Southwestern Internal Medicine Conference: vasculitis--it's time to reclassify

Acute febrile neutrophilic vasculitis of the skin of young Shar-Pei dogs

Three young Shar-Pei dogs were presented for signs of an acute widespread dermatopathy associated with fever and malaise. Cutaneous lesions initially consisted of multifocal areas of skin discolouration (haemorrhagic papules, macules or plaques) or oedema, preferentially affecting the head and limbs. In some locations, pus-filled bullae were evident also. Cutaneous lesions exuded seropurulent liquid and, in time, usually progressed to full thickness necrosis and ulceration. Lesions were so widespread and severe that one of the dogs was euthanased because its owners could not afford the reconstructive surgery required to close the skin deficits left at the completion of otherwise successful therapy. Histological examination of representative biopsies showed neutrophilic dermatitis and vasculitis, which ultimately resulted in ischaemic necrosis of skin. Therapy with immunosuppressive doses of corticosteroids, and in one case cyclophosphamide, resulted in prompt amelioration of the underlying inflammatory process, although regions of skin deprived of their blood supply eventually became necrotic and sloughed. Healing occurred through granulation, contraction and epithelialisation. The physical findings in these three dogs were so similar that it is likely all suffered from the same breed-related syndrome, an immune-mediated vasculitis precipitated by some event, such as vaccination or an undetected infection. Whatever the inciting cause, it was most likely a one-off event, as the two surviving dogs were readily weaned off immunosuppressive medication without relapse.

Therapy: Hyperbaric Oxygen as the Only Effective Treatment in Mutilating and Resistant Systemic Vasculitis

A forty year old man was seen in 1984 with a four year history of a painful vasculitis that responded transiently to plasma exchange. Diagnosis was revised to atypical pyoderma gangrenosum with further temporary benefit from lamprene and continuing maximally tolerated corticosteroids. The course fluctuated over the next ten years with gradual and increasing soft-tissue damage coupled with superimposed skin infections. A variety of organisms were isolated from the ulcerated areas, with each episode successfully managed on the basis of local debridement and appropriate antibiotic administration. In 1995, with extending skin devascularization, infectious bacterial episodes became more frequent and deep non-healing ulcers led to constant pain with virtual incapacity. In response to protocol hyperbaric oxygen therapy there was immediate reversal of the cutaneous damage, granulation tissue formed and new skin grew to cover the previous extensive deficits. As the lesions in his hands and feet improved so did his quality of life, with the patient again becoming ambulant and returning to work. Vascular access had become a major problem, and venography showed extensive occlusion with collateral circulation. A standard Hickman catheter was placed through the femoral vein into the inferior vena cava and functioned well over the next five years. At the end of 1996 the patient was admitted with an acute chest pain that was complicated by a major pulmonary embolus, from which he could not be resuscitated. This anecdotal experience demonstrates the important but underutilised benefits of hyperbaric oxygen in managing refractory, painful and penetrating skin ulcers. The cost of obtaining wound healing with reduction in pain by this form of treatment was approximately one-fifth of expenditure on previously ineffective management.

ANCA-associated glomerulonephritis: Relationship of main ANCA subtypes to renal outcome, age and sex of the patients

BACKGROUND

Antineutrophil cytoplasmic antibodies (ANCA) have been proven to be useful diagnostic tools in patients with systemic vasculitis and glomerulonephritis. These antibodies exist in two types, a cytoplasmic pattern (cANCA) and a perinuclear pattern (pANCA). The effect of the main ANCA subtypes on renal outcome and its relationship to demographic findings and clinical features of patients with ANCA-associated glomerulonephritis has not been adequately studied.

PATIENTS AND METHOD

In this prospective study, we compared the clinical features at presentation and the renal outcome after 1 year of follow-up between two groups of patients with cANCA (n=22) and pANCA (n=29) consecutively encountered over a one-year period.

RESULT

At presentation, rapidly progressive glomerulonephritis (RPGN), and after 1 year of follow-up, endstage renal disease (ESRD) were seen more commonly in patients with pANCA than cases with cANCA (P=0.001 and P=0.004, respectively). Seropositivity for cANCA was more common in male and pANCA in female patients (P=0.005). Occurrence of the pulmonary-renal syndrome or extra-renal manifestations, such as sinusitis and skin rash, did not differ significantly among the two groups of patients with cANCA and pANCA.

CONCLUSION

Patients with pANCA present more frequently with RPGN, leading to a poorer renal survival compared to cases with cANCA. RPGN and pANCA are more common in females.

Antineutrophil cytoplasmic antibodies as markers for systemic autoimmune disease

Antineutrophil cytoplasmic antibodies (ANCA) have been associated with systemic vasculitis for almost 15 years. Significant advances in our understanding of the ANCA phenomenon have occurred with recognition of broadening the spectrum of diseases associated with ANCA, identification of specific antigens recognized by ANCA, and development of antigen specific assays for clinical use. Nevertheless problems continue for the chest physician in interpretation of this test. Although antigen specific testing improves overall performance of the test, accurate assessment of pretest probability of disease is still important for effective use of ANCA testing.

Rupture of a hepatic artery aneurysm caused by Wegener's granulomatosis

Among vasculitis syndromes Wegener's granulomatosis (WG) is characterized by involvement of the upper and lower airways and kidneys. The associated vasculitis involves small and medium sized arteries and veins. Aneurysm formation and a segmental pattern of involvement of larger arteries is not typically seen in WG--a presentation more in keeping with polyarteritis nodosa. We report on a patient hospitalized with classical manifestations of WG who died suddenly of hypovolemic shock caused by intraperitoneal hemorrhage resulting from rupture of a hepatic artery aneurysm. The aneurysm was caused by involvement of the hepatic artery in the disease process. To our knowledge aneurysmatic dilatation of the hepatic artery due to WG has not been previously described. This case illustrates an unusual disease course in WG and the overlap which exists in classical vasculitis syndromes.

Persistent urticarial eruption in an asthmatic patient

This case demonstrates the importance of recognizing urticarial vasculitis in patients with chronic urticarial eruptions. The salient points in history that point towards the diagnosis of urticarial vasculitis include the presence of painful urticarial lesions that last longer than 24 hours and that heal leaving residual pigmentation. In some cases the urticaria may evolve into palpable purpura. An associated systemic illness that may resemble systemic lupus erythematosus should also suggest the diagnosis, which is established by skin biopsy. Histopathology reveals a leukocytoclastic vasculitis involving postcapillary venules. When associated with systemic vasculitis, the urticaria is likely to be of the hypocomplementemic variety, with immunoglobulin and complement deposition on biopsies, and with serum complement studies demonstrating classical pathway activation, low C1q levels, and anti-C1q precipitins. A variety of agents have been used in the management of urticarial vasculitis, including aspirin, nonsteroidal anti-inflammatory agents, corticosteroids, colchicine, dapsone, hydroxychloroquine, and cytotoxic agents such as cyclophosphamide and azathioprine.