"Essential" cutaneous vasculitis: what every rheumatologist should know about vasculitis of the skin

Catastrophic Cutaneous Polyarteritis Nodosa Exacerbated by Emotional Stress

We present the first case of a patient with indolent polyarteritis nodosa who suffered severe exacerbations following significant emotional stressors. This report highlights the close relationship between emotions and autoimmune diseases mediated by the deleterious effects of stressors presumptively by skewing immunity from Type 1 to Type 2.

Case Report: Vasculitis Triggered by SIRT in a Patient With Previously Untreated Cholangiocarcinoma

Arising from the biliary tract, cholangiocarcinoma is a rare and aggressive epithelial cancer. According to the primary site, it can be further classified into intrahepatic, perihilar and distal types. Due to the lack of symptoms early in the disease course, most patients are diagnosed at advanced stages. Being not candidates for curative surgical management, these patients are treated with palliative systemic chemotherapy, and their prognosis remains poor. Using radioisotopes like yttrium-90 -labeled microspheres (⁹⁰Y), radioembolization represents a local approach to treat primary and secondary liver tumors. In the case of intrahepatic cholangiocarcinoma, radioembolization can be used as a primary treatment, as an adjunct to chemotherapy or after failing chemotherapy. An 88-year-old man underwent radioembolization for a previously untreated stage II intrahepatic cholangiocarcinoma. One week later, he presented to our clinic with a non-pruritic maculopapular rash of the lower extremities and abdomen, worsening fatigue and low-grade fever. Laboratory exams, including hepatitis screening, were within normal limits. Showing positive immunofluorescence staining for immunoglobulin M (IgM) and complement 3 (C3) in vessel walls without IgA involvement, the skin biopsy results were compatible with leukocytoclastic vasculitis. Apart from the anticancer intervention, there have been no recent medication changes which could explain this complication. Notably, we did not observe any side effects during or after the perfusion scan with technetium-99m macroaggregated albumin (MAA) performed prior to radioembolization. The symptoms resolved quickly after a short course of colchicine and did not reappear at cholangiocarcinoma progression. In the absence of other evident causes, we conclude that the onset of leukocytoclastic vasculitis in our patient was directly linked to the administration of yttrium-90 -labeled microspheres. Our report therefore demonstrates that this condition can be a rare but manageable complication of ⁹⁰Y liver radioembolization.

Fatal Coronary Artery Vasculitis With Mixed Features

ABSTRACT

Atherosclerotic cardiovascular disease (ASCVD) is often investigated by medical examiners as a cause of sudden death. Because of the variation in presentation of atherosclerotic cardiovascular disease, the examiner must be cautious when assigning a final diagnosis. The presented case depended upon histologic examination of coronary artery lesions to reach an appropriate final diagnosis of vasculitis with mixed features. Autopsy findings showed hepatosplenic vasculitis with noncaseating granulomas, and multifocal diffuse coronary fibrosis with histologic findings consistent with late-stage polyarteritis nodosa (PAN). However, the patient lacked the hallmark renal involvement observed in PAN. Furthermore, the vasculitis within the liver showed a highly granulomatous appearance, more consistent with IgG4 disease. In these mixed-appearance cases with limited history, exact categorization of the disease may prove difficult to impossible. Herein, we review a differential diagnosis of classic vasculitides with a focus on those that commonly affect the coronary arteries in adults, namely, PAN.

Recognition and Management of Cutaneous Connective Tissue Diseases

Connective tissue diseases (CTDs) encompass a broad spectrum of clinical presentations that involve multidisciplinary management. Cutaneous findings are common in CTD and careful examination of these features aids in appropriate diagnosis and subsequent evaluation. Thorough work-up of CTD is crucial to properly identify disease subtypes and systemic involvement. Management plans can be developed based on diagnosis and systemic manifestations of disease. Disease management often requires treatment with pharmacotherapies with potential for toxicities, further underscoring the importance of diagnostic accuracy in this patient population. Evolving research strives to better elucidate the pathogenic mechanisms of CTDs allowing for more targeted treatment modalities.

Recognition and Management of Cutaneous Polyarteritis Nodosum Versus Livedoid Vasculitis: A Case Report

Cutaneous polyarteritis nodosum (CPAN) is a vasculitis of small and medium-sized muscular arteries of the dermis and subcutaneous tissue with no associated systemic involvement. A common presentation of CPAN can be misinterpreted as a non-invasive form of livedoid vasculitis, synonymous with the “atrophie blanche” which similarly presents as ivory-white stellate-shaped scars. Although hyperpigmentation can also be present, as seen in our 47-year-old female patient, cutaneous polyarteritis nodosum is unique due to the etiology of the inflammatory illness which requires a deep, segmented skin biopsy for diagnosis in order to identify the vessel inflammation. In this case report, we discuss a patient with a 20-year history of painful, recurrent ulcerations and polyneuritis with previous ulcer eruptions that healed as ivory-white stellate scarring. AB cutaneous forms of polyarteritis nodosum (PAN) may be only one manifestation of the disease, with other presentations in association with multi-organ system disease. This report will discuss the necessity of a high index of clinical suspicion with a clinical presentation similar to that of our patient. We will discuss the importance of early recognition and diagnosis of cutaneous vasculitis, such as CPAN, based on clinical presentation and history in hopes of limiting morbidity and the risk of progression to systemic forms of the disease. 

Diagnosis and management of cutaneous vasculitis in children

Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.

Cutaneous vasculitis: a rheumatologist perspective

Cutaneous vasculitis (CV) comprises a wide spectrum of diseases and displays a variety of clinical lesions, the most common being a palpable purpura. CV may be a process confined exclusively to the skin or be a manifestation of a more widespread entity associated to a variable grade of visceral involvement. In this regard, CV may occur as part of the clinical spectrum of primary systemic vasculitis, autoimmune diseases or less commonly as presenting manifestation of cancer or severe infections. An adequate clinical approach is required to establish optimal management of this condition.

The influence of connective tissue disease in the management of lower limb ischemia

INTRODUCTION

Vascular intervention for patients with connective tissue disease (CTD) and symptomatic limbs, particularly with tissue loss, is associated with poor outcomes. The aims of our study were to compare outcomes from arterial interventions for patients with CTD versus overall results for our unit and analyse available baseline patient characteristics to determine whether any features were associated with poor prognosis.

METHODS

We retrieved data from a prospectively maintained database of all patients undergoing interventions on the vascular unit since 1984. The database included coding for CTD and tissue loss at presentation. Information was retrieved for each patient with CTD identified for a period of 2 years postoperatively. Additional data were retrieved from patient's notes.

RESULTS

CTD was identified in 23 patients, 12 men and 11 women, with a median age of 68 years (range 42-84). The majority of patients suffered from rheumatoid arthritis. Of 13 patients who presented with peripheral arterial disease (PAD) and associated tissue loss, 12 underwent arterial procedures, and 1 had a primary amputation. Of 5 endovascular procedures performed, 4 failed, 2 immediately and 2 subsequently. Seven patients had major amputations at 6 months. At 2 years, 11 of 13 patients (84.6%) had major amputations, and of the remaining 2, 1 had persisting ulceration. In comparison, of the 10 patients presenting with critical limb ischemia without tissue loss, there was 1 amputation, which occurred at 12 months, and 1 patient died, a limb loss/death rate at 24 months of 20%. A backward binary logistic regression analysis showed that neither gender nor age had a significant effect in predicting limb loss, but tissue loss at presentation was associated with a significantly higher rate of amputation.

CONCLUSIONS

Patients with CTD and PAD who present with lower limb tissue loss appear to be at greater risk of limb loss after vascular intervention compared with the general vascular population managed by our unit. CTD patients with no tissue loss had outcomes comparable to the general vascular population. We suggest that the management of patients with CTD and PAD presenting with lower limb tissue loss should include focused, aggressive treatment of underlying inflammation and nutrition.

The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features

Cutaneous vasculitis may be associated with malignancies, and may behave as a paraneoplastic syndrome. This association has been reported in a variable proportion of patients depending on population selection. We conducted the current study to assess the frequency, clinical features, treatment, and outcome of paraneoplastic vasculitis in a large unselected series of 766 patients with cutaneous vasculitis diagnosed at a single university hospital. Sixteen patients (10 men and 6 women; mean age ± standard deviation, 67.94 ± 14.20 yr; range, 40-85 yr) presenting with cutaneous vasculitis were ultimately diagnosed as having an underlying malignancy. They constituted 3.80% of the 421 adult patients. There were 9 hematologic and 7 solid underlying malignancies. Skin lesions were the initial clinical presentation in all of them, and the median interval from the onset of cutaneous vasculitis to the diagnosis of the malignancy was 17 days (range, 8-50 d). The most frequent skin lesions were palpable purpura (15 patients). Other clinical manifestations included constitutional syndrome (10 patients) and arthralgia and/or arthritis (4 cases). Hematologic cytopenias (11 cases) as well as immature peripheral blood cells (6 cases) were frequently observed in the full blood cell count, especially in those with vasculitis associated with hematologic malignancies. Specific treatment for vasculitis was prescribed in 10 patients; nonsteroidal antiinflammatory drugs (4 patients), corticosteroids (3 patients), chloroquine (1 patient), antihistamines (1 patient), and cyclophosphamide (1 patient). Ten patients died due to the malignancy and 6 patients recovered following malignancy therapy. Patients with paraneoplastic vasculitis were older, more frequently had constitutional syndrome, and less frequently had organ damage due to the vasculitis than the remaining patients with cutaneous vasculitis. In summary, cutaneous paraneoplastic vasculitis is an entity not uncommonly encountered by clinicians. The most common underlying malignancy is generally hematologic. In these cases the presence of cytopenias and immature cells may be red flags for the diagnosis of cancer. In patients with paraneoplastic cutaneous vasculitis, the prognosis depends on the underlying neoplasia.

Pulmonary complications of systemic vasculitides

The pulmonary vasculitides are a heterogeneous group of diseases that often occur as a component of systemic vasculitic diseases. Most frequently, pulmonary vasculitis is observed in vasculitic syndromes that preferentially affect small vessels. Pulmonary involvement may develop because the lung has an extensive vascular and microvascular network. Sensitising antigens can easily reach the lung, and there are large numbers of vasoactive and activated immune cells in the lung. A diagnosis often can be made on the basis of clinical presentation and serologic studies, but biopsy of skin, nose, kidney, or lung may be necessary to ascertain the precise syndrome.

The purple digit: an algorithmic approach to diagnosis

The acute onset of purple digits is a concerning manifestation and may represent underlying, potentially life-threatening disease. Correctly identifying the etiology of purple digits is essential to proper management, and can aid in the diagnosis of systemic disease. Multiple causes of purple digits and significant overlap in clinical presentation can make diagnosis difficult. Despite the various causes of acute purple digits in the published literature, an algorithmic approach to the evaluation and management of the most common and alarming etiologies has yet to be established. The initial step in evaluating a patient with purple digits is to determine if the cause is associated with hypoxemia or trauma. If the patient is in a stable condition, the dermatologist needs to determine if the process could be related to cold exposure such as Raynaud phenomenon, acrocyanosis, pernio, cryoglobulinemia or frostbite. If the disease occurs independent of temperature, physical examination and histological evaluation of the skin is recommended. The lack of peripheral pulses are concerning for acute arterial thrombosis from peripheral vascular disease or arterial embolism. Non-blanching skin changes on the digit that lack inflammation and microthrombosis most likely represent a bleeding or platelet abnormality; however, if microthrombi are identified a more life-threatening processes such as purpura fulminans or embolic phenomenon may be occurring. Evidence of blood vessel inflammation suggests a leukocytoclastic vasculitis. The patient with a purple blanching digit and normal pulses requires an extensive historical review to help determine the cause. This review presents an algorithmic approach to assist in the evaluation and management of the purple digit.

Recurrent Optic Disc and Retinal Vasculitis in a Patient with Drug-Induced Urticarial Vasculitis

The purpose of this study was to report recurrent optic disc and retinal vasculitis in a patient with drug-induced urticarial vasculitis. Complete ophthalmological examination including fluorescein angiography and visual field examination were done. A 53-year-old woman with recurrent painful urticarial skin lesions following trimethoprim sulfamethoxazole usage had the clinical and histopathological diagnosis of urticarial vasculitis. Two years after cutaneous manifestations, she began to notice visual disturbances in both eyes that recurred at 1-year intervals. Her ophthalmological findings were consistent with recurrent vasculitis of the optic nerve and retina. Treatment with high-dose corticosteroids and hydroxychloroquine resulted in the resolution of cutaneous and ocular manifestations. This patient demonstrates that recurrent occlusive vasculitis of the optic nerve and retina can occur in this rare disease. These patients should be examined periodically by ophthalmologists.

An adult case of Henoch-Schönlein purpura complicating common peroneal nerve mononeuropathy

We present an adult patient with Henoch-Schönlein Purpura who developed mononeuropathy in the common peroneal nerve. Upon admission, the patient had palpable purpura in the arms and legs, polyarthralgia, abdominal pain, and leukocytoclastic vasculitis in the skin biopsy. These symptoms disappeared with 30 mg daily of oral prednisolone. One month later, after induction therapy, fever, livedo reticularis and peripheral mononeuropathy developed with hypocomplementemia and the patient was treated successfully with glucocorticoid pulse therapy.

Vasculite cutânea crioglobulinêmica induzida por infecção crônica pelo vírus da hepatite C

As vasculites cutâneas podem representar grande desafio clínico, mesmo após exame dermatológico cuidadoso e realização de exames complementares. Os autores apresentam caso de vasculite crioglobulinêmica cutânea associada à infecção crônica pelo vírus da hepatite C, salientando a importância do exame dermatológico na investigação diagnóstica. Discutem ainda a importância da busca da etiologia e da correta classificação no prognóstico e terapêutica das vasculites cutâneas.

Cutaneous manifestations of vasculitis

OBJECTIVES

To discuss the clinical features, diagnostic evaluation, and treatment options for cutaneous vasculitis.

METHODS

The literature in the PubMed database was reviewed regarding the presentation, pathophysiology, clinical workup, and treatment of cutaneous vasculitis.

RESULTS

Available classification criteria of vasculitis are based on histopathologic criteria or clinicohistologic features. These have been designed more for research purposes than for clinical application. Skin findings such as palpable purpura, nodules, urticaria, ulcers, and infarction are clues to the presence of vasculitis. Pathologic findings of fibrinoid necrosis, infiltration by neutrophils or lymphocytes, and deposition of complement and immunoglobulin may be helpful in reaching a specific diagnosis. However, there is considerable overlap across different conditions.

CONCLUSIONS

The correct diagnosis of cutaneous manifestations of vasculitis requires an understanding of vasculitis classification, recognition of specific clinical patterns, and the ability to interpret histopathologic data.

Vasculite cutânea de pequenos vasos: subtipos e tratamento - Parte II

Vasculite cutânea de pequenos vasos refere-se a grupo de doenças geralmente caracterizado por púrpura palpável, causada por vasculite leucocitoclástica das vênulas pós-capilares. Vasculites podem variar em gravidade, podendo manifestar-se como doença autolimitada, com acometimento de único órgão, ou como doença sistêmica, acometendo múltiplos órgãos, e evoluir para quadro de falência de múltiplos órgãos e sistemas. Esse grupo de doenças apresenta-se como desafio para o dermatologista, incluindo classificação e diagnóstico, avaliação laboratorial, tratamento e a necessidade de seguimento cuidadoso. Neste artigo são revistos os subtipos de vasculites cutâneas dos pequenos vasos e as opções atuais de tratamento; apresenta-se também abordagem detalhada para o diagnóstico e o tratamento do paciente com suspeita de vasculite cutânea e sistêmica.

Pregnancy and vasculitis

Until recently, the prognosis associated with many forms of systemic vasculitis was quite grim. Advances in this field have allowed us to begin to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis. Because the systemic vasculitides are rare diagnoses, many important questions remain unanswered. Overall, it seems that women who have inactive vasculitis may not be subject to unusual complications during pregnancy, but our understanding of the interaction between pregnancy and specific forms of vasculitis continues to evolve.

Vasculitis in the geriatric population

Vasculitis represents an uncommon but important group of disease entities that may affect older patients. The most common vasculitic disease in humans in giant cell arteritis, a disease process seen almost exclusively in patients older than 50 years in age. Vasculitic disease in geriatric patients presents unique challenges with regard to diagnosis and treatment. A thorough understanding of the vasculitic disease entities that may affect older patients as well as their diagnosis and management is essential in minimizing disease and treatment-related morbidity and mortality.

Buerger's disease manifesting nodular erythema with livedo reticularis

We report a patient with Buerger's disease (BD) who showed painful nodular erythema with livedo reticularis as an initial symptom. The patient developed this cutaneous manifestation in both lower extremities, and a skin biopsy demonstrated perivascular infiltration of mononuclear cells in the border zone between the dermis and subcutaneous tissue. Both nodular erythema and livedo reticularis were successfully treated with oral prednisolone, but both feet developed necrosis with ulcerations and had to be amputated 1.5 years later because of acute gangrene. Histopathology of the amputated tissue showed acute inflammation and multiple thrombi with recanalization in the posterior tibial arteries, leading to a diagnosis of BD. This disease should be considered as a possible diagnosis in refractory patients with nodular erythema and livedo reticularis, particularly when ulcerations and necrosis rapidly worsen.

Cutaneous Vasculitis Update: Small Vessel Neutrophilic Vasculitis Syndromes

A broad and diverse spectrum of vasculitic syndromes exists. These syndromes affect the skin with varying levels of associated systemic manifestations, running the gamut from a self-limited, localized, cutaneous phenomenon to rapidly progressive, multiorgan disease. The majority of cases of cutaneous vasculitis will show a neutrophilic small vessel vasculitis that can be either a primary (idiopathic) disorder (eg, cutaneous leukocytoclastic angiitis) or a secondary disorder that is associated with drugs, infection (eg, streptococcal infection, viral hepatitis), or underlying disease (eg, connective tissue disease, malignancy). Biopsy is the gold standard for the diagnosis of cutaneous vasculitis and also necessary for the detection of cutaneous vascular immune complexes by direct immunofluorescence. Based on the type of vessel disrupted by inflammation (small and/or muscular), the distribution of vasculitis in the dermis and subcutis, and predominate inflammatory cell-type mediating vessel wall damage, a list of relevant differential diagnoses can be generated. This histologic information coupled with extravascular findings such as tissue eosinophilia, tissue neutrophilia, and/or granulomas, plus pathophysiologic markers such as direct immunofluorescent examination for immune complexes and serologic evaluation for antineutrophil cytoplasmic antibodies allows for more accurate diagnosis of specific vasculitic entities. Herein, we review both primary and secondary vasculitic syndromes that affect the skin and show a small vessel neutrophilic mediated vasculitis.

Cutaneous vasculitis: diagnosis and management

Vasculitis is histologically defined as inflammatory cell infiltration and destruction of blood vessels. Vasculitis is classified as primary (idiopathic, eg, cutaneous leukocytoclastic angiitis, Wegener's granulomatosis) or secondary, a manifestation of connective tissue diseases, infections, adverse drug eruptions, or a paraneoplastic phenomenon. Cutaneous vasculitis, manifested as urticaria, purpura, hemorrhagic vesicles, ulcers, nodules, livedo, infarcts, or digital gangrene, is a frequent and often significant component of many systemic vasculitic syndromes such as lupus or rheumatoid vasculitis and antineutrophil cytoplasmic antibody-associated primary vasculitic syndromes such as Churg-Strauss syndrome. In most instances, cutaneous vasculitis represents a self-limited, single-episode phenomenon, the treatment of which consists of general measures such as leg elevation, warming, avoidance of standing, cold temperatures and tight fitting clothing, and therapy with antihistamines, aspirin, or nonsteroidal anti-inflammatory drugs. More extensive therapy is indicated for symptomatic, recurrent, extensive, and persistent skin disease or coexistence of systemic disease. For mild recurrent or persistent disease, colchicine and dapsone are first-choice agents. Severe cutaneous and systemic disease requires more potent immunosuppression (prednisone plus azathioprine, methotrexate, cyclophosphamide, cyclosporine, or mycophenolate mofetil). In cases of refractory vasculitis, plasmapheresis and intravenous immunoglobulin are viable considerations. The new biologic therapies that work via cytokine blockade or lymphocyte depletion such as tumor alpha inhibitor infliximab and the anti-B-cell antibody rituximab, respectively, are showing benefit in certain settings such as Wegener's granulomatosis, antineutrophil cytoplasmic antibody-associated vasculitis, Behçet's disease, and cryoglobulinemic vasculitis.

Retrospective analysis of adult patients with cutaneous leukocytoclastic vasculitis

A retrospective analysis was conducted on 93 adult patients with cutaneous leukocytoclastic vasculitis from St. Vincent's Hospital Melbourne to determine the classification, aetiology, severity and prognosis of this population of patients. We developed a new classification system for the purposes of our study based on modifications to the Chapel Hill Consensus Conference definitions for vasculitic syndromes. The results of our study indicate that an obvious cause was not found in 44.1% of patients. Of the patients with secondary vasculitis, the commonest causes were drugs and infections, accounting for a total of 40.9% of patients. Extracutaneous involvement was found in 39.8% of patients. Patients with symptoms resolving in less than 3 months accounted for 59.1% of the population, whereas 24.8% of patients had either symptoms lasting three or more months or evidence of recurrent symptomatology. There were 6 deaths (6.91%) and the rest were lost to follow up. The majority of patients in this retrospective series were classified as having hypersensitivity vasculitis, which is a relatively benign disorder limited mostly to skin with a low incidence of extracutaneous involvement (15.8%). Nevertheless, evidence of systemic involvement or sepsis need to be excluded as this may have important implications for patient treatment and outcome.

Cutaneous Vasculitis Update: Diagnostic Criteria, Classification, Epidemiology, Etiology, Pathogenesis, Evaluation and Prognosis

Vasculitis, inflammation of the vessel wall, can result in mural destruction with hemorrhage, aneurysm formation, and infarction, or intimal-medial hyperplasia and subsequent stenosis leading to tissue ischemia. The skin, in part due to its large vascular bed, exposure to cold temperatures, and frequent presence of stasis, is involved in many distinct as well as un-named vasculitic syndromes that vary from localized and self-limited to generalized and life-threatening with multi-organ disease. To exclude mimics of vasculitis, diagnosis of cutaneous vasculitis requires biopsy confirmation where its acute signs (fibrinoid necrosis), chronic signs (endarteritis obliterans), or past signs (acellular scar of healed arteritis) must be recognized and presence of extravascular findings such as patterned fibrosis or collagenolytic granulomas noted. Although vasculitis can be classified by etiology, many cases have no identifiable cause, and a single etiologic agent can elicit several distinct clinicopathologic expressions of vasculitis. Therefore, the classification of cutaneous vasculitis is best approached morphologically by determining vessel size and principal inflammatory response. These histologic patterns roughly correlate with pathogenic mechanisms that, when coupled with direct immunofluorescent examination, anti-neutrophil cytoplasmic antibody (ANCA) status, and findings from work-up for systemic disease, allow for specific diagnosis, and ultimately, more effective therapy. Herein, we review cutaneous vasculitis focusing on diagnostic criteria, classification, epidemiology, etiology, pathogenesis, and evaluation of the cutaneous vasculitis patient.

Enfermedad de Buerger (tromboangeítis obliterante)

Thromboangiitis obliterans (TAO) is a segmental, inflammatory, vasoocclusive disease that predominantly affects the small and medium-sized arteries and veins of the extremities. It most often occurs in young male smokers, especially those from Mediterranean and Asian countries. It is considered an autoimmune process related to the use of tobacco products. Clinically, it is characterized by the presence of painful, ischemic ulcers of the digits. Histopathological studies usually show an occlusive intraluminal thrombus with a predominantly acute inflammatory infiltrate. To make the diagnosis, it is important to exclude other causes of ischemia of the extremities, and different authors have proposed criteria to establish this diagnosis. Treatment is only effective if it is accompanied by abstention from tobacco. There are also different pharmacological and surgical strategies for its management.

Leg ulcers: uncommon presentations

Uncommon presentations like vasculitis or other immunologic causes and malignancy account for about 1% to 2% of patients suffering from leg ulcers. We focus on such uncommon leg ulcers including: cutaneous vasculitis causing cutaneous ulceration, other immunologic or metabolic cutaneous lesions such as pyoderma gangrenosum and necrobiosis lipoidica, and ulcers based on neoplastic etiology. A short description on leg ulcers in the tropics is also included. The described uncommon presentations of leg ulcers are typically difficult to diagnose and treat; it is a specialist's job to take care of patients with these types of ulcers. Multidisciplinary specialized wound healing concepts integrated in the national health care system, as an accepted expert function, is the ideal way to organize the wound healing area. Such a system would result in an earlier diagnosis and more sufficient treatment for patients with uncommon presentations of leg ulcers.

Vasculitis in the Geriatric Population

Vasculitis represents an uncommon but important group of disease entities that may affect older patients. The most common systemic vasculitic disease in humans is giant cell arteritis, a disease process seen almost exclusively in patients over the age of 50. Vasculitic disease in geriatric patients presents unique challenges with regard to diagnosis and treatment. A thorough understanding of the vasculitic disease entities that may affect older patients as well as their diagnosis and management is essential in minimizing disease and treatment related morbidity and mortality.

Cutaneous vasculitis

Vasculitis is defined as inflammation of blood vessels and can affect multiple organs. Several classification systems exist to categorize vasculitis such as vessel size, presence of anti-neutrophil cytoplasmic antibody, pathogenesis of the inflammation, and type of inflammatory cell infiltrate. Cutaneous vasculitis occurs as a manifestation of many diseases including rheumatologic diseases, hypersensitivity syndromes, infections, and malignancies. The diagnosis of the cutaneous vasculitis and the underlying cause requires a complete history and physical exam and usually a biopsy or angiogram. The treatment depends on the etiology of the inflammation and includes immunosuppression, withdrawal of the offending agent, antibacterial/antiviral agents, and chemotherapies. A clear understanding and approach to this condition will improve the physician's ability to provide optimal patient care.

Life-threatening purpura and vasculitis

Palpable purpura, the inflammation of blood vessels is the hallmark of vasculitis. It can be observed in a variety of settings, where vessels can be affected primarily or as a secondary event. Every patient with vasculitis should be considered to have a systemic disease unless proven otherwise. One or more systemic symptoms occur in at least 50% of patients and there is no way to predict systemic involvement. Patients may demonstrate mild systemic involvement like arthralgia and arthritis, fever and malaise or more severe symptoms such as massive proteinuria and raised creatinine leading to chronic renal failure, severe intestinal bleeding or perforation with a fatal outcome. In this article we will review the life-threatening aspects of purpura and vasculitis.

Clinical approach to cutaneous vasculitis

PURPOSE OF REVIEW

This review provides the readers with an update on the clinical approach of a patient seeking treatment with cutaneous vasculitis. It outlines the work-up for assessing patients with cutaneous vasculitis and discusses the essential features of the main conditions included within this category.

RECENT FINDINGS

Recent works on genetic and infectious factors implicated in the pathogenesis of Henoch-Schonlein purpura are discussed. Special attention is given to the prognosis and response to treatment. Also, recent reports on cutaneous vasculitis secondary to connective tissue diseases are reviewed.

SUMMARY

With this review, the reader will be able to establish the steps to be followed in the clinical approach to a patient seeking treatment with cutaneous vasculitis.

Ocular manifestations and concepts of systemic vasculitides

Vasculitic disorders are relatively rare. Their etiology and pathophysiology remain enigmatic, leading to confusing nomenclature and multiple classification schemes. Untreated vasculitis can be fatal. Early diagnosis is the key to successful treatment and better prognosis. However, early diagnosis can be difficult; vasculitic conditions usually present with non-specific symptoms for a long period before clinically overt manifestations occur. Ophthalmologists should be familiar with the ocular manifestations of the vasculitic disorders because they may not only be sight-threatening, but more importantly could be the presenting manifestations of active, potentially lethal systemic disease. This review summarizes clinical and ocular manifestations of systemic vasculitic disorders. Furthermore, it discusses general concepts in diagnosis and treatment of these diseases in an effort to provide a practical framework for the ophthalmologist evaluating patients with vasculitis.

Cutaneous vasculitis in primary Sjögren syndrome: classification and clinical significance of 52 patients

To analyze the different clinical and histologic types of cutaneous vasculitis in patients with primary Sjögren syndrome (SS), we investigated the clinical and immunologic characteristics of 558 consecutive patients with primary SS from our units and selected those with clinical evidence of cutaneous lesions, excluding drug reactions and xeroderma. All patients fulfilled 4 or more of the diagnostic criteria for SS proposed by the European Community Study Group in 1993. A total of 89 (16%) patients presented with cutaneous involvement (88 female patients and 1 male; mean age, 51.8 yr). The main cutaneous involvement was cutaneous vasculitis, present in 52 (58%) patients. There were 51 (98%) female patients and 1 (2%) male, with a mean age at diagnosis of cutaneous vasculitis of 51 years (range, 20-80 yr). Fourteen presented with cryoglobulinemic vasculitis, 11 with urticarial vasculitis, and the remaining 26, with cutaneous purpura not associated with cryoglobulins. A skin biopsy specimen was obtained in 38 patients (73%). Involvement of small-sized vessels was observed in 36 (95%) patients (leukocytoclastic vasculitis), while the remaining 2 (5%) presented with medium-sized vessel vasculitis (necrotizing vasculitis). Patients with cutaneous vasculitis had a higher prevalence of articular involvement (50% vs 29%, p = 0.044), peripheral neuropathy (31% vs 4%, p < 0.001), Raynaud phenomenon (40% vs 15%, p = 0.008), renal involvement (10% vs 0%, p = 0.028), antinuclear antibodies (88% vs 60%, p = 0.002), rheumatoid factor (78% vs 48%, p = 0.004), anti-Ro/SS-A antibodies (70% vs 43%, p = 0.011), and hospitalization (25% vs 4%, p = 0.005) compared with SS patients without vasculitis. Six (12%) patients died, all of whom had multisystemic cryoglobulinemia.In conclusion, cutaneous involvement was detected in 16% of patients with primary SS, with cutaneous vasculitis being the most frequent process. The main characteristics of SS-associated cutaneous vasculitis were the overwhelming predominance of small versus medium vessel vasculitis and leukocytoclastic versus mononuclear vasculitis, with a higher prevalence of extraglandular and immunologic SS features. Small vessel vasculitis manifested as palpable purpura, urticarial lesions, or erythematosus maculopapules, with systemic involvement in 44% of patients in association with cryoglobulins in 30%. Life-threatening vasculitis was closely related to cryoglobulinemia.

Autoimmune hepatitis, cryoglobulinaemia and untreated coeliac disease: a case report

The clinical presentation of adult coeliac disease is often uncharacteristic, with extraintestinal symptoms being the main findings. We report a 48-year-old woman who presented with type II, hepatitis-C-negative cryoglobulinaemia, elevated liver enzymes, and iron deficiency. Antinuclear antibodies were positive, and immunoglobulin G (IgG) levels were elevated. On liver biopsy, a diagnosis of type I autoimmune hepatitis with a possible autoimmune cholangitis overlap syndrome was made. Immunosuppressive treatment led to a normalization of transaminase levels and resolved the cryoglobulinaemic vasculitis. In addition, the patient exhibited low ferritin and iron levels, which led to the diagnosis of coeliac disease. Long-standing, untreated coeliac disease is recognized to be a trigger for autoimmune disorders and is known to be associated with other autoimmune diseases, but the association with autoimmune hepatitis or autoimmune cholangitis is reported rarely. We conclude that in patients with autoimmune liver disease and unspecific clinical signs, such as iron deficiency, coeliac disease must be ruled out.

Cutaneous polyarteritis nodosa in patients presenting with atrophie blanche

BACKGROUND

The term 'atrophie blanche' is used both as a descriptive term denoting ivory-white stellate scars on the lower limbs as well as a diagnostic label synonymous with livedoid vasculitis, an ill-defined entity. Medium-sized vasculitides, such as polyarteritis nodosa (PAN), occasionally present with ulceration resulting in ivory-white stellate scarring on the lower limbs and may potentially be misdiagnosed as livedoid vasculitis.

OBJECTIVES

To assess the occurrence, clinical and immunopathological features of medium-sized vasculitis in patients presenting with atrophie blanche without clinical and/or compression duplex ultrasonographic evidence of venous insufficiency.

METHODS

We retrospectively evaluated patients presenting with atrophie blanche at the Department of Dermatology of Johns Hopkins Medical Institutions, from April 1996 until April 2002, following the diagnostic guidelines for leg ulcers of the Division of Immunodermatology. Deep and multiple skin biopsies were performed for histology. Investigations for underlying vasculitis, thrombophilia, nerve conduction studies and compression duplex ultrasonography of the lower extremities were performed in all patients.

RESULTS

Of 29 consecutive patients presenting with atrophie blanche, six had underlying medium-sized vasculitis consistent with PAN, three of whom had previously been diagnosed to have segmental hyalinizing vasculitis/vasculopathy (livedoid vasculitis/vasculopathy) on superficial biopsies. All six patients with cutaneous PAN were women with a median age of 36.5 years (range 34-46) and with a median duration of the disease prior to diagnosis of 18 years (range 3-30). Of the six cutaneous PAN patients, four had neurological involvement evidenced by clinical symptoms and nerve conduction studies. No evidence of any other extracutaneous involvement was found. Erythrocyte sedimentation rate and tests for vasculitis and thrombophilic were normal in all six patients. None had evidence of venous insufficiency. Immunosuppressive therapy was effective in controlling PAN-associated cutaneous and neurological disease. Of the remaining 23 patients, two had antiphospholipid syndrome and one had homocystineaemia; all three also had evidence of venous insufficiency. One patient had multiple myeloma-associated type I cryoglobulinaemia and 19 patients had venous insufficiency alone. None of the non-PAN patients had abnormalities in the nerve conduction studies.

CONCLUSIONS

In patients presenting with atrophie blanche without evidence of venous insufficiency and thrombophilia, PAN should be excluded, particularly in the presence of mononeuritis multiplex. Repeated and deep biopsies are often necessary to reveal the accurate underlying pathology of necrotizing medium-sized vasculitis in the reticular dermis and the subcutis, especially in the setting of atrophie blanche lesions. Immunosuppressive therapy was effective in controlling the PAN-associated clinical manifestations.

Cutaneous vasculitis

Vasculitis can range in severity from a self-limited single-organ disorder to a life-threatening disease with the prospect of multiple-organ failure. This condition presents many challenges to the physician, including classification and diagnosis, appropriate laboratory workup, treatment, and the need for careful follow-up. The physician must not only be able to recognize vasculitis but also be able to provide a specific diagnosis (if possible) as well as recognize and treat any underlying etiologic condition. Most diagnostic criteria are based on the size of vessel involvement, which often correlates with specific dermatologic findings. This may allow the dermatologist to provide an initial diagnosis and direct the medical evaluation. This article reviews the classification and diagnosis of cutaneous vasculitic syndromes and current treatment options; it also presents a comprehensive approach to diagnosing and treating the patient with suspected cutaneous vasculitis. (J Am Acad Dermatol 2003;48:311-40.)

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the classification and clinical features of the various forms of cutaneous vasculitis. They should also have a rational approach to diagnosing and treating a patient with vasculitis.