvement of the management of UV by further research is necessary.
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Affiliation(s)
- Hanna Bonnekoh
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Jannis Jelden-Thurm
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Monique Butze
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Karoline Krause
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Pavel Kolkhir
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
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Urticarial vasculitis: Clinical and laboratory findings with a particular emphasis on differential diagnosis. J Allergy Clin Immunol 2022; 149:1137-1149. [PMID: 35396080 DOI: 10.1016/j.jaci.2022.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 12/22/2022]
Abstract
Urticarial vasculitis (UV) is a rare cutaneous vasculitis of small vessels characterized by recurrent episodes of wheal-like lesions that tend to last more than 24 hours, healing with a residual ecchymotic postinflammatory hyperpigmentation. The histopathologic pattern of UV is that of leukocytoclastic vasculitis, consisting of fibrinoid necrosis of dermal vessels' walls and neutrophil-rich perivascular inflammatory infiltrates. Although its etiopahogenesis remains still undefined, UV is now regarded as an immune complex-driven disease with activation of the complement cascade, leading to exaggerated production of anaphylatoxins that are responsible for neutrophil recruitment and activation. This condition can be categorized into 2 main entities according to serum complement levels: normocomplementemic UV and hypocomplementemic UV, the latter being associated with circulating anti-C1q autoantibodies and possible extracutaneous manifestations. Systemic multiorgan involvement may be seen particularly in syndromic hypocomplementemic UV, also known as McDuffie syndrome. This review summarizes the clinicopathological and laboratory features as well as the underlying pathophysiological mechanisms of UV. A focus on its main differential diagnoses is provided, that is, chronic spontaneous urticaria, bullous pemphigoid, IgA (Henoch-Schönlein purpura) and IgM/IgG immune complex vasculitis, lupus erythematous tumidus, Wells syndrome, erythema multiforme, cutaneous mastocytosis, cryopyrin-associated periodic syndromes, and coronavirus disease 2019-associated and anti-severe acute respiratory syndrome coronavirus 2-vaccine-associated urticarial eruptions.
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Corthier A, Jachiet M, Bertin D, Servais A, Barbet C, Bigot A, Doutre MS, Bessis D, Bouffandeau A, Moranne O, Jarrot PA, Bardin N, Terrier B, Burtey S, Puéchal X, Daniel L, Jourde-Chiche N. Biopsy-proven kidney involvement in hypocomplementemic urticarial vasculitis. BMC Nephrol 2022; 23:67. [PMID: 35172758 PMCID: PMC8851735 DOI: 10.1186/s12882-022-02689-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypocomplementemic urticarial vasculitis (HUV) is a rare systemic vasculitis. We aimed to describe the kidney involvement of HUV in a multicenter national cohort with an extended follow-up. METHODS All patients with HUV (international Schwartz criteria) with a biopsy-proven kidney involvement, identified through a survey of the French Vasculitis Study Group (FVSG), were included. A systematic literature review on kidney involvement of HUV was performed. RESULTS Twelve patients were included, among whom 8 had positive anti-C1q antibodies. All presented with proteinuria, from mild to nephrotic, and 8 displayed acute kidney injury (AKI), requiring temporary haemodialysis in 2. Kidney biopsy showed membrano-proliferative glomerulonephritis (MPGN) in 8 patients, pauci-immune crescentic GN or necrotizing vasculitis in 3 patients (with a mild to severe interstitial inflammation), and an isolated interstitial nephritis in 1 patient. C1q deposits were observed in the glomeruli (n = 6), tubules (n = 4) or renal arterioles (n = 3) of 8 patients. All patients received corticosteroids, and 9 were also treated with immunosuppressants or apheresis. After a mean follow-up of 8.9 years, 6 patients had a preserved renal function, but 2 patients had developed stage 3-4 chronic kidney disease (CKD) and 4 patients had reached end-stage kidney disease (ESKD), among whom 1 had received a kidney transplant. CONCLUSION Renal involvement of HUV can be responsible for severe AKI, CKD and ESRD. It is not always associated with circulating anti-C1q antibodies. Kidney biopsy shows mostly MPGN or crescentic GN, with frequent C1q deposits in the glomeruli, tubules or arterioles.
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Affiliation(s)
- Alice Corthier
- Department of Nephrology, Aix-Marseille Univ, Hôpital de la Conception, AP-HM, 147 Bd Baille, 13005, Marseille, France
| | - Marie Jachiet
- Department of Dermatology, Hôpital Saint Louis, AP-HP, Université Paris Diderot, Paris, France
| | - Daniel Bertin
- Laboratory of Immunology, Hôpital de la Conception, AP-HM, Marseille, France
| | - Aude Servais
- Department of Nephrology, Hôpital Necker, AP-HP, Paris, France
| | | | - Adrien Bigot
- Department of Internal Medicine, CHU de Tours, Tours, France
| | | | - Didier Bessis
- Department of Dermatology, Hôpital Saint Eloi, Université de Montpellier, Montpellier, France
| | | | - Olivier Moranne
- Department of Nephrology, Dialysis, Apheresis, CHU Caremeau, Nimes, France.,Université de Montpellier-Nîmes, Nîmes, France
| | - Pierre-André Jarrot
- Department of Internal Medicine and Clinical Immunology, Hôpital de la Conception, AP-HM, Marseille, France.,Aix-Marseille Univ, C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Nathalie Bardin
- Laboratory of Immunology, Hôpital de la Conception, AP-HM, Marseille, France.,Aix-Marseille Univ, C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Reference Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, Paris, France.,Paris Descartes University, Paris, France
| | - Stephane Burtey
- Department of Nephrology, Aix-Marseille Univ, Hôpital de la Conception, AP-HM, 147 Bd Baille, 13005, Marseille, France.,Aix-Marseille Univ, C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Reference Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, Paris, France.,Paris Descartes University, Paris, France
| | - Laurent Daniel
- Aix-Marseille Univ, C2VN, INSERM 1263, INRA 1260, Marseille, France.,Department of Pathology, Aix-Marseille Univ, Hôpital de la Timone, AP-HM, Marseille, France
| | - Noémie Jourde-Chiche
- Department of Nephrology, Aix-Marseille Univ, Hôpital de la Conception, AP-HM, 147 Bd Baille, 13005, Marseille, France. .,Aix-Marseille Univ, C2VN, INSERM 1263, INRA 1260, Marseille, France.
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12
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Abstract
The many forms of vasculitis are characterized by inflammation of blood vessels, leading to potentially long-term sequelae including vision loss, aneurysm formation and kidney failure. Accurate estimation of the incidence and prevalence has been hampered by the absence of reliable diagnostic criteria and the rarity of these conditions; however, much progress has been made over the past two decades, although data are still lacking from many parts of the world including the Indian subcontinent, China, Africa and South America. Giant cell arteritis occurs in those aged 50 years and over and seems to mainly affect persons of northern European ancestry, whereas Takayasu arteritis occurs mainly in those aged under 40 years. By contrast, Kawasaki disease mainly occurs in children aged under 5 years and is most common in children of Asian ancestry, and IgA vasculitis occurs in children and adolescents. Although much less common than giant cell arteritis, the different forms of antineutrophil cytoplasmic antibody-associated vasculitis are being increasingly recognized in most populations and occur more frequently with increasing age. Behçet syndrome occurs most commonly along the ancient silk road between Europe and China. Much work needs to be done to better understand the influence of ethnicity, geographical location, environment and social factors on the development of vasculitis.
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Affiliation(s)
- Richard A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Gulen Hatemi
- Department of Internal Medicine, Division of Rheumatology and Behçet's Disease Research Centre, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Jane C Burns
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Division of Rheumatology, Lund University and Department of Rheumatology, Skåne University Hospital, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
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13
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Sabroe RA, Lawlor F, Grattan CEH, Ardern-Jones MR, Bewley A, Campbell L, Flohr C, Leslie TA, Marsland AM, Ogg G, Sewell WAC, Hashme M, Exton LS, Mohd Mustapa MF, Ezejimofor MC. British Association of Dermatologists guidelines for the management of people with chronic urticaria 2021. Br J Dermatol 2021; 186:398-413. [PMID: 34773650 DOI: 10.1111/bjd.20892] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/30/2022]
Abstract
The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of urticaria. The document aims to: offer an appraisal of all relevant literature up to March 2020, focusing on any key developments address important, practical clinical questions relating to the primary guideline objective provide guideline recommendations and if appropriate research recommendations The guideline is presented as a detailed review with highlighted recommendations for practical use in primary, secondary and tertiary care, in addition to an updated Patient Information Leaflet (PIL; available on the BAD Skin Health Information website, https://www.skinhealthinfo.org.uk/a-z-conditions-treatments/).
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Affiliation(s)
- R A Sabroe
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, U.K
| | - F Lawlor
- St John's Institute of Dermatology, NHS Foundation Trust, Guy's and St Thomas, London, SE1 9RT, U.K
| | - C E H Grattan
- St John's Institute of Dermatology, NHS Foundation Trust, Guy's and St Thomas, London, SE1 9RT, U.K
| | - M R Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, U.K
| | - A Bewley
- Barts Health NHS Trust and Queen Mary University of London Medical School, London, E1 1BB, U.K
| | | | - C Flohr
- St John's Institute of Dermatology, NHS Foundation Trust, Guy's and St Thomas, London, SE1 9RT, U.K
| | - T A Leslie
- Royal Free London NHS Foundation Trust, Pond St, London, NW3 2QG, U.K
| | - A M Marsland
- University of Manchester & Salford Royal Hospital, Salford, M6 8HD, U.K
| | - G Ogg
- MRC Human Immunology Unit, The MRC Weatherall Institute of Molecular Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, OX3 9DS, U.K
| | | | - M Hashme
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - M C Ezejimofor
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
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14
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Heijke R, Ahmad A, Frodlund M, Wirestam L, Dahlström Ö, Dahle C, Kechagias S, Sjöwall C. Usefulness of Clinical and Laboratory Criteria for Diagnosing Autoimmune Liver Disease among Patients with Systemic Lupus Erythematosus: An Observational Study. J Clin Med 2021; 10:3820. [PMID: 34501268 PMCID: PMC8432263 DOI: 10.3390/jcm10173820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Abnormal liver function tests are frequently observed during follow-up of patients with systemic lupus erythematosus (SLE) but data on co-existence with autoimmune liver diseases (AILD) are scarce. This retrospective study aimed to describe the prevalence of autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) among well-characterized subjects with SLE. We also evaluated whether the presence of autoantibodies to complement protein 1q (C1q) and/or ribosomal P protein (anti-ribP) are, directly or inversely, associated with AIH, as proposed in some reports. The number of screened patients was 287 (86% females), and all cases were included in a regional Swedish cohort. Each subject of the study population met the 1982 American College of Rheumatology classification criteria and/or the Fries' diagnostic principle. By applying the simplified diagnostic AIH criteria combined with persistent transaminasemia, 40 (13.9%) cases reached at least "probable AIH". However, merely 8 of these had been diagnosed with AIH (overall AIH prevalence 2.8%). Neither anti-C1q nor anti-ribP associated significantly with AIH. By applying the recent PBC guidelines, 6 (2.1%) cases were found, but only 3 of them had actually been diagnosed with PBC and one additional subject was not identified by the guidelines (overall PBC prevalence 1.4%). Compared to prevalence data from the general Swedish population, both AIH and PBC were highly overrepresented in our study population. The sensitivity of the diagnostic AIH criteria was impeccable but the specificity was less impressive, mainly due to positive ANA and hypergammaglobulinemia. Based on our findings, among subjects with SLE, the AIH criteria are less useful and liver biopsy combined with detection of other AILD-associated autoantibodies should be performed.
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Affiliation(s)
- Rebecca Heijke
- Clinic of Internal Medicine, Region Jönköping County, SE-553 05 Jönköping, Sweden;
| | - Awais Ahmad
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Clinical Immunology, Linköping University, SE-581 85 Linköping, Sweden; (A.A.); (C.D.)
| | - Martina Frodlund
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, SE-581 85 Linköping, Sweden; (M.F.); (L.W.)
| | - Lina Wirestam
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, SE-581 85 Linköping, Sweden; (M.F.); (L.W.)
| | - Örjan Dahlström
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, SE-581 85 Linköping, Sweden;
| | - Charlotte Dahle
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Clinical Immunology, Linköping University, SE-581 85 Linköping, Sweden; (A.A.); (C.D.)
| | - Stergios Kechagias
- Department of Health, Division of Diagnostics and Specialist Medicine/Gastroenterology and Hepatology, Medicine and Caring Sciences, Linköping University, SE-581 85 Linköping, Sweden;
| | - Christopher Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, SE-581 85 Linköping, Sweden; (M.F.); (L.W.)
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15
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Gu SL, Jorizzo JL. Urticarial vasculitis. Int J Womens Dermatol 2021; 7:290-297. [PMID: 34222586 PMCID: PMC8243153 DOI: 10.1016/j.ijwd.2021.01.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 01/19/2023] Open
Abstract
Urticarial vasculitis is a rare clinicopathologic entity that is characterized by chronic or recurrent episodes of urticarial lesions. Skin findings of this disease can be difficult to distinguish visually from those of chronic idiopathic urticaria but are unique in that individual lesions persist for ≥24 hours and can leave behind dusky hyperpigmentation. This disease is most often idiopathic but has been linked to certain drugs, infections, autoimmune connective disease, myelodysplastic disorders, and malignancies. More recently, some authors have reported associations between urticarial vasculitis and COVID-19, as well as influenza A/H1N1 infection. Urticarial vasculitis can extend systemically as well, most often affecting the musculoskeletal, renal, pulmonary, gastrointestinal, and ocular systems. Features of leukocytoclastic vasculitis seen on histopathologic examination are diagnostic of this disease, but not always seen. In practice, antibiotics, dapsone, colchicine, and hydroxychloroquine are popular first-line therapies, especially for mild cutaneous disease. In more severe cases, immunosuppressives, including methotrexate, mycophenolate mofetil, azathioprine, and cyclosporine, as well as corticosteroids, may be necessary for control. More recently, select biologic therapies, including rituximab, omalizumab, and interleukin-1 inhibitors have shown promise for the treatment of recalcitrant or refractory cases.
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Affiliation(s)
- Stephanie L. Gu
- Department of Dermatology, Weill Cornell Medicine, New York, NY, United States
- Corresponding author.
| | - Joseph L. Jorizzo
- Department of Dermatology, Weill Cornell Medicine, New York, NY, United States
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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16
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Beeckmans H, Bos S, Vos R. Selection Criteria for Lung Transplantation: Controversies and New Developments. Semin Respir Crit Care Med 2021; 42:329-345. [PMID: 34030197 DOI: 10.1055/s-0041-1728756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.
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Affiliation(s)
- Hanne Beeckmans
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Bos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), BREATHE, Leuven, Belgium
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17
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Berry EC, Wells J, Morey A, Anantharajah A. Hypocomplementemic urticarial vasculitis syndrome presenting with bilateral scleritis. BMJ Case Rep 2021; 14:14/5/e240041. [PMID: 33972296 PMCID: PMC8112411 DOI: 10.1136/bcr-2020-240041] [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] [Indexed: 11/03/2022] Open
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare autoimmune disorder characterised by recurrent urticarial lesions and acquired hypocomplementemia with systemic manifestations. The authors present the case of a 70-year-old man who presented to the ophthalmology clinic with bilateral scleritis and ocular hypertension. He was diagnosed with HUVS after a 6-month period of bilateral scleritis, vestibulitis, significant weight loss, mononeuritis multiplex and recurrent urticarial vasculitis with pronounced persistent hypocomplementemia and the presence of anti-C1q antibodies. Disease control was eventually obtained with mycophenolate and prednisolone.
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Affiliation(s)
- Ella Claire Berry
- Canberra Health Services Library, ACT Government, Garren, Australian Capital Territory, Australia .,Ophthalmology Unit, Canberra Health Services, Garran, Australian Capital Territory, Australia
| | - Jane Wells
- Ophthalmology Unit, Canberra Health Services, Garran, Australian Capital Territory, Australia.,Department of Ophthalmology, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Adrienne Morey
- ACT Pathology, Canberra Health Services, Garran, Australian Capital Territory, Australia.,Australian National University Medical School, Garran, Australian Capital Territory, Australia
| | - Anthea Anantharajah
- Department of Immunology, Canberra Health Services, Garran, Australian Capital Territory, Australia.,John Curtin School of Medical Research, Canberra, Australian Capital Territory, Australia
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18
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Puhl V, Bonnekoh H, Scheffel J, Hawro T, Weller K, von den Driesch P, Röwert-Huber HJ, Cardoso J, Gonçalo M, Maurer M, Krause K. A novel histopathological scoring system to distinguish urticarial vasculitis from chronic spontaneous urticaria. Clin Transl Allergy 2021; 11:e12031. [PMID: 33949135 PMCID: PMC8099228 DOI: 10.1002/clt2.12031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/11/2021] [Indexed: 02/03/2023] Open
Abstract
Background Urticarial vasculitis (UV) is defined by long‐lasting urticarial lesions combined with the histopathologic findings of leukocytoclastic vasculitis. As one of the major unmet needs in UV, diagnostic criteria are rather vague and not standardized. Moreover, there seems to be considerable overlap with chronic spontaneous urticaria (CSU), particularly for the normocomplementemic variant of UV. Therefore, this study aimed to develop a diagnostic scoring system that improves the histopathologic discrimination between UV and CSU. Methods Lesional skin sections of patients with clinical and histopathologic diagnosis of UV (n = 46) and CSU (n = 51) were analyzed (blinded to the diagnosis) for the following pre‐defined criteria: presence of leukocytoclasia, erythrocyte extravasation, fibrin deposits, endothelial cell swelling, ectatic vessels, blurred vessel borders, dermal edema, intravascular neutrophil, and eosinophil numbers and numbers of dermal neutrophils, macrophages and mast cells. Results The greatest differences between UV and CSU samples were observed for leukocytoclasia (present in 76% of UV vs. 3.9% of CSU samples; p < 0.0001), erythrocyte extravasation (present in 41.3% of UV vs. 2.0% of CSU samples; p < 0.0001), and fibrin deposits (present in 27.9% of UV vessels vs. 9.7% of CSU vessels; p < 0.0001). Based on these findings, we developed a diagnostic score, the urticarial vasculitis score (UVS), which correctly assigned 37 of 46 cases of UV and 49 of 51 cases of CSU to the previously established diagnosis. Conclusion Our results suggest that the UVS, a combined quantitative assessment of the three criteria leukocytoclasia, fibrin deposits and extravasated erythrocytes, distinguishes UV from CSU in skin histopathology. The UVS, if validated in larger patient samples, may help to improve the diagnostic approach to UV.
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Affiliation(s)
- Viktoria Puhl
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hanna Bonnekoh
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Scheffel
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tomasz Hawro
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karsten Weller
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hans-Joachim Röwert-Huber
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - José Cardoso
- Department of Dermatology and Venereology, University Hospital and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Margarida Gonçalo
- Department of Dermatology and Venereology, University Hospital and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marcus Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karoline Krause
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
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19
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Peter J, Krause K, Staubach P, Wu MA, Davis M. Chronic Urticaria and Recurrent Angioedema: Clues to the Mimics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2220-2228. [PMID: 33906826 DOI: 10.1016/j.jaip.2021.03.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022]
Abstract
Urticaria and angioedema are experienced by up to 1 in 5 people, usually the result of common allergen or medication triggers and infections. Similarly, the majority of recurrent angioedema has an exogenous trigger, for example, angiotensin converting enzyme inhibitors, or is hereditary (type 1 and 2 hereditary angioedema); chronic spontaneous urticaria are most often autoimmune or autoallergic in routine clinical practice. There are, however, several skin and systemic conditions that can imitate the clinical appearance of either angioedema or urticaria, whereas there are several uncommon conditions that have chronic urticaria and/or recurrent angioedema as part of their disease manifestations. Correct diagnosis is paramount to ensuring subsequent tailored therapy for many of these conditions, and in many instances, diagnostic delay can be several years with morbid consequence. In this grand rounds article, we present 2 illustrative clinical cases as the backdrop to discussing a practical diagnostic approach for clinicians to recognize copycat phenotypes and "red flags" that should prompt further investigation of several uncommon mimics. We highlight key diagnostic features, epidemiology, and management for mimics where treatment is distinct from the common phenotypes of recurrent angioedema and chronic urticarias.
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Affiliation(s)
- Jonathan Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
| | - Karoline Krause
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Staubach
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maddalena Alessandra Wu
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Mark Davis
- Department of Dermatology, Mayo Clinic Rochester, Rochester, Minn
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20
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Dominguez B, Vigo R. Hypocomplementemic urticarial vasculitis syndrome associated with rapidly progressive glomerulonephritis: lessons for the clinical nephrologist. J Nephrol 2021; 34:953-957. [PMID: 33433859 DOI: 10.1007/s40620-020-00942-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Ronald Vigo
- Delray Medical Center, Delray Beach, Florida, USA
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21
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Vallianou K, Skalioti C, Liapis G, Boletis JN, Marinaki S. A case report of hypocomplementemic urticarial vasculitis presenting with membranoproliferative glomerulonephritis. BMC Nephrol 2020; 21:351. [PMID: 32811472 PMCID: PMC7433181 DOI: 10.1186/s12882-020-02001-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/31/2020] [Indexed: 01/17/2023] Open
Abstract
Background Hypocomplementemic urticarial vasculitis syndrome is an infrequent condition characterized by ocular, renal, gastrointestinal and pulmonary involvement with low serum complement levels and autoantibodies. Renal manifestations vary from microscopic hematuria to nephrotic syndrome and acute kidney injury. Accordingly differing histologic patterns have been reported. Case presentation We present the case of a 65 years old woman with a history of chronic uveitis who presented with arthralgias, urticarial rush, nephrotic syndrome, glomerular hematuria and low serum complement. Kidney biopsy revealed an immune-complex membranoproliferative glomerulonephritis. The patient received induction therapy with steroids, cyclophosphamide and hydroxychloroquine followed by rapid clinical improvement and remission of proteinuria. Maintenance treatment consisted of rituximab pulses. Conclusions The majority of hypocomplementemic urticarial vasculitis syndrome cases is idiopathic, although an association to drugs, infections or other autoimmune disorders has been recorded. Given the rarity and heterogeneity of the disease, no standard treatment is established.
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Affiliation(s)
- Kalliopi Vallianou
- Department of Nephrology and Renal Transplantation Unit, Faculty of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Chrysanthi Skalioti
- Department of Nephrology and Renal Transplantation Unit, Faculty of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Liapis
- Pathology Department, Laiko Hospital, Athens, Greece
| | - John N Boletis
- Department of Nephrology and Renal Transplantation Unit, Faculty of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation Unit, Faculty of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Kidney Involvement in Hypocomplementemic Urticarial Vasculitis Syndrome-A Case-Based Review. J Clin Med 2020; 9:jcm9072131. [PMID: 32640739 PMCID: PMC7408727 DOI: 10.3390/jcm9072131] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 11/16/2022] Open
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS), or McDuffie syndrome, is a rare small vessel vasculitis associated with urticaria, hypocomplementemia and positivity of anti-C1q antibodies. In rare cases, HUVS can manifest as an immune-complex mediated glomerulonephritis with a membranoproliferative pattern of injury. Due to the rarity of this disorder, little is known about the clinical manifestation, pathogenesis, treatment response and outcome of such patients. We describe here three cases of HUVS with severe renal involvement. These patients had a rapidly progressive form of glomerulonephritis with severe nephrotic syndrome against a background of a membranoproliferative pattern of glomerular injury with extensive crescent formation. Therefore, these patients required aggressive induction and maintenance immunosuppressive therapy, with a clinical and renal response in two patients, while the third patient progressed to end-stage renal disease. Because of the rarity of this condition, there are few data regarding the clinical presentation, pathology and outcome of such patients. Accordingly, we provide an extensive literature review of cases reported from 1976 until 2020 and place them in the context of the current knowledge of HUVS pathogenesis. We identified 60 patients with HUVS and renal involvement that had adequate clinical data reported, out of which 52 patients underwent a percutaneous kidney biopsy. The most frequent renal manifestation was hematuria associated with proteinuria (70% of patients), while one third had abnormal kidney function on presentation (estimated glomerular filtration (GFR) below 60 mL/min/1.73 m2). The most frequent glomerular pattern of injury was membranoproliferative (35%), followed by mesangioproliferative (21%) and membranous (19%). Similar to other systemic vasculitis, renal involvement carries a poorer prognosis, but the outcome can be improved by aggressive immunosuppressive treatment.
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Al Kamzari A, Al Musalhi B, Al Abrawi S, Al-Zakwani I, Abdwani R. Urticarial vasculitis in pediatric systemic lupus erythematosus. Pediatr Dermatol 2020; 37:651-655. [PMID: 32372441 DOI: 10.1111/pde.14184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/25/2020] [Accepted: 04/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES To determine the prevalence of urticarial vasculitis (UV) in a pediatric systemic lupus erythematosus (pSLE) cohort of Arab ethnicity from Oman and to describe their demographic, clinical, and laboratory features. METHODS We conducted a retrospective multicenter study among pediatric rheumatology centers in Oman over a 10-year period from 2008 to 2018. Analyses were performed using univariate statistics. RESULTS A total of 148 pSLE under the age of 13 years were included of which 30% (n = 44) were men. The overall mean age at SLE diagnosis was 7.6 ± 3.5 years while the mean disease duration was 10.1 ± 5.4 years. UV was diagnosed in 36% (n = 53) of pSLE patients. Patients with pSLE and UV were more likely to be male (57% vs 15%; P < .001), diagnosed at a younger age (5.9 vs 8.5 years; P < .001), have a family history of SLE (53% vs 36%; P = .044), and have associated conjunctivitis, (32% vs 5.3%; P < .001) but less likely to have CNS involvement (7.6% vs 20%; P = .045) or hematological manifestations such as leukopenia (9.4% vs 24%; P = .028) and thrombocytopenia (5.7% vs 18%; P = .045). This subgroup was also more likely to be associated with low C3 complement count (94% vs 66%; P < .001) and positive cytoplasmic ANCA (11% vs 0%; P = .022). CONCLUSION We report a high occurrence of UV in a pSLE cohort associated with unique demographic, clinical, and laboratory features.
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Affiliation(s)
- Ahmed Al Kamzari
- Child Health Department, Oman Medical Specialty Board, Muscat, Oman
| | | | | | - Ibrahim Al-Zakwani
- Pharmacology & Clinical Pharmacy Department, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman.,Gulf Health Research, Muscat, Oman
| | - Reem Abdwani
- Child Health Department, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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David C, Jachiet M, Pineton de Chambrun M, Gamez AS, Mehdaoui A, Zenone T, Gobert D, Aouba A, Peterschmitt A, Palat S, Lifermann F, Blockmans D, Feuillet-Soummer S, Mouthon L, Terrier B. Chronic obstructive pulmonary disease associated with hypocomplementemic urticarial vasculitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3222-3224.e1. [PMID: 32504842 DOI: 10.1016/j.jaip.2020.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/12/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Clémence David
- Department of Internal Medicine, Cochin Hospital, Paris, France; National Referral Centre for Systemic and Autoimmune Diseases, Cochin Hospital, Paris, France
| | - Marie Jachiet
- Department of Dermatology, Saint-Louis Hospital, Paris, France
| | - Marc Pineton de Chambrun
- Department of Internal Medicine and Intensive Care Medicine, Pitié-Salpétrière Hospital, Paris, France
| | - Anne Sophie Gamez
- Department of Pulmonology, Montpellier University Hospital, Montpellier, France
| | - Anas Mehdaoui
- Department of Pulmonology, Evreux Hospital, Evreux, France
| | - Thierry Zenone
- Department of Internal Medicine, Valence Hospital, Valence, France
| | - Delphine Gobert
- Department of Internal Medicine, Saint-Antoine Hospital, Paris, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Anne Peterschmitt
- Department of Internal Medicine, Grenoble Mutualist Hospital Group, Grenoble, France
| | - Sylvain Palat
- Department of Internal Medicine, Limoges Hospital, Limoges, France
| | | | - Daniel Blockmans
- Department of Internal Medicine, Leuven University Hospital, UZ Leuven, Belgium
| | - Séverine Feuillet-Soummer
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Luc Mouthon
- Department of Internal Medicine, Cochin Hospital, Paris, France; National Referral Centre for Systemic and Autoimmune Diseases, Cochin Hospital, Paris, France; Paris Descartes University, Université de Paris, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Cochin Hospital, Paris, France; National Referral Centre for Systemic and Autoimmune Diseases, Cochin Hospital, Paris, France; Paris Descartes University, Université de Paris, Paris, France.
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Kolkhir P, Bonnekoh H, Kocatürk E, Hide M, Metz M, Sánchez-Borges M, Krause K, Maurer M. Management of urticarial vasculitis: A worldwide physician perspective. World Allergy Organ J 2020; 13:100107. [PMID: 32180892 PMCID: PMC7063238 DOI: 10.1016/j.waojou.2020.100107] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Urticarial vasculitis (UV) is a rare type of leukocytoclastic vasculitis characterized by long lasting urticarial skin lesions and poor response to treatment. As of yet, no clinical guidelines, diagnostic criteria, or treatment algorithms exist, and the approaches to the diagnostic workup and treatment of UV patients may differ globally. We conducted an online survey to examine how UV patients are diagnosed and treated by international specialists and to reveal the greatest challenges in managing UV patients worldwide. METHODS Distribution of the questionnaire included an email to individuals in the World Allergy Organization (WAO) database, with no restrictions applied to the specialty, affiliation, or nationality of the participants (November 2018). The email contained a link (Internet address) to the online questionnaire. Responses were anonymous. The link to the questionnaire was further sent to the network of Urticaria Centers of Reference and Excellence (UCARE) in the Global Allergy and Asthma European Network (GA2LEN) as well as to the Turkish Dermatology Society and the Japanese Society of Allergology, who distributed the link to their members. In addition, the survey link was posted online in the group of the Russian Society of Allergologists and Immunologists. RESULTS We received 883 completed surveys from physicians in 92 countries. UV was reported to be rare in clinical practice, with an average of 5 patients per physician per year. More than two-thirds of physicians reported wheals, burning of the skin, and residual hyperpigmentation in 60-100% of UV patients. The most frequently reported reason for receiving referrals of patients with UV was to establish the diagnosis. The most important features for establishing the diagnosis of UV were wheals of longer than 24 hours duration (72%), the results of skin biopsy (63%), and post-inflammatory hyperpigmentation (46%). The most common tests ordered in UV patients were complete blood count, erythrocyte sedimentation rate, C-reactive protein, complement components, antinuclear antibodies, and skin biopsy. Physicians considered UV to be of unknown cause in most patients, and drugs and systemic lupus erythematosus to be the most common identifiable causes. Two of 3 physicians reported that they use second-generation antihistamines in standard dose as the first-line therapy in patients with UV. The greatest perceived challenges in the management of UV were the limited efficacy of drugs and the absence of clinical guidelines and treatment algorithms. CONCLUSIONS UV is a challenging disease. Skin biopsy, a gold standard for UV diagnosis, is not performed by many physicians. This may lead to misdiagnosis of UV, for example, as chronic spontaneous urticaria, and to inadequate treatment. International consensus-based recommendations for the classification of UV and the diagnostic workup and treatment, as well as prospective studies evaluating potentially safe and effective drugs for the treatment of UV, are necessary.
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Key Words
- ANA, antinuclear antibodies
- CRP, C-reactive protein
- CSU, Chronic spontaneous urticaria
- Diagnosis
- ESR, erythrocyte sedimentation rate
- GA2LEN, Global Allergy and Asthma European Network
- HUV, Hypocomplementemic urticarial vasculitis
- HUVS, Hypocomplementemic urticarial vasculitis syndrome
- Management
- NUV, Normocomplementemic urticarial vasculitis
- SLE, Systemic lupus erythematosus
- Treatment
- UCARE, Urticaria Centers of Reference and Excellence
- UV, Urticarial vasculitis
- Urticarial vasculitis
- WAO, World Allergy Organization
- Worldwide
- sgAHs, Second generation antihistamines
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Affiliation(s)
- Pavel Kolkhir
- Dermatological Allergology, UCARE Charité, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Division of Immune-mediated Skin Diseases, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Hanna Bonnekoh
- Dermatological Allergology, UCARE Charité, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Emek Kocatürk
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
| | - Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Martin Metz
- Dermatological Allergology, UCARE Charité, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad and Clínica El Avila, Caracas, Venezuela
| | - Karoline Krause
- Dermatological Allergology, UCARE Charité, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marcus Maurer
- Dermatological Allergology, UCARE Charité, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Skattum L. Clinical Complement Analysis-An Overview. Transfus Med Rev 2019; 33:207-216. [PMID: 31672339 DOI: 10.1016/j.tmrv.2019.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
The complement system plays an important role in varying types of disease, ranging from inflammatory and autoimmune disorders to immune deficiency states. In addition, new settings have emerged where complement analysis is of interest to monitor complement-directed therapy and aid identification of transplant complications. Therefore, it is critical that clinical laboratories offer optimized and timely complement analysis. This review presents a comprehensive overview of the most important complement analysis methods that are currently used. It also points to some areas within complement diagnostics where development is needed, for example, regarding certain analytes for which practical methods suitable for the routine laboratory are lacking. Furthermore, it contains a more detailed discussion on complement autoantibody assessment. The list of analyses providing clinically valuable information includes analysis of complement function, quantification of individual complement components and complement activation fragments, identification of autoantibodies to complement, as well as genetic complement analyses. There is still a shortage of commercially available methods suitable for high-throughput screening of complement deficiency and for assessment of complement activation, but development is under way. There is also ongoing work within the complement community to improve standardization of measurements, and recently, an extensive quality assurance program has been initiated.
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Affiliation(s)
- Lillemor Skattum
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, and Clinical Immunology and Transfusion Medicine, Region Skåne, Lund, Sweden.
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Abstract
Hemorrhagic rashes are observed in a wide variety of conditions, ranging from harmless to life-threatening. This review offers a stepwise approach, which helps limit the possible differential diagnoses based on the clinical manifestations and the clinical picture. The most common and most important conditions, including infectious, coagulation and embolic disorders, vasculitides, and vasculopathies, are briefly reviewed focusing on morphology. Dermatologists often need to distinguish among infectious, reactive, or autoimmune etiologies of the rash and determine if the condition is dangerous or even life-threatening in order to make the right decision. Dermatologic expertise provides vital input in the diagnosis and care of complex interdisciplinary patients, such as those with sepsis, purpura fulminans, and thrombotic thrombocytopenic purpura.
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Ladhani SN, Campbell H, Lucidarme J, Gray S, Parikh S, Willerton L, Clark SA, Lekshmi A, Walker A, Patel S, Bai X, Ramsay M, Borrow R. Invasive meningococcal disease in patients with complement deficiencies: a case series (2008-2017). BMC Infect Dis 2019; 19:522. [PMID: 31200658 PMCID: PMC6567562 DOI: 10.1186/s12879-019-4146-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/30/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To describe patients with inherited and acquired complement deficiency who developed invasive meningococcal disease (IMD) in England over the last decade. METHODS Public Health England conducts enhanced surveillance of IMD in England. We retrospectively identified patients with complement deficiency who developed IMD in England during 2008-2017 and retrieved information on their clinical presentation, vaccination status, medication history, recurrence of infection and outcomes, as well as characteristics of the infecting meningococcal strain. RESULTS A total of 16 patients with 20 IMD episodes were identified, including four with two episodes. Six patients had inherited complement deficiencies, two had immune-mediated conditions associated with complement deficiency (glomerulonephritis and vasculitis), and eight others were on Eculizumab therapy, five for paroxysmal nocturnal haemoglobinuria and three for atypical haemolytic uraemic syndrome. Cultures were available for 7 of 11 episodes among those with inherited complement deficiencies/immune-mediated conditions and the predominant capsular group was Y (7/11), followed by B (3/11) and non-groupable (1/11) strains. Among patients receiving Eculizumab therapy, 3 of the 9 episodes were due to group B (3/9), three others were NG but genotypically group B, and one case each of groups E, W and Y. CONCLUSIONS In England, complement deficiency is rare among IMD cases and includes inherited disorders of the late complement pathway, immune-mediated disorders associated with low complement levels and patients on Eculizumab therapy. IMD due to capsular group Y predominates in patient with inherited complement deficiency, whilst those on Eculizumab therapy develop IMD due to more diverse capsular groups including non-encapsulated strains.
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Affiliation(s)
- Shamez N. Ladhani
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
- Paediatric Infectious Diseases Research Group & Vaccine Institute, Institute of Infection & Immunity, St. Georges, University of London, London, UK
| | - Helen Campbell
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
| | - Jay Lucidarme
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Steve Gray
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Sydel Parikh
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
| | - Laura Willerton
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Stephen A. Clark
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Aiswarya Lekshmi
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Andrew Walker
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Sima Patel
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Xilian Bai
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Mary Ramsay
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
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Temiz SA, Ataseven A, Ozer I, Dursun R, Findik S. Refractory Urticarial Vasculitis Responsive to Methotrexate: Could It Be a New Treatment Option? CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2019. [DOI: 10.33808/marusbed.546841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Anti-C1q autoantibodies may be found in many conditions, most commonly in systemic lupus erythematosus (SLE) and hypocomplementemic urticarial vasculitis syndrome (HUVS), and are diagnostic markers as well as disease activity markers in lupus nephritis. Sera from patients with SLE and HUVS show partly distinct autoantibody reactivities to separated protein chains B and C of the first component of complement, C1q. These different binding specificities can be detected by Western blot analysis of the autoantibodies under reducing conditions. Results may help clinicians to differentiate between SLE and HUVS.
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Affiliation(s)
- Anci Verlemyr
- Clinical Immunology and Transfusion Medicine, Region Skåne, Sweden
| | - Lennart Truedsson
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden
| | - Lillemor Skattum
- Clinical Immunology and Transfusion Medicine, Region Skåne, Sweden.
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden.
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Ekdahl KN, Persson B, Mohlin C, Sandholm K, Skattum L, Nilsson B. Interpretation of Serological Complement Biomarkers in Disease. Front Immunol 2018; 9:2237. [PMID: 30405598 PMCID: PMC6207586 DOI: 10.3389/fimmu.2018.02237] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/10/2018] [Indexed: 01/07/2023] Open
Abstract
Complement system aberrations have been identified as pathophysiological mechanisms in a number of diseases and pathological conditions either directly or indirectly. Examples of such conditions include infections, inflammation, autoimmune disease, as well as allogeneic and xenogenic transplantation. Both prospective and retrospective studies have demonstrated significant complement-related differences between patient groups and controls. However, due to the low degree of specificity and sensitivity of some of the assays used, it is not always possible to make predictions regarding the complement status of individual patients. Today, there are three main indications for determination of a patient's complement status: (1) complement deficiencies (acquired or inherited); (2) disorders with aberrant complement activation; and (3) C1 inhibitor deficiencies (acquired or inherited). An additional indication is to monitor patients on complement-regulating drugs, an indication which may be expected to increase in the near future since there is now a number of such drugs either under development, already in clinical trials or in clinical use. Available techniques to study complement include quantification of: (1) individual components; (2) activation products, (3) function, and (4) autoantibodies to complement proteins. In this review, we summarize the appropriate indications, techniques, and interpretations of basic serological complement analyses, exemplified by a number of clinical disorders.
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Affiliation(s)
- Kristina N Ekdahl
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Barbro Persson
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Camilla Mohlin
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Kerstin Sandholm
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Lillemor Skattum
- Section of Microbiology, Immunology and Glycobiology, Department of Laboratory Medicine, Clinical Immunology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Bo Nilsson
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Watts RA, Robson J. Introduction, epidemiology and classification of vasculitis. Best Pract Res Clin Rheumatol 2018; 32:3-20. [DOI: 10.1016/j.berh.2018.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/18/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022]
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