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Wu Y, Wang M, Wang H, Ban C, Tang X, Luo Y. Comprehensive Interventional treatment for severe central airway collapse caused by Relapsing Polychondritis: A case report. Heliyon 2024; 10:e37680. [PMID: 39315186 PMCID: PMC11417259 DOI: 10.1016/j.heliyon.2024.e37680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/08/2024] [Accepted: 09/08/2024] [Indexed: 09/25/2024] Open
Abstract
Relapsing Polychondritis (RP) is a rare systemic inflammatory disease. One major cause of death for patients with RP is severe tracheobronchial tree collapse. Treatment guidelines for RP are mainly based on case reports. We report a rare and challenging case of RP in a patient who experienced asphyxia due to severe central airway collapse. The patient had previously been misdiagnosed with refractory asthma due to recurrent wheezing. Following interventions including bronchoscopic laser tracheobronchoplasty, stent placement, corticosteroid therapy, and both invasive and non-invasive mechanical ventilation, the patient was successfully stabilized and subsequently discharged from the hospital. Notably, after discharge, the patient did not require rehospitalisation for worsening respiratory symptoms and was managed with only a gradually tapering glucocorticoid regimen. In our case report, stent placement rapidly relieved asphyxia due to severe tracheobronchial stenosis, and laser tracheobronchoplasty may be a potential cure for diffuse airway collapse due to RP.
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Affiliation(s)
- Youqiang Wu
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Mingzhe Wang
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Hongwu Wang
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Chengjun Ban
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Xuechun Tang
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Yi Luo
- Respiratory Department, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
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Aden AA, Awadallah AS, Xie KZ, Wallerius KP, O'Byrne TJ, Bowen AJ, Edell ES, Bayan SL, Ekbom DC, Koster MJ. Medical Maintenance Therapy Following Laser Excision in Patients With Granulomatosis With Polyangiitis (GPA)-Associated Subglottic Stenosis. Otolaryngol Head Neck Surg 2024; 171:180-187. [PMID: 38482973 DOI: 10.1002/ohn.694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To report on a series of patients with cANCA/PR3-positive, granulomatosis with polyangiitis (GPA)-associated subglottic stenosis (SGS) and evaluate response to medical maintenance therapy with rituximab versus other immunosuppressants following initial endoscopic laser excision. STUDY DESIGN Retrospective chart review. SETTING Tertiary academic center. METHODS A retrospective chart review of patients with SGS and cANCA/PR3-positive GPA who received immunosuppressive maintenance therapy following endoscopic laser excision at our institution from June 1989 to March 2020 was performed. Data pertaining to patient demographics, clinical features, medications, and endoscopic laser procedures were collected. RESULTS A total of 27 patients (15 women) with mean age (range) of 40 (19-59) years and mean (range) follow-up of 12.6 years (1.5-28.6) were identified. Sixteen patients (60%) had limited GPA. Six patients (24%) had previously received local intervention with open surgery (n = 1, 4%) or endoscopic techniques (n = 5, 20%). All patients experienced symptom improvement following initial CO2 laser excision at our institution without any procedural complications or adverse events. Following initial laser excision, 15 patients (60%) were treated with rituximab and 10 patients (40%) were treated with nonrituximab immunosuppressive agents. Patients treated with rituximab were less likely to recur (P = 0.040). Limited GPA was associated with an increased incidence of recurrence (P = 0.031). Median time (years) to recurrence (range) was 3.2 (0.3-19.3) and was not significantly associated with treatment or GPA subtype. CONCLUSION Endoscopic CO2 laser excision is a safe and effective local intervention for GPA-associated SGS. Medical maintenance therapy with rituximab reduces risk of recurrence following initial laser excision relative to treatment with non-rituximab agents.
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Affiliation(s)
- Aisha A Aden
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew S Awadallah
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katherine Z Xie
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J O'Byrne
- Division of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Bowen
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dale C Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Koster
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Wheeler S, Andeen N, Reddy R. Isolated IgG4 related disease of the trachea. Respir Med Case Rep 2024; 49:102031. [PMID: 38712313 PMCID: PMC11070757 DOI: 10.1016/j.rmcr.2024.102031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/26/2024] [Indexed: 05/08/2024] Open
Abstract
IgG4 related disease (IgG4-RD) is a multisystem inflammatory disease and can affect several organs including salivary glands, orbits, lungs, pancreas, kidneys and lymph nodes. Up to 40 % of patients have allergic manifestations including asthma, chronic rhinosinusitis, eczema and asthma. Commonly pulmonary manifestations include pulmonary nodules ranging from <1 to 5 cm in diameter, interstitial opacities and mediastinal lymphadenopathy. Rarely, IgG4-RD presents as isolated tracheal disease. Symptoms include dyspnea and stridor due to airway narrowing. Diagnosis of IgG4-RD including tracheal IgG4-RD requires a biopsy. The histologic specimen is characterized by lymphoplasmacytic infiltrate with high density of IgG4 positive plasma cells, and storiform fibrosis (a cartwheel appearance of fibroblasts and inflammatory cells). Up to 30 % of patients with IgG4-RD have normal serum IgG4 levels. The mainstay of therapy is glucocorticoids for those with systemic disease. Rituximab is an alternative for those who cannot tolerate glucocorticoids or those with disease recurrence. Patients with tracheal disease often require balloon dilation. Recurrence is common in patients and up to two thirds of patients have residual disease despite treatment. These patients often require surgical resection of affected area for symptomatic relief.
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Affiliation(s)
- Sarah Wheeler
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Nicole Andeen
- Department of Pathology and Laboratory Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Raju Reddy
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
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Villeneuve T, Faguer S, Collot S, Pugnet G, Prévot G. HRCT imaging of pulmonary involvement in granulomatosis with polyangiitis and microscopic polyangiitis at disease onset and during follow-up. Semin Arthritis Rheum 2023; 63:152307. [PMID: 37948936 DOI: 10.1016/j.semarthrit.2023.152307] [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: 07/23/2023] [Revised: 10/28/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The pulmonary involvement in patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) is well known at disease onset but data during follow-up (after the induction regimen and when the first relapse occurs) are limited. Our goal was to analyze chest high-resolution computed tomography (HRCT) findings of (ANCA)-associated vasculitis patients. METHOD All consecutive unselected AAV patients over eighteen with positive ANCA status and with HRCT chest performed at the diagnosis were retrospectively enrolled between 2004 and 2019 at the Toulouse University Hospital (France). Two experienced pulmonologists and one expert respiratory radiologist reviewed independently HRCT chest scans. RESULTS A total of 157 AAV patients were included in the study. Two-thirds of AAV patients had pulmonary involvement at diagnosis. Diffuse alveolar hemorrhage (DAH) was observed in 31.2 % of cases, nodules and masses in 18.5 %, bronchial airway involvement in 13.4 %, and interstitial involvement in 12.7 %. Following the induction regimen, chest HRCT scans over a two-year period demonstrated significant improvement in DAH and nodular manifestations, whereas bronchial airway involvement exhibited variability and half of cases of interstitial lung disease (ILD) had progressive course. Outcomes and survival rates are better for nodular and bronchial involvement. DAH was the most frequent cause of deaths. Progressive fibrotic changes in ILD over time could impact prognosis despite AAV remission. CONCLUSION Employing a pattern-based approach with HRCT chest scans to assess lung involvement could be valuable in predicting treatment response, relapse, mortality, and could improved the management of AAV patients.
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Affiliation(s)
- Thomas Villeneuve
- Pulmonology Department, University Hospital Centre of Toulouse, Toulouse, France.
| | - Stanislas Faguer
- Nephrology and Organ Transplantation Department, National Referral Center for Rare Renal Diseases, University Hospital Centre of Toulouse, Toulouse, France
| | - Samia Collot
- Radiology Department, University Hospital Centre of Toulouse, Toulouse, France
| | - Grégory Pugnet
- Internal Medicine Department, University Hospital Centre of Toulouse, Toulouse, France
| | - Grégoire Prévot
- Pulmonology Department, University Hospital Centre of Toulouse, Toulouse, France
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Sorin B, Iudici M, Guerry MJ, Samson M, Bielefeld P, Maillet T, Nouvier M, Karras A, Meyer L, Lavigne C, Régent A, Durel CA, Fabre M, Charles P, Raimbourg Q, Lanteri A, Pugnet G, Rivière F, Pineton de Chambrun M, Cacoub P, Le Guenno G, Jourdain P, Mekinian A, Paule R, Dion J, Legendre P, Cohen P, Guillevin L, Puéchal X, Terrier B. Induction failure in granulomatosis with polyangiitis: a nationwide case-control study of risk factors and outcomes. Rheumatology (Oxford) 2023; 62:3662-3671. [PMID: 36847447 DOI: 10.1093/rheumatology/kead098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE To identify characteristics of granulomatosis with polyangiitis (GPA) associated with induction failure, describe salvage therapies and their efficacy. METHODS We conducted a nationwide retrospective case-control study of GPA with induction failure between 2006 and 2021. Each patient with induction failure was randomly paired to three controls matched for age, sex and induction treatment. RESULTS We included 51 patients with GPA and induction failure (29 men and 22 women). At induction therapy, median age was 49 years. Twenty-seven patients received intravenous cyclophosphamide (ivCYC) and 24 rituximab (RTX) as induction therapy. Patients with ivCYC induction failure more frequently had PR3-ANCA (93% vs 70%, P = 0.02), relapsing disease (41% vs 7%, P < 0.001) and orbital mass (15% vs 0%, P < 0.01) compared with controls. Patients with disease progression despite RTX induction therapy more frequently had renal involvement (67% vs 25%, P = 0.02) with renal failure (serum creatinine >100 µmol/l in 42% vs 8%, P = 0.02) compared with controls. After salvage therapy, remission was achieved at 6 months in 35 (69%) patients. The most frequent salvage therapy was switching from ivCYC to RTX (or vice versa), showing an efficacy in 21/29 (72%). Remission was achieved in nine (50%) patients with inappropriate response to ivCYC, while in patients with progression after RTX induction, remission was achieved in four (100%) who received ivCYC (with or without immunomodulatory therapy), but only in three (50%) after adding immunomodulatory therapy alone. CONCLUSION In patients with induction failure, characteristics of GPA, salvage therapies and their efficacy vary according to induction therapy and failure modality.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Michele Iudici
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Division of Rheumatology, Department of Internal Medicine and Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Mary-Jane Guerry
- Department of Nephrology, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Philip Bielefeld
- Department of Nephrology and Systemic Diseases, Hôpital François Mitterrand, Dijon, France
| | - Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Mathilde Nouvier
- Department of Nephrology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Lara Meyer
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Lavigne
- Department of Internal Medicine-Clinical Immunology, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marc Fabre
- Department of Internal Medicine, Centre Hospitalier Pierre Oudot, Bourgouin, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Quentin Raimbourg
- Department of Nephrology, Hôpital Bichat Claude Bernard, Paris, France
| | - Aurélia Lanteri
- Department of Internal Medicine-Infectious Diseases, Centre Hospitalier d'Antibes, Antibes, France
| | - Grégory Pugnet
- Department of Internal Medicine and Clinical Immunology, Hôpital Rangueil, Toulouse, France
| | - Frédéric Rivière
- Department of Pneumology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | | | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital d'Estaing, Clermont-Ferrand, France
| | - Pierre Jourdain
- Department of Nephrology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Arsène Mekinian
- Department of Internal Medicine, Hôpital Saint-Antoine, Paris, France
| | - Romain Paule
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Department of Clinical Immunology, Centre Hospitalier du Mans, Le Mans, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
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Maranini B, Guzzinati I, Casoni GL, Ballotta M, Lo Monaco A, Govoni M. Case Report: Middle lobe syndrome: a rare presentation in eosinophilic granulomatosis with polyangiitis. Front Immunol 2023; 14:1222431. [PMID: 37638004 PMCID: PMC10448582 DOI: 10.3389/fimmu.2023.1222431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023] Open
Abstract
Background Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of disorders characterized by necrotizing inflammation of small- and medium-sized blood vessels and the presence of circulating ANCA. Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic ANCA-associated vasculitis, characterized by peripheral eosinophilia, neuropathy, palpable purpuras or petechiae, renal and cardiac involvement, sinusitis, asthma, and transient pulmonary infiltrates. Middle lobe syndrome (MLS) is defined as recurrent or chronic atelectasis of the right middle lobe of the lung, and it is a potential complication of asthma. Case presentation Herein, we describe a case of MLS in a 51-year-old woman, never-smoker, affected by EGPA, presenting exclusively with leukocytosis and elevated concentrations of acute-phase proteins, without any respiratory symptom, cough, or hemoptysis. Chest computed tomography (CT) imaging documented complete atelectasis of the middle lobe, together with complete obstruction of lobar bronchial branch origin. Fiberoptic bronchoscopy (FOB) revealed complete stenosis of the middle lobar bronchus origin, thus confirming the diagnosis of MLS, along with distal left main bronchus stenosis. Bronchoalveolar lavage (BAL) did not detect any infection. Bronchial biopsies included plasma cells, neutrophil infiltrates, only isolated eosinophils, and no granulomas, providing the hypothesis of vasculitic acute involvement less likely. First-line agents directed towards optimizing pulmonary function (mucolytics, bronchodilators, and antibiotic course) were therefore employed. However, the patient did not respond to conservative treatment; hence, endoscopic management of airway obstruction was performed, with chest CT documenting resolution of middle lobe atelectasis. Conclusion To the best of our knowledge, this is the first detailed description of MLS in EGPA completely resolved through FOB. Identification of MLS in EGPA appears essential as prognosis, longitudinal management, and treatment options may differ from other pulmonary involvement in AAV patients.
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Affiliation(s)
- Beatrice Maranini
- Division of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | | | - Maria Ballotta
- Section of Anatomic Pathology, Azienda Ospedaliera Rovigo, Rovigo, Italy
| | - Andrea Lo Monaco
- Division of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Marcello Govoni
- Division of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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Jalaber C, Puéchal X, Saab I, Canniff E, Terrier B, Mouthon L, Cabanne E, Mghaieth S, Revel MP, Chassagnon G. Differentiating tracheobronchial involvement in granulomatosis with polyangiitis and relapsing polychondritis on chest CT: a cohort study. Arthritis Res Ther 2022; 24:241. [PMID: 36307863 PMCID: PMC9615207 DOI: 10.1186/s13075-022-02935-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background In patients with tracheobronchial involvement, the differential diagnosis between granulomatosis with polyangiitis (GPA) and relapsing polychondritis (RP) can be challenging. The aim of this study was to describe the characteristics of airway abnormalities on chest computed tomography (CT) in patients with GPA or RP and to determine whether specific imaging criteria could be used to differentiate them. Methods GPA and RP patients with tracheobronchial involvement referred to a national referral center from 2008 to 2020 were evaluated. Their chest CT images were reviewed by two radiologists who were blinded to the final diagnosis in order to analyze the characteristics of airway involvement. The association between imaging features and a diagnosis of GPA rather than RP was analyzed using a generalized linear regression model. Results Chest CTs from 26 GPA and 19 RP patients were analyzed. Involvement of the subglottic trachea (odds ratio for GPA=28.56 [95% CI: 3.17; 847.63]; P=0.001) and extensive airway involvement (odds ratio for GPA=0.02 [95% CI: 0.00; 0.43]; P=0.008) were the two independent CT features that differentiated GPA from RP in multivariate analysis. Tracheal thickening sparing the posterior membrane was significantly associated to RP (odds ratio for GPA=0.09 [95% CI: 0.02; 0.39]; P=0.003) but only in the univariate analysis and suffered from only moderate interobserver agreement (kappa=0.55). Tracheal calcifications were also associated with RP only in the univariate analysis (odds ratio for GPA=0.21 [95% CI: 0.05; 0.78]; P=0.045). Conclusion The presence of subglottic involvement and diffuse airway involvement are the two most relevant criteria in differentiating between GPA and RP on chest CT. Although generally considered to be a highly suggestive sign of RP, posterior tracheal membrane sparing is a nonspecific and an overly subjective sign. • The presence of subglottic involvement is in favor of GPA. • Extensive airway involvement is in favor of RP. • Posterior tracheal membrane sparing is a nonspecific and an overly subjective sign.
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Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
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Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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10
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Response to correspondence on ‘Challenge of a false positive acid-fast bacilli: A diagnostic conundrum’. J R Coll Physicians Edinb 2022; 52:189. [DOI: 10.1177/14782715221103946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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11
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Ekbote G, Gupta R, Negalur N, Tanna D. Severe tracheobronchial stenosis in granulomatosis with polyangiitis and type 2 respiratory failure. Arch Rheumatol 2022; 36:611-614. [PMID: 35382373 PMCID: PMC8957777 DOI: 10.46497/archrheumatol.2021.7709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/02/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Gayatri Ekbote
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Rajiva Gupta
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Natasha Negalur
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Dhaval Tanna
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
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12
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Sorin B, Samson M, Durel CA, Diot E, Guichard I, Grados A, Limal N, Régent A, Cohen P, Dion J, Legendre P, Le Guern V, Mouthon L, Guillevin L, Terrier B. Rituximab plus methotrexate combination as a salvage therapy in persistently active granulomatosis with polyangiitis. Rheumatology (Oxford) 2021; 61:2619-2624. [PMID: 34698818 DOI: 10.1093/rheumatology/keab791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/20/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the efficacy and safety of rituximab and methotrexate (RTX/MTX) combination therapy in ANCA-associated vasculitides (AAV). METHODS A retrospective French nationwide study was conducted in patients with AAV who received RTX/MTX combination therapy for persistently active disease. RESULTS Seventeen patients were included. All patients had granulomatosis with polyangiitis (GPA), with positive ANCA in 76% mainly with PR3-ANCA specificity. Sixteen (94%) were still active after rituximab and 11 (65%) after cyclophosphamide (oral and/or intravenous). Patients had experienced a median of 3 (2-4) flares. Manifestations requiring RTX/MTX combination therapy were subglottic or bronchial stenosis in 6 patients (35%), orbital mass in 6 (35%), disabling ENT involvement in 2 (12%), and epiduritis and pachymeningitis in 1 case each (6%). Median follow-up with combination was 11 months (11-26 months). At 6 months, global response was achieved in 15 patients (88%), including partial response in 11 (65%) and complete response in 4 (24%). At last evaluation, global response was achieved in 16 patients (94%). Seven patients (41%) experienced severe adverse events (grade 3 or 4), including infections in 4 (24%) and hepatitis in 2 (12%). Combination therapy was withdrawn in 4 patients (24%) but never for safety concerns. In contrast, MTX dose was decreased in 2 patients (12%) because of adverse events. One patient died of an unknown cause. CONCLUSION RTX/MTX combination therapy could be an effective salvage therapy to treat persistently active GPA with granulomatous manifestations, with an acceptable safety profile.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Maxime Samson
- Department of Internal Medicine and clinical immunology, Dijon University Hospital, Dijon, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
| | - Elisabeth Diot
- Department of Internal Medicine, Hôpital Bretonneau, Tours, France
| | - Isabelle Guichard
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, France
| | - Aurélie Grados
- Department of Internal Medicine, Centre Hospitalier de Niort, France
| | - Nicolas Limal
- Department of Internal Medicine, Hôpital Henri Mondor, Créteil, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | | | - Luc Mouthon
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
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Agrawal A, Baird BJ, Madariaga MLL, Blair EA, Murgu S. Multi-disciplinary management of patients with benign airway strictures: A review. Respir Med 2021; 187:106582. [PMID: 34481304 DOI: 10.1016/j.rmed.2021.106582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology & Bronchoscopy, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| | - Brandon J Baird
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Maria Lucia L Madariaga
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Elizabeth A Blair
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA.
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14
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CT findings of non-neoplastic central airways diseases. Jpn J Radiol 2021; 40:107-119. [PMID: 34398372 DOI: 10.1007/s11604-021-01190-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023]
Abstract
Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 73:1088-1105. [PMID: 34235880 DOI: 10.1002/acr.24634] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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16
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2021; 73:1366-1383. [PMID: 34235894 DOI: 10.1002/art.41773] [Citation(s) in RCA: 242] [Impact Index Per Article: 80.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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17
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New therapeutic strategies in lung vasculitis. Curr Opin Pulm Med 2021; 26:496-506. [PMID: 32740376 DOI: 10.1097/mcp.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To summarize the latest publications and provide a practical overview of treatment strategies for lung vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). RECENT FINDINGS In patients with severe ANCA-associated vasculitis, plasma exchange, as adjunctive therapy to standard treatment, is not associated with improved survival or reduced risk of end-stage kidney disease. A regimen with reduced dose of glucocorticoids is equally effective to induce remission as a standard regimen. In patients without organ or life-threatening disease, mycophenolate mofetil can be used in combination with oral glucocorticoid therapy to induce remission, however, with a higher risk of relapse than when using rituximab or cyclophosphamide. For maintenance of remission, a tailored regimen of rituximab infusion was equivalent to a fixed regimen, with fewer perfusions. Belimumab, a human IgG1(Equation is included in full-text article.)monoclonal antibody against B-lymphocyte stimulator, did not decrease the relapse rate when added to azathioprine and glucocorticoids. Avacopan, a complement C5a receptor inhibitor, was effective in replacing high-dose glucocorticoids in achieving complete remission of vasculitis. SUMMARY Significant advances have been made in the treatment strategy to both induce remission and maintain remission in patients with ANCA-associated vasculitis. The choice should take into consideration efficacy, cost-effectiveness, safety profile, ease of use, and possibility of individual tailoring of treatment.
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An J, Song JW. Life-Threatening Subglottic Stenosis of Granulomatosis with Polyangiitis: A Case Report. ACTA ACUST UNITED AC 2021; 57:medicina57050423. [PMID: 33925546 PMCID: PMC8145547 DOI: 10.3390/medicina57050423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/22/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by necrotizing granulomatous inflammation. Subglottic stenosis, which is defined as narrowing of the airway below the vocal cords, has a frequency of 16–23% in GPA. Herein, we present the case of a 39-year-old woman with subglottic stenosis manifesting as life-threatening GPA, which was recurrent under systemic immunosuppressive therapy. The patient underwent an emergency tracheostomy, intratracheal intervention, such as carbon dioxide (CO2) laser surgery and intralesional steroid injection via laryngomicroscopic surgery, and laryngotracheal resection with remodeling. Severe subglottic stenosis treatment requires active intratracheal intervention, surgery, and systemic immunosuppressive therapy.
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Affiliation(s)
- Jin An
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul 05278, Korea;
| | - Jae-Won Song
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, Korea
- Correspondence: ; Tel.: +82-2-440-7188; Fax: +82-2-440-8150
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19
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Chen LW, Lina I, Motz K, Berges AJ, Ospino R, Seo P, Hillel AT. Factors Affecting Dilation Interval in Patients With Granulomatosis With Polyangiitis-Associated Subglottic and Glottic Stenosis. Otolaryngol Head Neck Surg 2021; 165:845-853. [PMID: 33845664 DOI: 10.1177/01945998211004264] [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: 11/16/2022]
Abstract
OBJECTIVE Subglottic stenosis (SGS) is a known complication of granulomatosis with polyangiitis (GPA). We investigated the impact of medical and surgical interventions on the surgical dilation interval and characterized patients with glottic involvement. STUDY DESIGN A retrospective chart review of patients with GPA-associated SGS was performed from 2010 to 2019. SETTING Tertiary academic medical center. METHODS The impact of medical and surgical interventions on dilation interval was assessed. The prevalence of glottic involvement was assessed, and clinical characteristics and outcomes were compared with patients without glottic involvement. RESULTS A total of 39 patients with GPA-associated SGS were analyzed. Dilation intervals in patients receiving leflunomide (n = 4; median, 484 days; 95% CI, 405-1099) were greater than in those not receiving leflunomide (median, 155 days; 95% CI, 48-305; P = .033). The surgical technique used did not affect dilation interval. Patients with glottic involvement (n = 13) had a greater incidence of dysphonia (13/13 vs 15/26 [58%], P = .007) and a shorter dilation interval with involvement (median, 91 days; interquartile range, 70-277) versus without involvement (median, 377 days; interquartile range, 175-1148; hazard ratio, 3.38; 95% CI, 2.26-5.05; P < .001). Of 13 patients, 8 (62%) did not have glottic involvement on first presentation. CONCLUSION Although GPA is classically thought to affect the subglottis, it also involves the glottis in a subset of patients. These patients have greater complaints of dysphonia and require more frequent surgery. Systemic therapy may increase dilation intervals. In this preliminary study, patients taking leflunomide demonstrated an improvement, highlighting the need for further study of immunosuppression regimens in the treatment of GPA-associated SGS.
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Affiliation(s)
- Lena W Chen
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ioan Lina
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kevin Motz
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexandra J Berges
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rafael Ospino
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip Seo
- The Johns Hopkins Vasculitis Center, Department of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Konstantinidou S, Coyle P, Pandey G, Butler C. Multilevel tracheal granulomatosis with polyangiitis (GPA) lesions in a paediatric patient. BMJ Case Rep 2021; 14:e241064. [PMID: 33541970 PMCID: PMC7868245 DOI: 10.1136/bcr-2020-241064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Paula Coyle
- Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London, UK
| | - Gargi Pandey
- Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London, UK
| | - Colin Butler
- Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London, UK
- University College London Institute of Child Health, London, UK
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Hayashi K, Watanabe H, Yamamura Y, Asano Y, Katayama Y, Hiramatsu-Asano S, Ohashi K, Morishita M, Narazaki M, Matsumoto Y, Sada KE, Wada J. Granulomatosis with polyangiitis with obstructive pneumonia progressing to hypertrophic pachymeningitis: A case report. Medicine (Baltimore) 2021; 100:e24028. [PMID: 33546000 PMCID: PMC7837910 DOI: 10.1097/md.0000000000024028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Bronchial involvement alone is a rare initial manifestation of granulomatosis with polyangiitis (GPA). Herein, we report a case of refractory GPA with obstructive pneumonia caused by bronchial involvement. PATIENT CONCERNS A 65-year-old man complained of a 2-week cough and fever. DIAGNOSES Considering the presence of opacities and multiple consolidations in both lungs due to obstruction or stenosis on the bronchus, which did not respond to antibiotics, and proteinase-3-antineutrophil cytoplasmic autoantibody positivity, he was diagnosed with GPA. Positron emission tomography- computed tomography scan revealed no abnormal findings in the upper respiratory tract. INTERVENTIONS He was treated with prednisolone (PSL, 50 mg/d) and intravenous cyclophosphamide. OUTCOMES His general and respiratory symptoms improved. However, 8 weeks after PSL treatment at 20 mg/d, he developed a relapse of vasculitis along with sinusitis and hypertrophic pachymeningitis. Hence, PSL treatment was resumed to 50 mg/d, and weekly administration of rituximab was initiated. Consequently, the symptoms gradually mitigated. LESSONS GPA with bronchial involvement is often intractable and requires careful follow-up, which should include upper respiratory tract and hypertrophic pachymeningitis assessment.
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Mendel A, Ennis D, Go E, Bakowsky V, Baldwin C, Benseler SM, Cabral DA, Carette S, Clements-Baker M, Clifford AH, Cohen Tervaert JW, Cox G, Dehghan N, Dipchand C, Dhindsa N, Famorca L, Fifi-Mah A, Garner S, Girard LP, Lessard C, Liang P, Noone D, Makhzoum JP, Milman N, Pineau CA, Reich HN, Rhéaume M, Robinson DB, Rumsey DG, Towheed TE, Trudeau J, Twilt M, Yacyshyn E, Yeung RSM, Barra LB, Khalidi N, Pagnoux C. CanVasc Consensus Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitis: 2020 Update. J Rheumatol 2020; 48:555-566. [PMID: 32934123 DOI: 10.3899/jrheum.200721] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In 2015, the Canadian Vasculitis Research Network (CanVasc) created recommendations for the management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada. The current update aims to revise existing recommendations and create additional recommendations, as needed, based on a review of new available evidence. METHODS A needs assessment survey of CanVasc members informed questions for an updated systematic literature review (publications spanning May 2014 to September 2019) using Medline, Embase, and Cochrane. New and revised recommendations were developed and categorized according to the level of evidence and strength of each recommendation. The CanVasc working group used a 2-step modified Delphi procedure to reach > 80% consensus on the inclusion, wording, and grading of each new and revised recommendation. RESULTS Eleven new and 16 revised recommendations were created and 12 original (2015) recommendations were retained. New and revised recommendations are discussed in detail within this document. Five original recommendations were removed, of which 4 were incorporated into the explanatory text. The supplementary material for practical use was revised to reflect the updated recommendations. CONCLUSION The 2020 updated recommendations provide rheumatologists, nephrologists, and other specialists caring for patients with AAV in Canada with new management guidance, based on current evidence and consensus from Canadian experts.
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Affiliation(s)
- Arielle Mendel
- A. Mendel, MD, MSc, C.A. Pineau, MD, Division of Rheumatology, Lupus and Vasculitis Clinic, McGill University, Montréal, Québec;
| | - Daniel Ennis
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Ellen Go
- E. Go, MD, R.S. Yeung, MD, PhD, Division of Rheumatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Volodko Bakowsky
- V. Bakowsky, MD, Division of Rheumatology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia
| | - Corisande Baldwin
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Susanne M Benseler
- S.M. Benseler, MD, PhD, M. Twilt, MD, PhD, Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta
| | - David A Cabral
- D.A. Cabral, MBBS, Division of Pediatric Rheumatology, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia
| | - Simon Carette
- S. Carette, MD, MPhil, C. Pagnoux, MD, MSc, MPH, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario
| | - Marie Clements-Baker
- M. Clements-Baker, MD, T.E. Towheed, MD, MS, Division of Rheumatology, Queen's University, Kingston, Ontario
| | - Alison H Clifford
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Jan Willem Cohen Tervaert
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Gerard Cox
- G. Cox, MB, Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario
| | - Natasha Dehghan
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Christine Dipchand
- C. Dipchand, MD, MSc, Division of Nephrology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia
| | - Navjot Dhindsa
- D. Ennis, MD, C. Baldwin, MD, N. Dehghan, MD, N. Dhindsa, MD, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia
| | - Leilani Famorca
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Aurore Fifi-Mah
- A. Fifi-Mah, MD, Division of Rheumatology, University of Calgary, Calgary, Alberta
| | - Stephanie Garner
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Louis-Philippe Girard
- L.P. Girard, MD, MSc, Division of Nephrology, University of Calgary, Calgary, Alberta
| | - Clode Lessard
- C. Lessard, MD, Centre de Recherche Musculo-Squelettique, Trois-Rivières, Québec
| | - Patrick Liang
- P. Liang, MD, Division of Rheumatology, Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec
| | - Damien Noone
- D. Noone, MB, BCh, BAO, MSc, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Jean-Paul Makhzoum
- J.P. Makhzoum, MD, M. Rhéaume, MD, Division of Internal Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - Nataliya Milman
- N. Milman, MD, MSc, Division of Rheumatology, The Ottawa Hospital, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Christian A Pineau
- A. Mendel, MD, MSc, C.A. Pineau, MD, Division of Rheumatology, Lupus and Vasculitis Clinic, McGill University, Montréal, Québec
| | - Heather N Reich
- H.N. Reich, MD, PhD, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario
| | - Maxime Rhéaume
- J.P. Makhzoum, MD, M. Rhéaume, MD, Division of Internal Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - David B Robinson
- D.B. Robinson, MD, MSc, Section of Rheumatology, University of Manitoba, Winnipeg, Manitoba
| | - Dax G Rumsey
- D.G. Rumsey, MD, MSc, Division of Pediatric Rheumatology, University of Alberta, Edmonton, Alberta
| | - Tanveer E Towheed
- M. Clements-Baker, MD, T.E. Towheed, MD, MS, Division of Rheumatology, Queen's University, Kingston, Ontario
| | - Judith Trudeau
- J. Trudeau, MD, Division of Rheumatology, CISSS Chaudière-Appalaches, Université Laval, Québec City, Québec
| | - Marinka Twilt
- S.M. Benseler, MD, PhD, M. Twilt, MD, PhD, Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta
| | - Elaine Yacyshyn
- A.H. Clifford, MD, J.W. Cohen Tervaert, MD, PhD, E. Yacyshyn, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta
| | - Rae S M Yeung
- E. Go, MD, R.S. Yeung, MD, PhD, Division of Rheumatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Lillian B Barra
- L.B. Barra, MD, Division of Rheumatology, Department of Medicine, Western University, London, Ontario, Canada
| | - Nader Khalidi
- L. Famorca, MD, S. Garner, MD, MSc, N. Khalidi, MD, Division of Rheumatology, McMaster University, Hamilton, Ontario
| | - Christian Pagnoux
- S. Carette, MD, MPhil, C. Pagnoux, MD, MSc, MPH, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario
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Dion GR, De la Chapa JS, Bettenhausen W, Dominguez LM, Simpson CB. Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis. Laryngoscope 2020; 131:1816-1820. [PMID: 32902896 DOI: 10.1002/lary.29085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis. STUDY DESIGN This was a retrospective review. METHODS Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS. RESULTS A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02). CONCLUSIONS In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1816-1820, 2021.
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Affiliation(s)
- Gregory R Dion
- Dental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, U.S.A
| | | | - Whitney Bettenhausen
- Department of Otolaryngology-Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, U.S.A
| | - Laura M Dominguez
- Department of Otolaryngology-Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, U.S.A
| | - C Blake Simpson
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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24
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Kuwata R, Shirota Y, Ishii T. Severe Acute Atelectasis Caused by Complete Obstruction of Left Main Stem Bronchus Associated with Granulomatosis with Polyangiitis. J Rheumatol 2020; 47:1293-1294. [PMID: 32739901 DOI: 10.3899/jrheum.190971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Ryo Kuwata
- Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Miyagi, and National Center for Global Health and Medicine, Tokyo
| | - Yuko Shirota
- Department of Hematology and Rheumatology, Tohoku University Hospital, and Department of Hematology and Rheumatology, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi;
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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25
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Quinn KA, Gelbard A, Sibley C, Sirajuddin A, Ferrada MA, Chen M, Cuthbertson D, Carette S, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Ytterberg SR, Merkel PA, Grayson PC. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology (Oxford) 2020; 58:2203-2211. [PMID: 31199488 DOI: 10.1093/rheumatology/kez217] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe tracheobronchial disease in patients with granulomatosis with polyangiitis (GPA) and evaluate the utility of dynamic expiratory CT to detect large-airway disease. METHODS Demographic and clinical features associated with the presence of subglottic stenosis (SGS) or endobronchial involvement were assessed in a multicentre, observational cohort of patients with GPA. A subset of patients with GPA from a single-centre cohort underwent dynamic chest CT to evaluate the airways. RESULTS Among 962 patients with GPA, SGS and endobronchial disease were identified in 95 (10%) and 59 (6%) patients, respectively. Patients with SGS were more likely to be female (72% vs 53%, P < 0.01), younger at time of diagnosis (36 vs 49 years, P < 0.01), and have saddle-nose deformities (28% vs 10%, P < 0.01), but were less likely to have renal involvement (39% vs 62%, P < 0.01). Patients with endobronchial disease were more likely to be PR3-ANCA positive (85% vs 66%, P < 0.01), with more ENT involvement (97% vs 77%, P < 0.01) and less renal involvement (42% vs 62%, P < 0.01). Disease activity in patients with large-airway disease was commonly isolated to the subglottis/upper airway (57%) or bronchi (32%). Seven of 23 patients screened by dynamic chest CT had large-airway pathology, including four patients with chronic, unexplained cough, discovered to have tracheobronchomalacia. CONCLUSION SGS and endobronchial disease occur in 10% and 6% of patients with GPA, respectively, and may occur without disease activity in other organs. Dynamic expiratory chest CT is a potential non-invasive screening test for large-airway involvement in GPA.
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Affiliation(s)
- Kaitlin A Quinn
- Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA.,Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Alexander Gelbard
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, TN, USA
| | - Cailin Sibley
- Division of Arthritis & Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
| | | | - Marcela A Ferrada
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Marcus Chen
- National Institutes of Health, NHLBI, Bethesda, MD, USA
| | - David Cuthbertson
- Biostatistics and Informatics, University of South Florida, Tampa, FL, USA
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada
| | - Nader A Khalidi
- Division of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Larry W Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Ytterberg
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Peter A Merkel
- Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
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26
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a small to medium vessel vasculitis associated with excess morbidity and mortality. This review explores how management of AAV has evolved over the past two decades with pivotal randomized controlled trials shaping the management of induction and maintenance of remission. Contemporary AAV care is characterized by approaches that minimize the cumulative exposure to cyclophosphamide and glucocorticoids, increasingly use rituximab for remission induction and maintenance, and consider therapies with less toxicity (for example, methotrexate, mycophenolate mofetil) for manifestations of AAV that do not threaten organ function or survival. Simultaneously, improvements in outcomes, such as renal and overall survival, have been observed. Additional trials and observational studies evaluating the comparative effectiveness of agents for AAV in various patient subgroups are needed. Prospective studies are necessary to assess the effect of psychosocial interventions on patient reported outcomes in AAV. Despite the expanding array of treatments for AAV, little guidance on how to personalize AAV care is available to physicians.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eli M Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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27
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Baskaran R, Ko UJ, Davaa E, Park JE, Jiang Y, Lee J, Yang SG. Doxycycline-Eluting Core-Shell Type Nanofiber-Covered Trachea Stent for Inhibition of Cellular Metalloproteinase and Its Related Fibrotic Stenosis. Pharmaceutics 2019; 11:pharmaceutics11080421. [PMID: 31430987 PMCID: PMC6723391 DOI: 10.3390/pharmaceutics11080421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/04/2019] [Accepted: 08/14/2019] [Indexed: 12/13/2022] Open
Abstract
In this study, we fabricated a doxycycline (doxy)-eluting nanofiber-covered endotracheal stent for the prevention of stent intubation-related tissue fibrosis and re-stenosis. The nanofiber was deposited directly on the outer surface of the stent using a coaxial electrospinning method to form a doxy-eluting cover sleeve. Poly(d,l-lactide) was used as the shell-forming polymer and dedicated drug release-control membrane. Polyurethane was selected as the drug-loading core polymer. The compositional ratio of the core to shell was adjusted to 1:0, 1:2, and 1:4 by changing the electro-spray rate of each polymeric solution and microscopic observation of nanofibers using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and the fluorescence microscopy proved core-shell structure of nanofibers. The in vitro release study suggested that the release of doxy could be controlled by increasing the compositional ratio of the shell. The growth of HT1080 fibrosarcoma cells was inhibited by the 10% doxy-containing nanofiber. The real-time polymerase chain reaction (PCR) in HT1080 cells and xenografted tissue models indicated that the doxy-releasing nanofiber inhibited mRNA expression of metalloproteinases (MT1-MMP, MMP-2, and MMP-9). Overall, our study demonstrates that a doxy-eluting core-shell nanofiber stent can be successfully fabricated using coaxial electrospinning and displays the potential to prevent fibrotic re-stenosis, which is the most problematic clinical complication of tracheal stent intubation.
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Affiliation(s)
- Rengarajan Baskaran
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
| | - Un-Jeong Ko
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
| | - Enkhzaya Davaa
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
| | - Ji Eun Park
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
- Inha Institute of Aerospace Medicine, Inha University College of Medicine, Incheon 22332, Korea
| | - Yixin Jiang
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
- Inha Institute of Aerospace Medicine, Inha University College of Medicine, Incheon 22332, Korea
| | - Junghan Lee
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea
- Inha Institute of Aerospace Medicine, Inha University College of Medicine, Incheon 22332, Korea
| | - Su-Geun Yang
- Department of Biomedical Science, Inha University College of Medicine, Incheon 22332, Korea.
- Inha Institute of Aerospace Medicine, Inha University College of Medicine, Incheon 22332, Korea.
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28
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Geier C, Steed K. 'Carpal tunnel syndrome' and 'tennis elbow' as prodromes for granulomatosis with polyangiitis (formerly Wegener's granulomatosis). BMJ Case Rep 2019; 12:12/2/bcr-2018-227348. [PMID: 30824462 DOI: 10.1136/bcr-2018-227348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 62-year-old man presented with excruciating joint pains, back stiffness and numbness of his hands and feet. Over the past 18 months, he had experienced similar episodes for which the diagnoses of bilateral carpal tunnel syndrome and lateral epicondylitis had been made. Physical examination revealed polyarticular arthritis affecting the shoulders, wrists and right knee. Palpable purpura overlying the calves and ankles was present. Laboratory tests showed markedly elevated erythrocyte sedimentation rate and C-reactive protein in the setting of negative blood and urine cultures. Rheumatoid factor and antinuclear antibodies were negative. Chest CT demonstrated bilateral pulmonary infiltrates. A punch biopsy of the rash showed leukocytoclastic vasculitis. Anti-proteinase-3 titers returned strongly positive. A diagnosis of granulomatosis with polyangiitis was made. Treatment with high-dose steroids, followed by rituximab resulted in normalisation of inflammatory markers with subsequent resolution of joint pains, rash and pulmonary infiltrates and improvement of neuropathic symptoms.
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Affiliation(s)
- Christian Geier
- Division of Rheumatology, Columbia University, New York, New York, USA
| | - Kelly Steed
- Division of Rheumatology, Columbia University, New York, New York, USA.,Division of Rheumatology, James J Peters VA Medical Center, Bronx, New York, USA
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29
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Yaguchi D, Ichikawa M, Shizu M, Inoue N, Kobayashi D, Imai N. Bronchoscopic local steroid spray to prevent bronchial tuberculosis-induced cicatricial bronchial stenosis: A case series. Medicine (Baltimore) 2018; 97:e11464. [PMID: 29995804 PMCID: PMC6076191 DOI: 10.1097/md.0000000000011464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATONALE Cicatricial bronchial stenosis or obstruction occurring in the healing process of endobronchial tuberculosis (ET) is a problematic complication of tuberculous airway lesions. Prevention by internal medical treatment is desired. PATIENT CONCERNS This case series describes four patients who diagnosed ET with Type IIIb (protruding ulcer-type) based on Arai's classification of bronchoscopic findings of bronchial tuberculosis. DIAGNOSES Endobronchial tuberculosis. INTERVENTIONS A local steroid spray was applied bronchoscopically to active protruding ulcer-type lesions (which are likely to cause cicatricial stenosis) that extended in the transverse direction and occupied one-half or more of the circumference on bronchoscopy. OUTCOMES Cicatricial stenosis was prevented in two of four patients. Treatment was discontinued in athird patient because tolerance could not be achieved, although the patient's condition had improved. In the fourth patient, treatment was switched to systemic steroid administration because of a problem with tolerance and the broad range of the lesion; however, stenosis remained. LESSONS Local steroid spray-applied bronchoscopically to bronchial tuberculosis lesions in the ulcer formation and granulation periods may help prevent stenosis.
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30
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Blackabey V, Gan RWC, Buglass H, Kaul V, Ward VMM. Granulomatosis with polyangiitis causing subglottic stenosis-two cases and their management. AME Case Rep 2018; 2:17. [PMID: 30264013 DOI: 10.21037/acr.2018.03.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/06/2018] [Indexed: 11/06/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is characterised by vasculitis of small and medium sized blood vessels and granulomatous lesions of the respiratory tract. The aetiology is unclear, however it is thought to be due to an autoimmune process with about 92% of patients with the disease being antineutrophilic cytoplasmic antibodies (ANCA) positive. Patients normally present in early adulthood, more commonly in the winter months. Seventy percent of patients with GPA present with ear, nose or throat symptoms. These include nasal congestion, crusting, epistaxis, nasal septal perforation and nasal saddle deformity. Lesions in the airway can lead to subglottic stenosis with resultant airway obstruction. Treatment of the disease complicated by subglottic stenosis is not straightforward and the benefits and risks of options including medical and surgical management need to be weighed up and tailored to each individual case. We describe two cases of GPA complicated by airway obstruction due to subglottic stenosis and their management.
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Affiliation(s)
- Victoria Blackabey
- Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK
| | | | - Helen Buglass
- Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK
| | - Veena Kaul
- Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK
| | - Victoria M M Ward
- Department of Otolaryngology, Pinderfields General Hospital, Wakefield, UK
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31
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Barba T, Khouatra C, Traclet J J, Cordier JF, Cottin V. Diffuse bronchiectasis and airflow obstruction in granulomatosis with polyangiitis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2018; 35:81-84. [PMID: 32476884 DOI: 10.36141/svdld.v35i1.6298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/26/2017] [Indexed: 11/02/2022]
Abstract
Parenchymal lung nodes and diffuse intra-alveolar hemorrhage are the archetypal pulmonary manifestations of Granulomatosis with Polyangiitis (GPA). The occurrence of diffuse bronchiectasis and airflow obstruction during GPA is unusual. We report here 3 patients with GPA who developed diffuse bronchiectasis during follow-up. The airflow obstruction seemed then to evolve independently from the GPA itself and ultimately led to respiratory insufficiency. Bronchiectases promoted the occurrence of opportunistic infections, especially with atypical mycobacteria. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 81-84).
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Affiliation(s)
- T Barba
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne, Lyon, France
| | - C Khouatra
- Hospices Civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, Service de pneumologie, Lyon, France, Univ Lyon, Université Lyon I, INRA, UMR754, Lyon, France
| | - J Traclet J
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne, Lyon, France.,Hospices Civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, Service de pneumologie, Lyon, France, Univ Lyon, Université Lyon I, INRA, UMR754, Lyon, France
| | - J F Cordier
- Hospices Civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, Service de pneumologie, Lyon, France, Univ Lyon, Université Lyon I, INRA, UMR754, Lyon, France
| | - V Cottin
- Hospices Civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, Service de pneumologie, Lyon, France, Univ Lyon, Université Lyon I, INRA, UMR754, Lyon, France
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32
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Henes FO, Laudien M, Linsenhoff L, Bremer JP, Oqueka T, Adam G, Schön G, Bannas P. Accuracy of Magnetic Resonance Imaging for Grading of Subglottic Stenosis in Patients With Granulomatosis With Polyangiitis: Correlation With Pulmonary Function Tests and Laryngoscopy. Arthritis Care Res (Hoboken) 2018; 70:777-784. [PMID: 28772006 DOI: 10.1002/acr.23332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 07/25/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare magnetic resonance imaging (MRI)-based and laryngoscopy-based subglottic stenosis (SGS) grading with pulmonary function testing (PFT) in patients with granulomatosis with polyangiitis (GPA). METHODS In this retrospective study, we included 118 examinations of 44 patients with GPA and suspected SGS. All patients underwent MRI, laryngoscopy, and PFT. Stenosis was graded on a 4-point scale by endoscopy and MRI using the Meyer-Cotton (MC) score (score 1: ≤50%, 2: 51-70%, 3: 71-99%, and 4: 100%) and as percentage by MRI. Results were compared with peak expiratory flow (PEF) and maximum inspiratory flow (MIF) from PFT, serving as objective functional reference. RESULTS In MRI, 112 of 118 examinations (95%) were rated positive for SGS (grade 1 [n = 82], grade 2 [n = 26], and grade 3 [n = 4]), whereas in laryngoscopy 105 of 118 examinations (89%) were rated positive for SGS (grade 1 [n = 73], grade 2 [n = 24], and grade 3 [n = 8]). MRI and laryngoscopy agreed in 75 of 118 examinations (64%). MRI determined higher scores in 20 examinations (17%) and lower scores in 23 examinations (19%) compared to laryngoscopy. MC scores as determined by both MRI and laryngoscopy showed comparable correlations with PEF (r = -0.363, P = 0.016, and r = -0.376, P = 0.012, respectively) and MIF (r = -0.340, P = 0.024, and r = -0.320, P = 0.034, respectively). The highest correlation was found between MRI-based stenosis grading in percentage with PEF (r = -0.441, P = 0.003) and MIF (r = -0.413, P = 0.005). CONCLUSION MRI and laryngoscopy provide comparable results for grading of SGS in GPA and correlate well with PFT. MRI is an attractive noninvasive and radiation-free alternative for monitoring the severity of SGS in patients with GPA.
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Affiliation(s)
- Frank O Henes
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Jan P Bremer
- Klinikum Bad Bramstedt GmbH and University of Luebeck, Bad Bramstedt, Germany
| | - Tim Oqueka
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
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33
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Subglottic Stenosis in Granulomatosis With Polyangiitis: The Role of Laryngotracheal Resection. Ann Thorac Surg 2018; 105:249-253. [DOI: 10.1016/j.athoracsur.2017.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/11/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022]
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34
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Pulmonary Perfusion Scan Mimicking Hepatobiliary Scintigraphy in a Patient With an Uncommon Manifestation of Granulomatosis With Polyangiitis. Clin Nucl Med 2017; 42:571-572. [DOI: 10.1097/rlu.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Web-like bronchial stenosis secondary to granulomatosis with polyangiitis. ACTA ACUST UNITED AC 2017; 14:119-120. [PMID: 28610986 DOI: 10.1016/j.reuma.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/26/2017] [Accepted: 05/07/2017] [Indexed: 11/21/2022]
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36
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Fatal Progressive Membranous Obliterative Bronchitis: A Sequela of Influenza? J Bronchology Interv Pulmonol 2017; 24:88-91. [PMID: 27984386 DOI: 10.1097/lbr.0000000000000353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Occlusion of the bronchial orifices by tissue-like structures is an uncommonly reported finding: it has been referred to as bronchial webs, bronchial synechiae, vanishing bronchus syndrome, or membranous obliterative bronchitis. It differs from bronchiolitis obliterans, a well-described clinical entity that involves smaller airways not visualized on bronchoscopy. Although initially only recognized as a congenital condition, later reports have described it in situations where chronic inflammation results in the irritation of the airways. Here we report a case of a woman with postinfectious bronchiectasis who developed membranous occlusion of multiple subsegmental bronchi, resulting in progressive airflow obstruction and postobstructive collapse of involved lung parenchyma. This process eventually caused her demise. It the first report of membranous occlusion of the bronchi in an adult who does not have cystic fibrosis or a history of lung transplantation. Clinicians should be aware of this entity, and further research could help illuminate its pathogenesis and management.
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Filocamo G, Torreggiani S, Agostoni C, Esposito S. Lung involvement in childhood onset granulomatosis with polyangiitis. Pediatr Rheumatol Online J 2017; 15:28. [PMID: 28410589 PMCID: PMC5391594 DOI: 10.1186/s12969-017-0150-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/20/2017] [Indexed: 12/25/2022] Open
Abstract
Granulomatosis with polyangiitis is an ANCA-associated systemic vasculitis with a low incidence in the pediatric population. Lung involvement is a common manifestation in children affected by granulomatosis with polyangiitis, both at disease's onset and during flares. Its severity is variable, ranging from asymptomatic pulmonary lesions to dramatic life-threatening clinical presentations such as diffuse alveolar haemorrhage. Several radiologic findings have been described, but the most frequent abnormalities detected are nodular lesions and fixed infiltrates. Interstitial involvement, pleural disease and pulmonary embolism are less common. Histology may show necrotizing or granulomatous vasculitis of small arteries and veins of the lung, but since typical features may be patchy, the site for lung biopsy should be carefully chosen with the help of imaging techniques such as computed tomography. Bronchoalveolar lavage is helpful to confirm the diagnosis of alveolar haemorrhage. Pulmonary function tests are frequently altered, showing a reduction in the diffusion capacity for carbon monoxide, which can be associated with obstructive abnormalities related to airway stenosis. Nodular lung lesions tend to regress with immunosuppressive therapy, but lung disease may also require second line treatments such as plasmapheresis. In cases of massive diffuse alveolar haemorrhage, ventilator support is crucial in the management of the patient.
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Affiliation(s)
- Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Commenda 9, 20122, Milan, Italy.
| | - Sofia Torreggiani
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Carlo Agostoni
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Susanna Esposito
- grid.9027.cPediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
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Ugan Y, Doğru A, Aynalı G, Şahin M, Tunç ŞE. A clinical threat in patients with granulomatosis polyangiitis in remission: Subglottic stenosis. Eur J Rheumatol 2017; 5:69-71. [PMID: 29657878 DOI: 10.5152/eurjrheum.2017.16025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 05/30/2016] [Indexed: 12/18/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic necrotizing granulomatous disease that involves small- and medium-sized arteries and affects the main respiratory tracts and kidneys. Upper respiratory tract involvement usually occurs in 90% of patients, who most frequently present with symptoms of chronic sinusitis. Subglottic stenosis (SS) is a rare and severe complication that is usually observed in approximately 15% of patients. Here we present a case of SS in a patient with limited form of GPA during remission.
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Affiliation(s)
- Yunus Ugan
- Division of Rheumatology, Department of Internal Medicine, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Atalay Doğru
- Division of Rheumatology, Department of Internal Medicine, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Giray Aynalı
- Department of Otorhinolaryngology, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Mehmet Şahin
- Division of Rheumatology, Department of Internal Medicine, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Şevket Ercan Tunç
- Division of Rheumatology, Department of Internal Medicine, Süleyman Demirel University School of Medicine, Isparta, Turkey
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Tajarernmuang P, Limsukon A, Liwsrisakun C, Wannasopha Y. Severe bilateral bronchial stenosis with acute respiratory failure from granulomatosis with polyangiitis. Respirol Case Rep 2016; 4:e00189. [PMID: 28031825 PMCID: PMC5167307 DOI: 10.1002/rcr2.189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/08/2016] [Accepted: 08/14/2016] [Indexed: 11/09/2022] Open
Abstract
We report a 48‐year‐old female patient hospitalized with dyspnoea, wheezing, and respiratory failure due to bilateral main bronchial stenosis from granulomatosis with polyangiitis (GPA) involvement. By computed tomography imaging and flexible bronchoscopy, we measured the narrowest diameter at 2 mm. The patient promptly recovered from respiratory failure after treatment with flexible bronchoscopic balloon dilatation (BBD) without any procedure‐related adverse event. This report showed the benefits of urgent flexible BBD that was used as a rescue therapy in a GPA patient who presented life‐threatening acute respiratory failure from severe bilateral bronchial stenosis.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Atikun Limsukon
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Chalerm Liwsrisakun
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Yutthaphan Wannasopha
- Department of Radiology, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
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Fijolek J, Wiatr E, Gawryluk D, Martusewicz-Boros MM, Orlowski TM, Dziedzic D, Polubiec-Kownacka M, Oniszh K, Langfort R, Roszkowski-Sliz K. Intratracheal Dilation-injection Technique in the Treatment of Granulomatosis with Polyangiitis Patients with Subglottic Stenosis. J Rheumatol 2016; 43:2042-2048. [PMID: 27633822 DOI: 10.3899/jrheum.151355] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE An analysis of subglottic stenosis (SGS) occurrence frequency in patients with granulomatosis with polyangiitis (GPA) based on the time of appearance of clinical symptoms, and an assessment of treatment effectiveness, in particular with the intratracheal dilation-injection technique (IDIT). METHODS Review and treatment with IDIT of 34 patients with SGS associated with GPA. RESULTS SGS developed in 34 of 250 patients with GPA (13.6%) and was not reflective of disease activity in the organs in 15 of 34 patients (44%): 11 cases after and 4 cases during immunosuppressive therapy (IST) when patients did not have organ symptoms. All patients underwent IDIT and in total, the treatment resulted in immediate improvement. In addition, in 21 cases, IST was applied because of other organ involvement or of the lack of longterm efficacy of IDIT. The median time of response was 37 months and the median interval between sessions was 5 months. None of the patients required tracheostomy after beginning IDIT in our hospital. CONCLUSION SGS often occurs independently of other features of active GPA. IDIT is a safe and effective technique in the treatment of GPA-related SGS. It should be performed in all patients with GPA who develop significant SGS and in those with multiorgan disease concomitantly with IST. In patients with isolated SGS, IDIT also makes IST and tracheostomy unnecessary.
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Affiliation(s)
- Justyna Fijolek
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland. .,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases.
| | - Elzbieta Wiatr
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Dariusz Gawryluk
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Magdalena Maria Martusewicz-Boros
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Tadeusz Maria Orlowski
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Dariusz Dziedzic
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Malgorzata Polubiec-Kownacka
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Karina Oniszh
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Renata Langfort
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
| | - Kazimierz Roszkowski-Sliz
- From the Third Department of Pneumonology, and Department of Thoracic Surgery, and Department of Radiology, and Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland.,J. Fijolek, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; E. Wiatr, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; D. Gawryluk, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; M.M. Martusewicz-Boros, PhD, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases; T.M. Orlowski, Professor, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; D. Dziedzic, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; M. Polubiec-Kownacka, PhD, Department of Thoracic Surgery, National Research Institute of Tuberculosis and Lung Diseases; K. Oniszh, PhD, Department of Radiology, National Research Institute of Tuberculosis and Lung Diseases; R. Langfort, Professor, Department of Pathology, National Research Institute of Tuberculosis and Lung Diseases; K. Roszkowski-Sliz, Professor, Third Department of Pneumonology, National Research Institute of Tuberculosis and Lung Diseases
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Lee PY, Adil EA, Irace AL, Neff L, Son MBF, Lee EY, Perez-Atayde A, Rahbar R. The presentation and management of granulomatosis with polyangiitis (Wegener's Granulomatosis) in the pediatric airway. Laryngoscope 2016; 127:233-240. [PMID: 27113905 DOI: 10.1002/lary.26013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 02/19/2016] [Accepted: 03/04/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Granulomatosis with polyangiitis (GPA) is a necrotizing inflammatory disease that can affect the airway. The purpose of this study was to present a case of pediatric laryngotracheal GPA and provide management recommendations based on a thorough review of the literature. DATA SOURCES Retrospective chart and literature review REVIEW METHODS: A pediatric patient with laryngotracheal and pulmonary manifestations of GPA who underwent chemotherapy and intralesional corticosteroid injection is described. An extensive literature review of pediatric GPA affecting the larynx/trachea was also performed. RESULTS A pediatric patient presented with acute respiratory distress. Flexible laryngoscopy revealed a laryngeal mass. Magnetic resonance imaging showed circumferential subglottic stenosis, and chest computed tomography demonstrated multiple pulmonary nodules. Laryngeal and tracheal biopsy revealed granulation tissue and primary vasculitis. Labs demonstrated positive cytoplasmic antineutrophil cytoplasmic antibody, consistent with GPA. Methylprednisone, rituximab, cyclophosphamide, and intralesional steroid injection resulted in remission after 12 weeks. Review of the literature revealed two pediatric cases series and 10 case reports of GPA affecting the larynx or trachea. CONCLUSIONS There is a higher prevalence of GPA of the airway in children when compared to adults. Biopsy of the airway lesion may not be necessary and has lower diagnostic yield compared to other GPA subsites. Medical management includes induction therapy followed by maintenance therapy once the disease is in remission. Most patients will require a surgical intervention to maintain the airway. LEVEL OF EVIDENCE NA Laryngoscope, 127:233-240, 2017.
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Affiliation(s)
- Pui Y Lee
- Department of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Eelam A Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Laura Neff
- Department of Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri
| | - Mary Beth F Son
- Department of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Antonio Perez-Atayde
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
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Horta-Baas G, Hernández-Cabrera MF, Catana R, Pérez-Cristóbal M, Barile-Fabris LA. Subglottic stenosis in granulomatosis with polyangiitis (Wegener's granulomatosis): Report of 4 cases. ACTA ACUST UNITED AC 2015; 12:267-73. [PMID: 26718390 DOI: 10.1016/j.reuma.2015.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 10/25/2015] [Accepted: 10/30/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Subglottic stenosis (SGS) in granulomatosis with polyangiitis (GPA) may result from active disease or from chronic recurrent inflammation. The objective of the study was to describe the clinical features and treatment of patients with subglottic stenosis. METHODS We retrospectively reviewed the medical records of all patients with SGS due to GPA diagnosed at Rheumatology deparment between January 2000 and June 2015. RESULTS We present 4 cases of SGS at our department during a period of 15 years. The interval between the presentation of the GPA and SGS varied between 2 and 144 months. The leading symptoms of SGS were dyspnoea on exertion and stridor. Three patients presented SGS without evidence of systemic activity. Two patients presented SGS grade i and received tracheal dilatation; two recurred and three needed a tracheostomy due to severe airway-limiting stenosis. CONCLUSION SGS presents high morbidity. Even though subglottic dilatation provides symptomatic relief, recurrences may present. Severe airway-limiting stenosis often requires tracheostomy.
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Affiliation(s)
- Gabriel Horta-Baas
- Servicio de Reumatología, Hospital General Regional 220, Instituto Mexicano del Seguro Social, Toluca, Estado de México, México.
| | | | - Rocío Catana
- Servicio de Reumatología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
| | - Mario Pérez-Cristóbal
- Servicio de Reumatología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
| | - Leonor Adriana Barile-Fabris
- Servicio de Reumatología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
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