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Masiak A, Jassem E, Dębska-Ślizień A, Bułło-Piontecka B, Kowalska B, Chmielewski M. Co-existence of ANCA-associated vasculitides with immune-mediated diseases: a single-center observational study. Rheumatol Int 2024; 44:1521-1528. [PMID: 38914775 PMCID: PMC11222238 DOI: 10.1007/s00296-024-05631-3] [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: 04/09/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody-associated vasculitides (AAV) is a group of systemic necrotizing small vessel autoimmune diseases, with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) being the two most common. The co-existence of AAV with different immune-mediated diseases (autoimmune disesases - AID) might affect the clinical presentation of the primary disease. The purpose of the study was to assess the co-existence of AAV with AID and to investigate whether it affects the characteristics and the course of AAV. METHODS A retrospective single-center study was performed to identify patients with a diagnosis of MPA or GPA and concomitant AID, and to investigate their clinical features and characteristics. The group consisted of consecutive unselected AAV patients treated at a large university-based hospital, since 1988 with follow-up until 2022. RESULTS Among 284 patients diagnosed either with GPA (232) or MPA (52), 40 (14,1%) had co-existing AIDs. The most frequent were: Hashimoto thyroiditis (16 cases), rheumatoid arthritis (8 cases), followed by psoriasis (6 cases), pernicious anemia (3 cases), and alopecia (3 cases). Patients with autoimmune comorbidities had a significantly longer time between the onset of symptoms and the diagnosis (26 vs. 11 months, p < 0.001). Laryngeal involvement (20.0% vs. 9.0%, p = 0,05), peripheral nervous system disorders (35.0% vs. 13.9%, p < 0.001), and neoplasms (20.0% vs. 8.6%, p = 0,044) were more common in patients with AID comorbidities, compared to subjects without AID. In contrast, renal involvement (45.0% vs. 70.9%, p = 0.001) and nodular lung lesions (27.5% vs. 47.5%, p = 0.044) were significantly less frequent in patients with co-morbidities. Following EUVAS criteria, patients with autoimmune co-morbidities had a generalized form of the disease without organ involvement (52.5% vs. 27.2%, p = 0.007), while the others had a higher percentage of generalized form with organ involvement (38.3% vs. 20.0%, p = 0.007). CONCLUSIONS The coexistence of AAV with different autoimmune diseases is not common, but it might affect the clinical course of the disease. Polyautoimmunity prolonged the time to diagnosis, but the AAV course seemed to be milder. Particular attention should be paid to the increased risk of cancer in these patients. It also seems reasonable that AAV patients should receive a serological screening to exclude the development of overlapping diseases.
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Affiliation(s)
- Anna Masiak
- Department of Rheumatology, Clinical Immunology, Geriatrics and Internal Medicine, Medical University of Gdansk, Gdańsk, Poland.
| | - Ewa Jassem
- Department of Pulmonology and Allergology, Medical University of Gdansk, Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdańsk, Poland
| | - Barbara Bułło-Piontecka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdańsk, Poland
| | - Bożena Kowalska
- Department of Otolaryngology, Medical University of Gdansk, Gdańsk, Poland
| | - Michał Chmielewski
- Department of Rheumatology, Clinical Immunology, Geriatrics and Internal Medicine, Medical University of Gdansk, Gdańsk, Poland
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Uysal C, Ketenci Ertas S, Civan M, Akgun H, Kocyigit I. Pauci-immune crescentic glomerulonephritis caused to dilemma in a patient with suspected systemic lupus erythematosus: a case report. CEN Case Rep 2024; 13:174-180. [PMID: 37837535 PMCID: PMC11144177 DOI: 10.1007/s13730-023-00825-3] [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: 04/09/2023] [Accepted: 09/13/2023] [Indexed: 10/16/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease and there is a distinct differentiation of clinical manifestations. Lupus nephritis (LN) is clinically apparent in approximately half of patients. A kidney biopsy is essential to define the kidney injury, exclude other injurious causes, and determine the histopathologic subtypes. Autoantibodies are crucial to the pathogenesis and the deposition of immune complexes in glomeruli is a hallmark of LN. The histopathology of LN is quite varied. Despite pauci-immune LN being an unexpected condition in SLE, it has been observed rarely with the presence of antineutrophil cytoplasmic autoantibodies (ANCA). We present a young male who was admitted to the emergency with syncope. The brain imaging revealed small infarct areas and signs of cerebral vasculitis. Also, he had elevated inflammatory markers, moderate proteinuria, and preserved kidney function. Anti-nuclear antibodies and anti-dsDNA were positive. Pauci-immune crescentic glomerulonephritis (PICGN) was observed in a kidney biopsy, however, ANCA was negative. SLE diagnosis was established by neurological manifestation, specific antibodies, proteinuria, and kidney biopsy findings. We administered a combination induction regimen, including pulse steroid and parenteral cyclophosphamide. The proteinuria was resolved in the follow-up. Our case highlights that SLE-associated ANCA-negative PICGN can be the initial presentation in the absence of typical manifestations. LN exhibits various pathological mechanisms in the kidney. As a consequence, SLE should be considered in the differential diagnosis of all forms of kidney injury.
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Affiliation(s)
- Cihan Uysal
- Department of Nephrology, Erciyes University School of Medicine, Dede Efendi Street, Köşk District, Melikgazi, 38030, Kayseri, Turkey.
| | | | - Merve Civan
- Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Hulya Akgun
- Department of Pathology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Ismail Kocyigit
- Department of Nephrology, Erciyes University School of Medicine, Dede Efendi Street, Köşk District, Melikgazi, 38030, Kayseri, Turkey
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Campos MAG, Valois TDO, Magalhães LE, Vasques LF, de Medeiros RG, Costa DMDN, Salgado Filho N, Nogueira RMDR, Neves PDMDM, Silva GEB. ANCA-associated glomerulonephritis and lupus nephritis following COVID-19 vaccination: a case report and literature review. Front Immunol 2024; 14:1298622. [PMID: 38299140 PMCID: PMC10828972 DOI: 10.3389/fimmu.2023.1298622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024] Open
Abstract
With the coverage of COVID-19 vaccination, it has been possible to observe the potential side effects of SARS-CoV-2 vaccines, with the most common ones being fever, myalgia, headache, and fatigue. However, an association has been observed between new and recurrent kidney injuries, mainly glomerulonephritis and lupus nephritis associated with ANCA, with the Pfizer-BioNTech, Moderna, Sinovac, and AstraZeneca vaccines, although the relationship between them is not clear. We report a case of ANCA-related vasculitis and lupus glomerulonephritis after the second dose of the AstraZeneca vaccine. The elderly patient presented significant worsening of kidney function after immunosuppression and complications after a new onset COVID-19 infection that led to death. We provide a literature review about kidney damage related to ANCA vasculitis after COVID-19 vaccine, aiming for a better understanding of the pathophysiological mechanism of kidney injury, its presentation, and treatment.
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Affiliation(s)
- Marcos Adriano Garcia Campos
- Clinical Hospital of State University Júlio de Mesquita Filho, State University of São Paulo, Botucatu, São Paulo, Brazil
| | - Tiago de Oliveira Valois
- Divison of Nephrology, University Hospital of the Federal University of Maranhão, São Luís, Maranhão, Brazil
| | - Luís Eduardo Magalhães
- Clinical Hospital of State University Júlio de Mesquita Filho, State University of São Paulo, Botucatu, São Paulo, Brazil
| | | | | | - Denise Maria do Nascimento Costa
- Divison of Nephrology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
- Recife Medical School, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Natalino Salgado Filho
- Clinical Hospital of State University Júlio de Mesquita Filho, State University of São Paulo, Botucatu, São Paulo, Brazil
| | | | | | - Gyl Eanes Barros Silva
- Clinical Hospital of State University Júlio de Mesquita Filho, State University of São Paulo, Botucatu, São Paulo, Brazil
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Reesor E, Bhavsar SV. Overlapping systemic lupus erythematosus, seropositive erosive rheumatoid arthritis, and ANCA-associated vasculitis: A case report and literature review. Mod Rheumatol Case Rep 2023; 8:21-25. [PMID: 37804186 DOI: 10.1093/mrcr/rxad056] [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: 06/23/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Abstract
The overlap of rheumatoid arthritis and systemic lupus erythematosus is well described, with a syndrome known as 'rhupus'. ANCA-associated vasculitis, however, is uncommonly associated with other autoimmune conditions. Here, we present a case of lupus, rheumatoid arthritis, and ANCA-associated vasculitis, with significant time elapsed between presentations, resulting in an accumulation of the three diagnoses over the course of 35 years. The patient was diagnosed with lupus at age 45, presenting with inflammatory polyarthritis, thrombocytopenia, leukopenia, positive ANA, positive anti-DNA, and hypocomplementemia. She was maintained on hydroxychloroquine therapy with minimal disease activity. Approximately 20 years later, she had a flare of polyarthritis with bilateral wrist erosive arthropathy and a positive rheumatoid factor, diagnosed as rheumatoid arthritis. Anti-TNFα therapy was initiated, and she was stable for a further 10 years. At age 79, she developed ANCA-associated vasculitis AAV with pulmonary and renal manifestations, treated with rituximab induction therapy and steroids. She recovered and her MPO-ANCA titre normalised. One year later, off the anti-TNFα, she again experienced an acute kidney injury with a repeat rise in MPO-ANCA. She was re-induced and maintained on steroids and rituximab. This novel case highlights the range of possible overlap syndromes, as well as how multiple autoimmune diagnoses can evolve over decades in previously stable disease. There is growing work around polyautoimmunity with ANCA-associated vasculitis and other systemic autoimmune diseases, which has potential to identify common aetiologies and pathogenesis. Knowledge of these overlap syndromes can help to recognise and manage these conditions in a timely manner.
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Affiliation(s)
- Emma Reesor
- Department of Medicine, Division of Rheumatology, McMaster University, Hamilton, ON, Canada
- Internal Medicine, McMaster University, Waterloo, ON, Canada
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Yang S, Zhou J. Systemic lupus erythematosus and antineutrocytic cytoplasmic antibody-associated vasculitis overlap syndrome presenting mainly with alveolar hemorrhage: A case report and literature review. Medicine (Baltimore) 2023; 102:e36356. [PMID: 38050315 PMCID: PMC10695521 DOI: 10.1097/md.0000000000036356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/22/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are 2 different diseases that can manifest in the same person, which are known as SLE/AAV overlap syndrome. This overlap syndrome is difficult to diagnose, a high rate of missed diagnosis and misdiagnosis, and a poor prognosis. PATIENT CONCERNS A 52-year-old woman was diagnosed with SLE in 2019. She was readmitted to our hospital in October 2021 because of abdominal pain and melasma for 10 days. DIAGNOSES She had positive anti-dsDNA, decreased complement C3 and C4, fever, polyarthralgia, and hemolytic anemia. She was diagnosed as microscopic polyangiitis according to the American College of Rheumatology 2022 AAV classification criteria (she had 4 items: no nasal lesions, eosinophils < 1 × 109, negative c/PR3-ANCA antibodies, and positive p-ANCA antibodies. The score was 6 points). INTERVENTIONS The patient was treated with methylprednisolone 200 mg and cyclophosphamide 0.2 g immunosuppressive therapy. OUTCOMES After 2 months of follow-up, the patient's symptoms, including abdominal pain, melena, hematuria, and hemoptysis, resolved completely. And she underwent a reexamination of chest computed tomography and the results showed the previous exudation had been absorbed. LESSONS AAV should be considered in lupus patients with the above symptoms, especially the progressive decrease of hemoglobin. Relevant examinations are needed to confirm the diagnosis. Early diagnosis and accurate treatment of SLE/AAV overlap syndrome are beneficial to patients' better prognosis and control the treatment cost.
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Affiliation(s)
- Siyu Yang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Rheumatology Department, The Second People’s Hospital of Yibin City, Yibin, China
| | - Jin Zhou
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Rheumatology Department, The Second People’s Hospital of Yibin City, Yibin, China
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Kawagoe M, Odajima K, Asakawa S, Nagura M, Arai S, Yamazaki O, Tamura Y, Ohashi R, Iwakura T, Yasuda H, Shibata S, Fujigaki Y. A Diagnostic and Therapeutic Dilemma Concerning Exostosin 1/Exostosin 2-associated Lupus-like Membranous Nephropathy with Positive Antinuclear Antibody in an Elderly Man with Various Immune Abnormalities. Intern Med 2023; 62:3187-3194. [PMID: 36948625 PMCID: PMC10686739 DOI: 10.2169/internalmedicine.1251-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/12/2023] [Indexed: 03/24/2023] Open
Abstract
Exostosin 1 (EXT1) and exostosin 2 (EXT2)-associated membranous nephropathy (MN) may be associated with active autoimmune disease. We encountered an elderly man who presented with EXT1/EXT2-associated lupus-like MN with full house immune deposits, monoclonal gammopathy of uncertain significance and Sjögren's syndrome. The patient exhibited various other immune abnormalities. Although he did not fulfill the criteria of clinical systemic lupus erythematosus (SLE), he met a stand-alone renal criterion of the Systemic Lupus International Collaborating Clinics (SLICC) 2012. Whether or not a stand-alone renal criterion with EXT1/EXT2 positivity, as in the present patient, can efficiently guide decisions regarding the diagnosis and treatment of SLE remains a clinical dilemma.
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Affiliation(s)
- Mika Kawagoe
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Kohei Odajima
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
| | - Takamasa Iwakura
- Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Hideo Yasuda
- Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Karlsson L, Zickert A, Svenungsson E, Schmidt-Mende J, Faustini F, Gunnarsson I. Urinary aberrations in systemic lupus erythematosus not always indicative of lupus nephritis: a cross-sectional cohort study. Clin Rheumatol 2023; 42:2981-2986. [PMID: 37439924 PMCID: PMC10587235 DOI: 10.1007/s10067-023-06682-w] [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: 03/17/2023] [Revised: 05/25/2023] [Accepted: 06/17/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Kidney biopsy is the reference tool for diagnosing and guiding treatment strategies in inflammatory renal diseases, such as lupus nephritis (LN). We investigated the histopathological findings in first-time kidney biopsies from a large cohort of SLE patients. We focused on the occurrence and type of histopathological findings other than LN, and fulfillment of renal criteria in established SLE classification systems were analyzed. METHODS We retrospectively included SLE patients (n = 139) who underwent a first kidney biopsy between 1995 and 2021, upon clinical suspicion of renal involvement. Based on histology, two groups were defined, LN and non-LN, for which clinical and laboratory features were compared. RESULTS Findings consistent with LN according to ISN/RPS classification system were present in 123/139 patients (88.5%) and findings not consistent with LN were present in 16 /139 (11.5%). Non-LN patients were older at SLE diagnosis compared to LN patients (M, years 38.0 vs. 30.1, p=0.013) and had longer disease duration (M, years 11.9 vs 0.5) (p=0.027). Among non-LN patients 85.7% met the SLICC criteria item for renal SLE, seen in 94.7% in the LN group (ns). For the ACR/EULAR criteria, 66.7% of the non-LN group fulfilled the criteria compared to 74.8% in LN patients (ns). Proteinuria below the criteria cut-off level (< 0.5 g/24 h) was seen in 20% of patients with class III/IV LN. CONCLUSION Our data confirm the importance of kidney biopsy for ruling out the presence of renal pathology other than LN. Patients with low-grade proteinuria may exhibit severe types of LN, which reinforces the need for early biopsies to detect LN. Key Points • Our findings show that histopathology changes other than lupus nephritis may occur in a significant number of patients with clinical and laboratory signs of novel kidney involvement. • Low-grade proteinuria does not exclude findings of active lupus nephritis that require the start of immunosuppressive therapy. • The study stresses the importance of performing kidney biopsies also in the presence of low-grade proteinuria or when signs of kidney function abnormalities occur. • This is crucial as early detection and prompt initiation of therapy may improve outcomes in lupus nephritis.
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Affiliation(s)
- Linnea Karlsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Sweden
| | - Agneta Zickert
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Sweden
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Sweden
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Schmidt-Mende
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Francesca Faustini
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Sweden
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Iva Gunnarsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Sweden.
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden.
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Yamazaki T, Takahashi H, Takeuchi K, Sakamoto E, Tominaga K, Sakurabayashi S, Abe T, Sano T, Wada Y, Kuwahara N, Shimizu A, Takeuchi Y. Rare case of exostosin 1/exostosin 2-related membranous lupus nephritis concomitant with dual ANCA- and anti-GBM antibody-associated crescentic glomerulonephritis effectively diagnosed by mass spectrometry: a case report. BMC Nephrol 2023; 24:218. [PMID: 37488532 PMCID: PMC10364369 DOI: 10.1186/s12882-023-03268-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/13/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Recent developments in mass spectrometry (MS) have revealed target antigens for membranous nephropathy (MN), including phospholipase A2 receptor and exostosin 1/exostosin 2 (EXT1/2). EXT1/2 are known antigens of autoimmune disease-related MN, especially membranous lupus nephritis. We describe the case of an elderly man who developed nephrotic syndrome followed by progressive renal dysfunction. CASE PRESENTATION A 78-year-old man presented with rapidly progressive renal dysfunction with proteinuria and hematuria. Three years previously, he had developed leg edema but did not receive any treatment. Laboratory tests showed elevated anti-nuclear antibody (Ab), anti-dsDNA Ab titer, and hypocomplementemia, indicating systemic lupus erythematous. Myeloperoxidase anti-neutrophil cytoplasmic Ab (ANCA) and anti-glomerular basement membrane (GBM) Ab were also detected. The renal pathologic findings were compatible with crescentic glomerulonephritis (GN), whereas non-crescentic glomeruli exhibited MN without remarkable endocapillary or mesangial proliferative change. Immunofluorescence microscopy revealed glomerular IgG, C3, and C1q deposition. All IgG subclasses were positive in glomeruli. Anti-PLA2R Ab in serum was negative. MS analysis was performed to detect the antigens of MN, and EXT1/2 was detected in glomeruli. Therefore, we reached a diagnosis of membranous lupus nephritis concurrent with both ANCA-associated vasculitis and anti-GBM-GN. The simultaneous occurrence of these three diseases is extremely rare. CONCLUSIONS This is the first report of EXT1/2-related membranous lupus nephritis concurrent with ANCA-associated vasculitis and anti-GBM-GN. This case demonstrates the usefulness of MS in diagnosing complicated cases of MN.
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Affiliation(s)
- Takuya Yamazaki
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Haruka Takahashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
- Omigawahimawari Clinic, Chiba, Japan
| | - Kazuhiro Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan.
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
| | - Emi Sakamoto
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kenta Tominaga
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Syun Sakurabayashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | | | - Yukihiro Wada
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Naomi Kuwahara
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
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Palleti SK, Larson H, Avula S, Picken MM, Wadhwa A. Subarachnoid Hemorrhage in Autoimmune Vasculitis: A Rare Presentation of Systemic Lupus Erythematosus-Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis Overlap Syndrome. Cureus 2023; 15:e38482. [PMID: 37273402 PMCID: PMC10238284 DOI: 10.7759/cureus.38482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) and systemic lupus erythematosus (SLE), though they share similar clinical characteristics, are distinguishable based on specific characteristics. The concomitant presentation of SLE and AAV as overlap syndrome is rare and makes the diagnosis challenging. Here, we describe a rare case of SLE and AAV overlaps presenting with hemorrhagic stroke as initial presentation, which has been reported only once before. The presence of several positive autoantibodies made the diagnosis challenging, but a kidney biopsy provided the definitive diagnosis and aided in initiating immunosuppressive therapy. The patient did not respond to standard initial surgical measures to lower elevated intracranial pressure and showed significant improvement to immunosuppressive therapy proving the temporal relationship. The authors of this case study aim to highlight the importance of considering SLE-AAV overlap in patients presenting with features similar to those described in the case report and intervening early, as delays in diagnosis can be fatal.
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Affiliation(s)
- Sujith K Palleti
- Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, USA
- Nephrology, Loyola University Medical Center, Maywood, USA
| | - Hanna Larson
- Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, USA
- Nephrology, Loyola University Medical Center, Maywood, USA
| | - Sreekant Avula
- Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, USA
| | - Maria M Picken
- Pathology, Loyola University Medical Center, Maywood, USA
| | - Anuradha Wadhwa
- Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, USA
- Nephrology, Loyola University Medical Center, Maywood, USA
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10
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Alamoudi WA, Sollecito TP, Stoopler ET, France K. Oral manifestations of anti-neutrophil cytoplasmic antibody-associated vasculitis: an update and narrative review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:372-384. [PMID: 36639252 DOI: 10.1016/j.oooo.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystem disorder of small blood vessels subdivided into granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Oral manifestations (OMs) have been reported to include mucosal ulceration, gingival enlargement, alveolar bone necrosis, tooth loss, oro-antral communication, palatal perforation, parotitis, and candidal infection mainly in GPA. They may appear during the course of the disease, as a disease flare-up, or as the presenting sign. These OMs are often nonspecific and can mimic an array of conditions, therefore formulating a differential diagnosis can be challenging. This review updates the OMs of GPA, and, for the first, time includes OMs of other AAVs. It provides recommendations for the overall assessment and the diagnosis and management of all AAV OMs with considerations for treatment coordination. The role of oral health care providers in multidisciplinary care is highlighted.
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Affiliation(s)
- Waleed A Alamoudi
- Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; UCL Eastman Dental Institute, University College London, London, UK
| | - Thomas P Sollecito
- University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - Eric T Stoopler
- University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - Katherine France
- University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA.
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Maldonado Martin M, Rivas Becerra B, Vega Cabrera C. [Systemic lupus erythematosus and ANCA-associated vasculitis overlap syndrome]. Med Clin (Barc) 2023; 160:48-49. [PMID: 36253203 DOI: 10.1016/j.medcli.2022.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 12/29/2022]
Affiliation(s)
| | - Begoña Rivas Becerra
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, España; Universidad Autónoma de Madrid, Madrid, España
| | - Cristina Vega Cabrera
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, España; Universidad Autónoma de Madrid, Madrid, España
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12
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Tiwari AK, Setya D, Tanna D, Arora D, Aggarwal G, Gupta R, Bansal SB, Sethi SK. Patient outcome in antibody-positive systemic vasculitis treated with therapeutic plasma exchange. Asian J Transfus Sci 2023; 17:79-84. [PMID: 37188030 PMCID: PMC10180801 DOI: 10.4103/ajts.ajts_50_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) has been advocated as an adjunct to steroids and cytotoxic drugs in treating patients suffering from vasculitis and presenting with active disease, but we still have insufficient evidence on its effectiveness in improving the clinical response, especially in India. This study was planned to study the clinical outcome in severe vasculitic presentations treated with TPE as an adjunctive therapy. MATERIALS AND METHODS A retrospective analysis of TPE procedures performed from July 2013 to July 2017 in the department of transfusion medicine at a large tertiary care hospital was done. All consecutive patients admitted with new diagnosis of systemic vasculitis presenting with active disease and severe presentations such as advanced renal failure or severe respiratory abnormalities or life-threatening vasculitis affecting the gastrointestinal tract, neurological and musculoskeletal system; who needed TPE for removal of preformed antibodies, were included in the study. RESULTS There were a total of 31 patients in whom TPE was performed for severe systemic vasculitis; 26 adults and five pediatric. Six patients tested positive for perinuclear fluorescence, 13 for cytoplasmic fluorescence (cANCA), two for atypical antineutrophil cytoplasmic autoantibody, seven for anti-glomerular basement membrane antibodies, two for antinuclear antibodies (ANA), and one patient tested positive for ANA as well as cANCA before the augmentation of TPE. Out of 31, seven patients showed no clinical improvement and succumbed to the disease. At the end of desired number of procedures, 19 tested negative and five tested weak positive for their respective antibodies. CONCLUSION Favorable clinical outcomes were observed with TPE in patients with antibody-positive systemic vasculitis.
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Affiliation(s)
- Aseem Kumar Tiwari
- Department of Transfusion Medicine, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Divya Setya
- Department of Transfusion Medicine, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Dhaval Tanna
- Department of Rheumatology and Clinical Immunology, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Dinesh Arora
- Department of Transfusion Medicine, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Geet Aggarwal
- Department of Transfusion Medicine, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Rajiva Gupta
- Department of Rheumatology and Clinical Immunology, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Shyam Bihari Bansal
- Department of Nephrology, Kidney and Urology Institute, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Sidharth Kumar Sethi
- Department of Nephrology, Kidney and Urology Institute, Medanta – The Medicity, Gurgaon, Haryana, India
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13
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Khil J, Nguyen TM, Troxell ML, Zheng S. Systemic Lupus Erythematosus and ANCA-Associated Vasculitis Overlap Syndrome: A Case Report. Kidney Med 2022; 4:100544. [DOI: 10.1016/j.xkme.2022.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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14
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Zhang N, Ji C, Bao X, Yuan C. Clinical significance of HEp-2 cell cytoplasmic patterns in anti-neutrophil cytoplasmic antibody associated vasculitis. Medicine (Baltimore) 2022; 101:e29498. [PMID: 35758387 PMCID: PMC9276407 DOI: 10.1097/md.0000000000029498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
The study was to investigate the clinical characteristics and significance of antinuclear antibody (ANA) cytoplasmic patterns in ANCA-associated vasculitis (AAV) from Southwest China.A retrospective study including 232 AAV patients from Peoples Hospital of Deyang City was performed. These included 115 patients with ANA cytoplasmic pattern as observation group and 117 patients without ANA cytoplasmic pattern as control group.Chest involvement (60.00 vs 46.15, P = .035), cardiovascular involvement (5.21 vs 29.91, P < .001), and renal involvement (37.39 vs 77.78, P = .001) were different between groups.Total protein (69.55 vs 64.01, P < .001), triglyceride (1.41 vs 1.18, P = .023), mean cell volume (89.76 vs 87.59, P = .040), and estimated glomerular filtration rate (76.67 vs 50.87, P = .035) were higher in ANA cytoplasmic patterns group. Creatinine (73.00 vs 117.50, P = .011), white blood cell (6.93 vs 8.86, P = .001), platelet (196.0 vs 239.0, P = .017), anti-myeloperoxidase (2.44 vs 3.42, P = .042), and anti-proteinase 3 (1.00 vs 4.93, P = .007) were lower in this group. In multivariate analysis, creatinine (odds ratio [OR] = 1.21, 95% confidence interval [CI]: 1.06-1.38), triglyceride (OR = 1.97, 95% CI: 1.10-3.48), and anti-myeloperoxidase (OR = 1.64, 95% CI: 1.37-1.95) were independent risk factors of AAV renal involvement. Total protein (OR = .95, 95% CI: 0.91-0.99) was an independent protective factor of AAV renal involvement. Chi-square test showed that speckled pattern was different among anti-neutrophil cytoplasmic antibody patterns (χ2 = 18.526, P < .001).In summary, HEp-2 cell cytoplasmic patterns have certain clinical significance in AAV, which is a new exploration of the clinical value of ANA.
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Affiliation(s)
- Naidan Zhang
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
| | - Chaixia Ji
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
| | - Xiao Bao
- Department of Rheumatology, Peoples Hospital of Deyang City, Deyang, China
| | - Chengliang Yuan
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
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15
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Involvement of neutrophil extracellular traps in the pathogenesis of glomerulonephritis in a case of systemic lupus erythematosus and antineutrophil cytoplasmic antibody-associated vasculitis overlap syndrome. CEN Case Rep 2022; 11:339-346. [PMID: 35025058 PMCID: PMC9343508 DOI: 10.1007/s13730-021-00682-y] [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: 08/05/2021] [Accepted: 12/23/2021] [Indexed: 11/01/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are autoimmune diseases that often cause rapidly progressive glomerulonephritis, with neutrophil extracellular traps (NETs) involved in their pathogenesis. However, the involvement of NETs in the renal damage caused by SLE/AAV overlap syndrome has not been clarified yet. In this study, we detected renal deposition of NETs in a patient with SLE/AAV overlap syndrome. In addition, a significantly increased level of NET-inducing activity was observed in the patient's serum, which improved with treatment. On the other hand, a markedly lower level of NET degradation was observed in the patient's serum as compared to healthy subjects' sera, without any posttreatment changes. These findings suggest that NETs may play a role in the pathogenesis of renal injury associated with SLE/AAV overlap syndrome.
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16
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Level and avidity of antineutrophil cytoplasmic antibodies specific to lactoferrin are useful biomarkers in systemic lupus erythematosus. Clin Rheumatol 2021; 41:709-720. [PMID: 34618258 DOI: 10.1007/s10067-021-05926-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 08/27/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate specificity, level, and avidity of antineutrophil cytoplasmic antibodies (ANCA) in systemic lupus erythematosus (SLE). There are no studies of ANCA avidity in SLE. METHODS Level (ELISA) and avidity (ELISA) of myeloperoxidase (MPO-), proteinase 3 (PR3-), lactoferrin (LF-), cathepsin G, elastase (EL-), and bactericidal/permeability increasing protein (BPI)-ANCA in 142 SLE patients were studied. SLE activity was measured by SLEDAI-2 K. 25/40 ANCA-positive patients were immunoserologically followed (12 ± 2 months). RESULTS 40/142 (28.2%) SLE patients were ANCA-positive: LF- (21/40), MPO- (19/40), EL- (6/40), PR3- (3/40), and BPI-ANCA (1/40). Only LF-ANCA were associated with renal manifestations (p < 0.05), and positive predictive value for renal involvement in ANCA-positive SLE was 76.2%. LF-ANCA-positive patients had higher SLEDAI-2 K (p < 0.05) and more frequently had anti-dsDNA (p < 0.05), low C3 (p < 0.001), and low C4 (p < 0.05) than LF-ANCA-negative patients. LF-ANCA level was in a positive correlation with SLEDAI-2 K, anti-dsDNA, and anti-C1q (p < 0.01) and in a negative correlation with C3 and C4 (p < 0.05). LF-ANCA avidity was higher than MPO-, EL-, PR3-, and BPI-ANCA avidity (p < 0.01). In LF-ANCA-positive patients, renal manifestations were associated with higher LF-ANCA level (p < 0.01) and avidity (p < 0.05). Based on LF-ANCA level and avidity, the receiver operating characteristic curves for discriminating patients with and without renal involvement had areas under the curves of 0.988 (95% CI: 0.949-1.00) and 0.813 (95% CI: 0.607-1.00), respectively. After the follow-up period, number of LF-ANCA-positive patients decreased (p < 0.01). CONCLUSIONS In contrast to other ANCAs, only LF-ANCA level correlated with activity and standard serological SLE markers. LF-ANCA level and avidity might be biomarkers of renal involvement in SLE. LF-ANCA are promising serological marker in SLE. Key Points • LF- and MPO-ANCA were most frequently found, while EL-, PR3-, and BPI-ANCA were rarely detected in SLE. • In contrast to other ANCAs, only LF-ANCA were associated with renal involvement, and their level correlated with the activity and standard serological markers of SLE. • LF-ANCA avidity was higher than other ANCAs' avidity; LF-ANCA level and avidity might be useful biomarkers of renal manifestations in SLE. • Detection of ANCA specificity, level, and avidity may help in the diagnosis of particular clinical SLE phenotypes.
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17
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Mashinchi B, Aryannejad A, Namazi M, Moradi S, Masoumi Z, Parsaei A, Masoumi M. A case of C-ANCA-positive systematic lupus erythematous and ANCA-associated vasculitis overlap syndrome superimposed by COVID-19: a fatal trio. Mod Rheumatol Case Rep 2021; 7:117-121. [PMID: 34480174 PMCID: PMC8499895 DOI: 10.1093/mrcr/rxab007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/11/2021] [Accepted: 05/14/2021] [Indexed: 01/07/2023]
Abstract
Coronavirus disease 2019 (COVID-19) poses a substantial challenge for rheumatologists and rheumatologic patients. They are concerned about the reciprocal interaction between connective tissue diseases, such as systemic lupus erythematosus (SLE), and the virus. Here, we report a 21-year-old female SLE patient presented to the emergency department with gastrointestinal symptoms and kidney involvement evidence. Based on the pathology and laboratory assessments, she was suspected of C-antineutrophil cytoplasmic antibody (ANCA) positive SLE and ANCA-associated vasculitis overlap syndrome (SLE/AAV OS), and plasmapheresis was performed every other day due to this diagnosis alongside the high titer of C-ANCA. We also administered methylprednisolone [1 g/day, intravenous (IV)] for 3 days, followed by dexamethasone with the maintenance dosage (1 mg/kg/day, IV). Although the patient's general condition improved the next days, her condition deteriorated suddenly on the 7th day of hospitalisation. She got intubated and went to the intensive care unit. Despite taking possible measures to manage the patient's condition, she eventually passed away due to severe acute respiratory distress syndrome, triggered by COVID-19. The distinct role of C-ANCA in SLE/AAV vascular damage and activating neutrophil cytokine release accompanied by the impaired immune system while facing COVID-19 seems to lead to increased morbidity and mortality in such patients. This report is presented to bring into consideration the possible role of C-ANCA in the prognosis of COVID-19 in SLE/AAV OS patients.
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Affiliation(s)
| | | | - Mansoor Namazi
- Clinical Research Center and Development, Qom University of Medical Sciences, Qom, Iran
| | - Soroush Moradi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Masoumi
- Clinical Research Center and Development, Qom University of Medical Sciences, Qom, Iran
| | | | - Maryam Masoumi
- Corresponding Author: Maryam Masoumi, Clinical Research and Development Center, Qom University of Medical Sciences and Health Services, Qom, Iran, E-mail: , phone: +98919-012-3098, Fax: +9825-3612-2000, Postal code: 3719964797
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18
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Brevet P, Curie A, Princivil C, Zarnitsky C, Alcaix D. [ANCA vasculitis preceded by isolated joint manifestations. Report of two cases and literature review]. Rev Med Interne 2021; 42:650-653. [PMID: 34147260 DOI: 10.1016/j.revmed.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 03/23/2021] [Accepted: 05/09/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Joint manifestations of ANCA (antineutrophil cytoplasmic antibody) associated vasculitis (AAV) are extremely common in the progression of systemic damages. However, the joint involvement is rarely isolated. The diagnosis and the treatment are difficult in this particular situation and few data are available on the topic. CASE REPORT We have observed two cases of joint manifestation revealing AAV we are going to describe here. The evolution toward a more severe disease raises the question of the treatment managing. The place of the ANCA research in relation to other immune tests is also discussed. CONCLUSION Isolated joint manifestations of ANCA vasculitis are rare but can lead to a delay in diagnosis. ANCA vasculitis should be considered in seronegative symmetrical polyarthritis by looking for ANCA in a second line biological test. Methotrexate is the first treatment option to be considered. In case of insufficient response or failure, rituximab seems an interesting option in this context.
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Affiliation(s)
- P Brevet
- Rheumatology department, Rouen University Hospital Center, 1, rue de Germont, 76031 Rouen, France.
| | - A Curie
- Internal Medicine department, Rouen University Hospital Center, 1, rue de Germont, 76031 Rouen, France.
| | - C Princivil
- Rheumatology department, Le Havre Monod Hospital, 29, avenue Pierre-Mendes France, 76290 Montivilliers, France.
| | - C Zarnitsky
- Rheumatology department, Le Havre Monod Hospital, 29, avenue Pierre-Mendes France, 76290 Montivilliers, France.
| | - D Alcaix
- Rheumatology department, Le Havre Monod Hospital, 29, avenue Pierre-Mendes France, 76290 Montivilliers, France.
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Raval JJ, Ruiz CR, Heywood J, Weiner JJ. SLE strikes the heart! A rare presentation of SLE myocarditis presenting as cardiogenic shock. BMC Cardiovasc Disord 2021; 21:294. [PMID: 34120592 PMCID: PMC8201668 DOI: 10.1186/s12872-021-02102-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/06/2021] [Indexed: 11/15/2022] Open
Abstract
Background Although systemic lupus erythematosus (SLE) can affect the cardiovascular system in many ways with diverse presentations, a severe cardiogenic shock secondary to SLE myocarditis is infrequently described in the medical literature. Variable presenting features of SLE myocarditis can also make the diagnosis challenging. This case report will allow learners to consider SLE myocarditis in the differential and appreciate the diagnostic uncertainty.
Case presentation A 20-year-old Filipino male presented with acute dyspnea, pleuritic chest pain, fevers, and diffuse rash after being diagnosed with SLE six months ago and treated with hydroxychloroquine. Labs were notable for leukopenia, non-nephrotic range proteinuria, elevated cardiac biomarkers, inflammatory markers, low complements, and serologies suggestive of active SLE. Broad-spectrum IV antibiotics and corticosteroids were initiated for sepsis and SLE activity. Blood cultures were positive for MSSA with likely skin source. An electrocardiogram showed diffuse ST-segment elevations without ischemic changes. CT chest demonstrated bilateral pleural and pericardial effusions with dense consolidations. Transthoracic and transesophageal echocardiogram demonstrated reduced left ventricular ejection fraction (LVEF) 45% with no valvular pathology suggestive of endocarditis. Although MSSA bacteremia resolved, the patient rapidly developed cardiopulmonary decline with a repeat echocardiogram demonstrating LVEF < 10%. A Cardiac MRI was a nondiagnostic study to elucidate an etiology of decompensation given inability to perform late gadolinium enhancement. Later, cardiac catheterization revealed normal cardiac output with non-obstructive coronary artery disease. As there was no clear etiology explaining his dramatic heart failure, endomyocardial biopsy was obtained demonstrating diffuse myofiber degeneration and inflammation. These pathological findings, in addition to skin biopsy demonstrating lichenoid dermatitis with a granular “full house” pattern was most consistent with SLE myocarditis. Furthermore, aggressive SLE-directed therapy demonstrated near full recovery of his heart failure. Conclusion Although myocarditis during SLE flare is a well-described cardiac manifestation, progression to cardiogenic shock is infrequent and fatal. As such, SLE myocarditis should be promptly considered. Given the heterogenous presentation of SLE, combination of serologic evaluation, advanced imaging, and myocardial biopsies can be helpful when diagnostic uncertainty exists. Our case highlights diagnostic methods and clinical course of a de novo presentation of cardiogenic shock from SLE myocarditis, then rapid improvement.
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Affiliation(s)
- Jaydeep J Raval
- Division of Rheumatology, Department of Internal Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA.
| | - Christina Rodriguez Ruiz
- Department of Cardiology, Scripps Clinic/Green Hospital, San Diego, CA, USA.,, 9898 Genessee Ave, La Jolla, CA, 92037, USA
| | - James Heywood
- Department of Cardiology, Scripps Clinic/Green Hospital, San Diego, CA, USA.,, 9898 Genessee Ave, La Jolla, CA, 92037, USA
| | - Jason J Weiner
- Division of Rheumatology, Department of Internal Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA
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A Case of Systemic Lupus Erythematosus and Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis Overlap Syndrome. Case Rep Rheumatol 2021; 2021:6690658. [PMID: 33505756 PMCID: PMC7808812 DOI: 10.1155/2021/6690658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/22/2020] [Indexed: 11/23/2022] Open
Abstract
An overlap of systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibodies- (ANCA-) associated vasculitis (AAV) is extremely rare: approximately 40 cases have been reported to date. A literature review indicates that they are more common in women in their forties, and simultaneous onset has been reported in 69% of cases. In addition, both lupus nephritis and ANCA-associated glomerulonephritis were observed on renal biopsy. This report presents the case of a 35-year-old woman with an 8-month history of polyarthralgia who was admitted to our hospital. She was diagnosed with SLE due to typical clinical presentation of the disease: polyarthritis, lymphocytopenia, hypocomplementemia, presence of antinuclear and anti-dsDNA antibodies, and proteinuria. However, purpura were scattered, and the titer of antimyeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA) was high. A skin biopsy revealed leukocytoclastic vasculitis that involved poor immune complex deposition. A renal biopsy showed necrotizing glomerulonephritis with cellular and fibrocellular crescent formation that involved deposition of IgM and C3c only in the mesangial area and the peripheral capillaries. Additionally, no electron-dense deposits were observed under electron microscopy. These pathological findings were consistent with AAV rather than with SLE. Therefore, we finally diagnosed the patient with both SLE and microscopic polyangiitis. After treatment with methylprednisolone and intravenous cyclophosphamide pulse therapies, renal function improved and MPO-ANCA levels decreased. In cases of suspected overlap between SLE and AAV, appropriate diagnosis and treatment are important.
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21
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Xu ZG, Li WL, Wang X, Zhang SY, Zhang YW, Wei X, Li CD, Zeng P, Luan SD. Systemic lupus erythematosus and antineutrophil cytoplasmic antibody-associated vasculitis overlap syndrome in a 77-year-old man: A case report. World J Clin Cases 2021; 9:707-713. [PMID: 33553412 PMCID: PMC7829731 DOI: 10.12998/wjcc.v9.i3.707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are classically thought to cause renal impairment and small vessel vasculitis with different pathophysiologies. Their overlap constitutes a rare rheumatologic disease. To date, only dozens of such cases with biopsy-proven glomerulonephritis have been reported worldwide typically in women of childbearing age. Here, we present a unique clinical case due to its rarity and individualized treatment of a Chinese man in his eighth decade of life.
CASE SUMMARY A 77-year-old man was admitted to several hospitals for shortness of breath and received nonspecific treatments over the past 3 years. As his symptoms were not completely relieved, he visited our hospital for further treatment. Laboratory examinations revealed kidney dysfunction, severe anaemia, hypocom-plementemia, glomerular proteinuria, and microscopic haematuria. Antinuclear antibodies, as well as anti-dsDNA antibodies, were positive. Computed tomography of the chest showed right pleural effusion. Renal biopsy was performed, and histology suggested crescentic glomerulonephritis, pauci-immune type. After treatment with plasmapheresis, glucocorticoid, and cyclo-phosphamide, the disease was in remission, and the patient remained in a stable condition for over 3 years post-hospital discharge.
CONCLUSION Due to its complexity and rarity, SLE and AAV overlap syndrome is easily misdiagnosed. An accurate diagnosis and treatment at the earliest stage may significantly improve the condition and reduce irreversible organ injury.
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Affiliation(s)
- Zi-Gan Xu
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Wei-Long Li
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Xi Wang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Shu-Yuan Zhang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Ying-Wei Zhang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Xing Wei
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Chun-Di Li
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Ping Zeng
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Shao-Dong Luan
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
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22
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Wang S, Shang J, Xiao J, Zhao Z. Clinicopathologic characteristics and outcomes of lupus nephritis with positive antineutrophil cytoplasmic antibody. Ren Fail 2021; 42:244-254. [PMID: 32228220 PMCID: PMC7067160 DOI: 10.1080/0886022x.2020.1735416] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims: The aim was to determine whether anti-neutrophil cytoplasmic antibody (ANCA)-positive serology in patients with lupus nephritis (LN) is associated with different clinicopathologic features and outcomes.Methods: In our retrospective analysis, 283 patients were enrolled between 2013 and 2018. Thirty-six patients were ANCA-positive, and this group was compared with the remaining 247 patients who were confirmed as ANCA-negative at the time of biopsy.Results: ANCA-positive LN patients exhibited higher anti-dsDNA antibody titers and serum creatinine levels and lower serum hemoglobin concentrations than ANCA-negative LN patients. On pathological evaluation, segmental endocapillary hypercellularity observed by light microscopy was significantly more common in the ANCA-positive group. This feature was not significantly different in the treatment group, but the response to treatment was significantly different, as was remission (76.1% vs 69.4%, p < 0.001), between the ANCA-negative and ANCA-positive groups. During follow-up, the times to renal replacement therapy (RRT) and death were significantly different between the two unmatched groups (chi-square test, p = 0.041). Multivariate Cox analysis revealed that neurological disorders, ANCA positivity, and the chronicity index (CI) remained independent risk factors for patient survival. Pulmonary infection was the main cause of death and was most often due to fungal infection.Conclusion: ANCA-positive LN patients typically exhibited higher anti-dsDNA antibody titers, lower serum hemoglobin concentrations and worse renal function than ANCA-negative LN patients. Fungal infection was the main cause of death. We observed that ANCA positivity was an independent risk factor for patient survival.
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Affiliation(s)
- Shuai Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin Shang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Xiao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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23
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Bourse Chalvon N, Orquevaux P, Giusti D, Gatouillat G, Tabary T, Tonye Libyh M, Chrusciel J, Drame M, Stockton-Bliard G, Amoura Z, Arnaud L, Lorenz HM, Blaison G, Bonnotte B, Magy-Bertrand N, Revuz S, Voll RE, Hinschberger O, Schwarting A, Pham BN, Martin T, Pennaforte JL, Servettaz A. Absence of Anti-Glomerular Basement Membrane Antibodies in 200 Patients With Systemic Lupus Erythematosus With or Without Lupus Nephritis: Results of the GOODLUPUS Study. Front Immunol 2020; 11:597863. [PMID: 33381119 PMCID: PMC7768036 DOI: 10.3389/fimmu.2020.597863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/10/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Anti-glomerular basement membrane (GBM) antibodies are pathogenic antibodies first detected in renal-limited anti-GBM disease and in Goodpasture disease, the latter characterized by rapidly progressive crescentic glomerulonephritis combined with intra-alveolar hemorrhage. Studies have suggested that anti-GBM antibody positivity may be of interest in lupus nephritis (LN). Moreover, severe anti-GBM vasculitis cases in patients with systemic lupus erythematosus (SLE) have been described in the literature, but few studies have assessed the incidence of anti-GBM antibodies in SLE patients. Objective The main study objective was to determine if positive anti-GBM antibodies were present in the serum of SLE patients with or without proliferative renal damage and compared to a healthy control group. Methodology This retrospective study was performed on SLE patients’ sera from a Franco-German European biobank, developed between 2011 and 2014, from 17 hospital centers in the Haut-Rhin region. Patients were selected according to their renal involvement, and matched by age and gender. The serum from healthy voluntary blood donors was also tested. Anti-GBM were screened by fluorescence enzyme immunoassay (FEIA), and then by indirect immunofluorescence (IIF) in case of low reactivity detection (titer >6 U/ml). Results The cohort was composed of 100 SLE patients with proliferative LN (27% with class III, 67% with class IV, and 6% with class V), compared to 100 SLE patients without LN and 100 controls. Patients were mostly Caucasian and met the ACR 1997 criteria and/or the SLICC 2012 criteria. Among the 300 tested sera, no significant levels of anti-GBM antibodies were detected (>10 U/ml) by the automated technique, three sera were found “ambivalent” (>7 U/ml): one in the SLE with LN group and two in the SLE without LN group. Subsequent IIF assays did not detect anti-GBM antibodies. Conclusion Anti-GBM antibodies were not detected in the serum of Caucasian patients with SLE, even in case of renal involvement, a situation favoring the antigenic exposure of glomerular basement membranes. Our results reaffirm the central role of anti-GBM antibodies as a specific diagnostic biomarker for Goodpasture vasculitis and therefore confirm that anti-GBM antibody must not be carried out in patients with SLE (with or without LN) in the absence of disease-suggestive symptoms.
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Affiliation(s)
- Nellie Bourse Chalvon
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Pauline Orquevaux
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Delphine Giusti
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Gregory Gatouillat
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Thierry Tabary
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Marcelle Tonye Libyh
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Jan Chrusciel
- Département d'information médicale et d'évaluation des performances, santé publique, Centre Hospitalier de Troyes, Troyes, France
| | - Moustapha Drame
- Département de Délégation à la Recherche Clinique et à l'Innovation, University Hospital of Martinique, Fort-de-France, Martinique
| | | | - Zahir Amoura
- Service de Médecine interne, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Clinic for Hematology, Oncology and Rheumatology, Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Gilles Blaison
- Département de médecine interne, Hôpital Pasteur, Colmar, France
| | - Bernard Bonnotte
- Département de Médecine Interne et d'immunologie Clinique, Centre Hospitalier Regional Universitaire De Dijon, Dijon, France
| | - Nadine Magy-Bertrand
- Département de médecine interne, Centre Hospitalier Universitaire de Besançon, Besancon, France
| | - Sabine Revuz
- Département de médecine interne, Hôpital Belle-Isle, Metz, France
| | - Reinhard Edmund Voll
- Department of Rheumatology and Clinical Immunology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Oliver Hinschberger
- Département de médecine interne, Groupe Hospitalier de la Région de Mulhouse et Sud Alsace (GHRMSA), Mulhouse, France
| | - Andreas Schwarting
- Universitäres Centrum für Autoimmunität Mainz, Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Bach Nga Pham
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Thierry Martin
- Immunologie Clinique et Médecine Interne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Loup Pennaforte
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Amelie Servettaz
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
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Golas VL, Lao KM, Misuraca MS, Li W, Marrone MG, Kanaan HD, Zhang PL. The clinical features of overlap syndrome (ANCA-associated crescentic glomerulonephritis [AACGN] and immune complex-mediated glomerulonephritis) are similar to those of AACGN alone. Int Urol Nephrol 2020; 53:515-521. [PMID: 33025405 DOI: 10.1007/s11255-020-02654-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/14/2020] [Indexed: 12/01/2022]
Abstract
The overlap syndromes of anti-neutrophil cytoplasmic antibodies (ANCA)-associated crescentic glomerulonephritis (AACGN) and variants of immune complex medicated glomerulopathy (ICMGN) have been reported. But very few have compared AACGN alone with the overlap syndromes (AACGN plus ICMGN). The aim of this retrospective study was to make that comparison, following serum creatinine (sCr) to determine whether the two groups (AACGN-only group versus overlap group) would behave differently over time. We identified 14 cases with dual diagnoses of AACGN and various ICMGN in the overlap group. Data were collected and compared with 15 randomly selected AACGN-only cases over the similar period of time. The overlap syndrome represented 0.35% of our overall biopsies (14/4049). All 14 patients were ANCA positive and had crescentic formation. The percentage of crescents in the biopsies ranged from 10 to 78%. ICMGN included the following: membranoproliferative glomerulonephritis, post-infectious glomerulonephritis, membranous glomerulopathies, idiopathic mesangial proliferative glomerulonephritis, lupus nephritis, and IgA nephropathy. With the exception one biopsy revealing lupus nephritis class III, most of the ICMGN were mild. When compared to the AACGN-only group, there were no significant differences in clinical and histologic indices including age, percent of crescents, and sCr (on biopsy days, and over the follow-up periods), although the numbers of follow-up cases were limited over time. Our findings suggest that AACGN was the dominant disease process in the majority of overlap syndromes between AACGN and ICMGN, similar to the clinical processes of AACGN-only disease, therefore, the AACGN in overlap syndrome cases should be the main target for clinical management.
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Affiliation(s)
- Victoria L Golas
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Kriselle Maris Lao
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Michael S Misuraca
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Wei Li
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Mark G Marrone
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Hassan D Kanaan
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Ping L Zhang
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA. .,Division of Anatomic Pathology, William Beaumont Hospital, Beaumont LaboratoryRoyal Oak, MI, 48073, USA.
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25
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Moiseev S, Cohen Tervaert JW, Arimura Y, Bogdanos DP, Csernok E, Damoiseaux J, Ferrante M, Flores-Suárez LF, Fritzler MJ, Invernizzi P, Jayne D, Jennette JC, Little MA, McAdoo SP, Novikov P, Pusey CD, Radice A, Salama AD, Savige JA, Segelmark M, Shoenfeld Y, Sinico RA, Sousa MJ, Specks U, Terrier B, Tzioufas AG, Vermeire S, Zhao MH, Bossuyt X. 2020 international consensus on ANCA testing beyond systemic vasculitis. Autoimmun Rev 2020; 19:102618. [PMID: 32663621 DOI: 10.1016/j.autrev.2020.102618] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
This document follows up on a 2017 revised international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in granulomatosis with polyangiitis and microscopic polyangiitis and focuses on the clinical and diagnostic value of ANCA detection in patients with connective tissue diseases, idiopathic interstitial pneumonia, autoimmune liver diseases, inflammatory bowel diseases, anti-glomerular basement membrane (GBM) disease, infections, malignancy, and during drug treatment. Current evidence suggests that in certain settings beyond systemic vasculitis, ANCA may have clinical, pathogenic and/or diagnostic relevance. Antigen-specific ANCA targeting proteinase-3 and myeloperoxidase should be tested by solid phase immunoassays in any patient with clinical features suggesting ANCA-associated vasculitis and in all patients with anti-GBM disease, idiopathic interstitial pneumonia, and infective endocarditis associated with nephritis, whereas in patients with other aforementioned disorders routine ANCA testing is not recommended. Among patients with autoimmune liver diseases or inflammatory bowel diseases, ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1 who do not have conventional autoantibodies or in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn's disease. In these cases, ANCA should be tested by indirect immunofluorescence as the target antigens are not yet well characterized. Many questions concerning the optimal use of ANCA testing in patients without ANCA-associated vasculitis remain to be answered.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Jan Willem Cohen Tervaert
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Canada and Maastricht University, Maastricht, The Netherlands
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa, Greece
| | - Elena Csernok
- Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center Tübingen-Kirchheim, Medius Klinik Kirchheim, University of Tübingen, Kirchheim-Teck, Germany
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marc Ferrante
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Invernizzi
- Division Gastroenterology and Center for Autoimmune Liver Diseases, University of Milano-Bicocca School of Medicine, Monza, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - J Charles Jennette
- Division of Nephropathology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Antonella Radice
- Microbiology and Virology Institute, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
| | - Alan D Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Judith A Savige
- Department of Medicine, Melbourne Health, University of Melbourne, Melbourne, Australia
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Department of Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria-José Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Severine Vermeire
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking-Tsinghua Centre for Life Sciences, Beijing, China
| | - Xavier Bossuyt
- Laboratory Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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26
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Muniz MPR, Brito LPAF, Vale PHC, Guedes FL, Oliveira TKM, de Araújo Brito DJ, Filho NS, Dantas M, Silva GEB. Renal involvement in systemic lupus erythematosus: additional histopathological lesions. Arch Med Sci 2020; 19:1398-1409. [PMID: 37732045 PMCID: PMC10507776 DOI: 10.5114/aoms.2020.96617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/21/2020] [Indexed: 09/22/2023] Open
Abstract
A common criticism of the classification of lupus nephritis is the relative scarcity of information regarding tubular, interstitial, and vascular changes compared to the available information regarding glomerular changes, even though their potential for independent progression is known. This study reviewed the importance of less explored lesions by the current and widely used 2003 classification of lupus nephritis of the International Society of Nephrology/Renal Pathology Society (ISN/RPS), with emphasis on the tubulointerstitial, podocyte, and vascular lesions, increasingly recognised as being important in the pathogenesis and prognosis of the disease. Recognition of these lesions can help with therapeutic decision-making, thereby allowing better results for patients with systemic lupus erythematosus.
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Affiliation(s)
- Monique Pereira Rêgo Muniz
- Department of Nephrology, Presidente Dutra Universitary Hospital, University of Maranhão (UFMA), São Luís, MA, Brazil
| | | | - Pedro Henrique Cavalcante Vale
- Department of Nephrology, Onofre Lopes Universitary Hospital, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | - Felipe Leite Guedes
- Department of Nephrology, Onofre Lopes Universitary Hospital, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil
| | | | - Dyego José de Araújo Brito
- Department of Nephrology, Presidente Dutra Universitary Hospital, University of Maranhão (UFMA), São Luís, MA, Brazil
| | - Natalino Salgado Filho
- Department of Nephrology, Presidente Dutra Universitary Hospital, University of Maranhão (UFMA), São Luís, MA, Brazil
| | - Márcio Dantas
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRPUSP), Ribeirão Preto, SP, Brazil
| | - Gyl Eanes Barros Silva
- Department of Nephrology, Presidente Dutra Universitary Hospital, University of Maranhão (UFMA), São Luís, MA, Brazil
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRPUSP), Ribeirão Preto, SP, Brazil
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27
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A Case of Systemic Lupus Erythematosus/Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Overlap Syndrome with Dissociated Pathological and Immunological Findings. Case Rep Nephrol 2020; 2020:5698708. [PMID: 32509365 PMCID: PMC7246398 DOI: 10.1155/2020/5698708] [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: 12/18/2019] [Accepted: 04/29/2020] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus/antineutrophil cytoplasmic antibody-associated vasculitis overlap syndrome (SLE/AAV OS) describes a pathological condition that presents with overlapping features of two diseases. There have been few reports of SLE/AAV OS and none from Japan. We present the case of a 59-year-old woman admitted with chief complaints of fever and decreased renal function. SLE was suspected due to the identification of four items from the diagnostic criteria of the American College of Rheumatology, including positivity for anti-ds-DNA and antinuclear antibodies. However, pathological findings from the kidney biopsy suggested pauci-immune crescentic glomerulonephritis. She was also diagnosed with AAV according to the Chapel Hill Consensus Conference (CHCC) 2012 definitions and the classification algorithm of AAV. SLE/AAV OS was suspected, we started immunosuppressant therapy, and subsequently her renal function improved. In previous reports, initial immunological and pathological findings generally concur. In cases where clinical and pathological features appear to conflict, as in the present case, a treatment strategy decision should be based on pathological and immunological findings to improve the prognosis of OS.
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28
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Fernando SL, Boyle T. Presence of dual anti-MPO and anti-PR3 antibodies in Systemic Lupus Erythematosus/ANCA-Associated Vasculitis. J Clin Pathol 2020; 73:687-688. [PMID: 32513843 DOI: 10.1136/jclinpath-2019-206244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/29/2020] [Accepted: 05/19/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Suran L Fernando
- Immunology Laboratory, New South Wales Health Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Therese Boyle
- Immunology Laboratory, New South Wales Health Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia .,Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia
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29
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Weiner SM, Waldherr R. Stellenwert der Nierenbiopsie bei Lupusnephritis. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1121-8852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
ZusammenfassungBei systemischem Lupus erythematodes (SLE) findet sich häufig eine renale Mitbeteiligung, der verschiedene pathogenetische Mechanismen zugrunde liegen. Die Nierenbeteiligung hat einen negativen Einfluss auf die Prognose des SLE, insbesondere bei progredienter Niereninsuffizienz. Eine Nierenbiopsie ist aufgrund der Heterogenität der Nierenbeteiligung und der damit verbundenen therapeutischen Konsequenzen unabdingbar. Sie kann durch nicht-invasive Untersuchungen wie die Urindiagnostik oder Serologie nicht ersetzt werden, da das Ausmaß der Proteinurie oder der Mikrohämaturie keine sicheren Rückschlüsse auf den Schweregrad, die Pathogenese und die Prognose der Nierenbeteiligung erlauben. Die Nierenbiopsie gibt neben der korrekten Klassifikation der Lupusnephritis (LN) Informationen über die Mitbeteiligung des Niereninterstitium, der intrarenalen Gefäße und der Aktivität sowie Chronizität der Nephritis. Auch kann der Pathologe die Frage beantworten, inwieweit mit einer Besserung der Nierenfunktion unter Therapie gerechnet werden kann. Der folgende Beitrag gibt einen Überblick über den Stellenwert der Nierenbiopsie bei SLE, der revidierten Klassifikation der LN von 2018 einschließlich Sonderformen der LN und über die Implikationen des Biopsie-Ergebnisses für die Therapie.
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Affiliation(s)
- Stefan Markus Weiner
- 2. Medizinische Abteilung, Krankenhaus der Barmherzigen Brüder, Trier
- KfH Nierenzentrum Nordallee, KfH Kuratorium für Dialyse und Nierentransplantation e. V., Trier
| | - Rüdiger Waldherr
- Pathologisches Institut, Ruprecht Karls Universität Heidelberg, Heidelberg
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30
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Farah RI, Shahin NA, Alawneh M, Adwan M. Rapidly progressive glomerulonephritis due to systemic lupus erythematosus and ANCA-associated vasculitis overlap. Lupus 2020; 29:983-986. [PMID: 32316845 DOI: 10.1177/0961203320920368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Systemic lupus erythematosus (SLE) and ANCA-associated vasculitis (AAV) are different autoimmune diseases. While vasculitis can be seen in the SLE clinical course as a secondary phenomenon, and may indicate a severe disease, primary vasculitis such as AAV rarely occurs in association with SLE. We present a 44-year-old woman who presented with rapidly progressive glomerulonephritis which was histologically identified as a combination of crescentic and lupus nephritis in the presence of myeloperoxidase ANCA antibody. The frequency of this association is very rare. The clinical, histological and immunological features are different in SLE/AAV overlap syndrome and need different treatment options, which may include rituximab, to achieve complete recovery. Since SLE/AAV overlap can be serious at presentation, the physician must be aware of this syndrome.
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Affiliation(s)
- Randa I Farah
- Nephrology Division, Internal Medicine Department, School of Medicine, The University of Jordan, Amman, Jordan
| | - Nisreen Abu Shahin
- Department of Pathology and Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohannad Alawneh
- Internal Medicine Department, School of Medicine, The University of Jordan, Amman, Jordan
| | - Marwan Adwan
- Rheumatology Division, Internal Medicine Department, School of Medicine, The University of Jordan, Amman Jordan
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31
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Systemic Lupus Erythematosus (SLE) with Acute Nephritis, Antineutrophil Cytoplasmic Antibody- (ANCA-) Associated Vasculitis, and Thrombotic Thrombocytopenic Purpura (TTP): A Rare Case Report with Literature Review. Case Rep Rheumatol 2020; 2019:8750306. [PMID: 31934484 PMCID: PMC6942753 DOI: 10.1155/2019/8750306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 11/17/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal disorder that requires urgent identification and treatment. The association of TTP with systemic lupus erythematosus (SLE) and vasculitis has been reported, however, never simultaneously. A 33-year-old woman with a history of SLE presented with acute abdominal pain, fever, arthralgias, and skin rash. She had acute severe hypertension, diffuse abdominal tenderness, and petechial rash. Diagnostic work-up revealed active urine sediment with proteinuria and hematuria and elevated creatinine, anemia, and thrombocytopenia. She was diagnosed with acute lupus nephritis and early microangiopathic hemolytic anemia in the setting of hypertensive urgency and started on intravenous methylprednisolone 500 mg once a day. Within 48 hours, she developed shock with multiorgan dysfunction and succumbed to her illness. Laboratory tests later showed ADAMTS13 activity less than 10% consistent with TTP and p-antineutrophil cytoplasmic antibody (ANCA) positivity. Autopsy revealed small-vessel vasculitis of the visceral organs. Kidney biopsy demonstrated diffuse proliferative glomerulonephritis. This case illustrates the occurrence of SLE nephritis, p-ANCA vasculitis, and severe TTP with rapidly fatal course, and the importance of having a low threshold for initiating plasma exchange therapy. Here, we discuss the case and provide a literature review on cases of TTP with SLE and vasculitis.
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Falasinnu T, O'Shaughnessy MM, Troxell ML, Charu V, Weisman MH, Simard JF. A review of non-immune mediated kidney disease in systemic lupus erythematosus: A hypothetical model of putative risk factors. Semin Arthritis Rheum 2019; 50:463-472. [PMID: 31866044 DOI: 10.1016/j.semarthrit.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
About half of patients with systemic lupus erythematosus (SLE) are diagnosed with lupus nephritis (LN). Patients with SLE are also at increased risk for diabetes, hypertension and obesity, which together account for >70% of end-stage renal disease in the general population. The frequencies of non-LN related causes of kidney disease, and their contribution to kidney disease development and progression among patients with SLE have been inadequately studied. We hypothesize that a substantial, and increasing proportion of kidney pathology in patients with SLE might not directly relate to LN but instead might be explained by non-immune mediated factors such as diabetes, hypertension, and obesity. The goal of the manuscript is to draw attention to hypertension, diabetes and obesity as potential alternative causes of kidney damage in patients with SLE. Further, we suggest that misclassification of kidney disease etiology in patients with SLE might have important ramifications for clinical trial recruitment, epidemiologic investigation, and clinical care. Future studies aiming to elucidate and distinguish discrete causes of kidney disease - both clinically and histologically - among patients with SLE are desperately needed as improved understanding of disease mechanisms is paramount to advancing therapeutic discovery. Collaboration among rheumatologists, pathologists, nephrologists, and endocrinologists, and the availability of dedicated research funding, will be critical to the success of such efforts.
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Affiliation(s)
- Titilola Falasinnu
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States
| | | | - Megan L Troxell
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Vivek Charu
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Michael H Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, David Geffen School of Medicine, UCLA, United States
| | - Julia F Simard
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States; Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, United States.
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Meyler D, Arrascaeta-Llanes A, Gupta R, Godhwani S. A unique presentation of a rare disease: biopsy proven systemic lupus erythematosus and microscopic polyangitis: an overlap syndrome. J Community Hosp Intern Med Perspect 2019; 9:433-436. [PMID: 31723391 PMCID: PMC6830228 DOI: 10.1080/20009666.2019.1659659] [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: 06/13/2019] [Accepted: 08/19/2019] [Indexed: 11/15/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) and ANCA-associated vasculitis are classically thought to be separate diseases with different pathophysiologies. An overlap of these diseases has been reported few times in the literature. We present a unique case of a Caucasian male in his third decade of life, without a previous personal or family history of autoimmune disease, with serological and biopsy findings of both diseases occurring simultaneously. ANCA, typically p-ANCA, can be detected in up to 30% of SLE patients and can be higher with renal involvement. Patients with overlap syndrome have increased complications and higher mortality rates than those with either disease alone. Our patient was found to have necrotizing and crescentic glomerulonephritis, most consistent with ANCA vasculitis, specifically microscopic polyangitis with MPO positive staining. The biopsy also revealed abundant immune-complex deposits consistent with WHO class V diffuse membranous lupus glomerulonephritis. These diseases are typically seen in young to middle aged females, and given the rarity of this case, biopsy findings were confirmed by two pathologists from separate institutions. Presentations of autoimmune diseases and vasculitis can be multi-systemic. Immediate action and appropriate work up with a multidisciplinary team is required for optimal patient care. Our patient displayed pulmonary-renal involvement in addition to systemic features such as fevers, myalgia and profound anemia. Considering overlap syndromes, especially in patients with underlying connective tissue disease or systemic vasculitis, is vital for the prevention of excess morbidity in this population.
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Affiliation(s)
- Diana Meyler
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | | | - Ravi Gupta
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | - Sanjay Godhwani
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
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Hamano Y, Ito F, Suzuki O, Koura M, Matsuoka S, Kobayashi T, Sugitani Y, Wali N, Koyanagi A, Hino O, Suzuki S, Sugamata R, Yoshizawa H, Yumura W, Maruyama N, Kameoka Y, Noda Y, Hasegawa Y, Arai T, Suzuki K. Vasculitis and crescentic glomerulonephritis in a newly established congenic mouse strain derived from ANCA-associated vasculitis-prone SCG/Kj mice. Autoimmunity 2019; 52:208-219. [DOI: 10.1080/08916934.2019.1658191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Yoshitomo Hamano
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
- Team for Molecular Regulation of Aging, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Fuyu Ito
- Asia International Institute of Infectious Disease Control, Teikyo University, Tokyo, Japan
| | - Osamu Suzuki
- The National Institutes of Biomedical Innovation, Health and Nutrition, Osaka, Japan
| | - Minako Koura
- The National Institutes of Biomedical Innovation, Health and Nutrition, Osaka, Japan
| | - Shuji Matsuoka
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Toshiyuki Kobayashi
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshinobu Sugitani
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Nadila Wali
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ai Koyanagi
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Okio Hino
- Department of Pathology and Oncology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shoichi Suzuki
- Asia International Institute of Infectious Disease Control, Teikyo University, Tokyo, Japan
| | - Ryuichi Sugamata
- Asia International Institute of Infectious Disease Control, Teikyo University, Tokyo, Japan
| | | | - Wako Yumura
- Department of Nephrology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Naoki Maruyama
- Team for Molecular Regulation of Aging, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | | | - Yoshihiro Noda
- Laboratory Animal Facility, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Yasuko Hasegawa
- Department of Pathology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Tomio Arai
- Department of Pathology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Kazuo Suzuki
- Asia International Institute of Infectious Disease Control, Teikyo University, Tokyo, Japan
- A-CLIP Institute, Chiba, Japan
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Ayurvedic Management of Systemic Lupus Erythematosus overlap Vasculitis. J Ayurveda Integr Med 2019; 10:294-298. [PMID: 31421962 PMCID: PMC6938929 DOI: 10.1016/j.jaim.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 07/01/2018] [Accepted: 08/31/2018] [Indexed: 11/21/2022] Open
Abstract
Systemic Lupus erythematosus is the classic prototype of multisystem disease of autoimmune origin. SLE may be associated Vasculitis as an overlap syndrome. In this paper, a patient diagnosed as SLE with Vasculitis, which was managed successfully by Ayurveda treatment was discussed. A 39-year-old female patient came to hospital with complaint of severe pain and burning sensation in both the legs for two months, associated with ulceration and gangrene of toes of both the legs for the last 15 days. She was diagnosed as SLE overlap vasculitis from a higher medical centre with relevant investigations and advised to go for amputation. As patient was not willing for surgery, alternatively opted for Ayurveda treatment. The condition was diagnosed as disease Vatarakta according to Ayurveda and treatment was planned accordingly. Treatment was planned by selecting suitable oral medicines, suitable panchakarma procedures along with the ulcer management. Tinospora cordifolia was the main drug of choice. Treatment was successful and able to save the limb. Patient was followed up for more than a year without any complications and relapses.
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Patients with ANCA-Associated Glomerulonephritis and Connective Tissue Diseases: A Comparative Study from the Maine-Anjou AAV Registry. J Clin Med 2019; 8:jcm8081218. [PMID: 31416296 PMCID: PMC6723780 DOI: 10.3390/jcm8081218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The overlap between antineutrophil cytoplasmic antibody (ANCA) associated glomerulonephritis (ANCA-GN) and connective tissue diseases (CTD) has been reported mainly as case series in the literature. Frequency of this association, as well as presentation and outcomes are unknown. MATERIALS AND METHODS Patients from the Maine-Anjou ANCA-associated vasculitides (AAV) registry with ANCA-GN diagnosed between 01/01/2000 and 01/01/2018, ANCA positivity, and at least six months of follow-up, were included. RESULTS 106 out of 142 patients fulfilled the inclusion criteria and were analyzed. CTD was present at ANCA-GN diagnosis in 16 (15.1%) patients. The most common CTD were rheumatoid arthritis, Sjogren syndrome and systemic sclerosis. Compared to the control group, females were more represented in the CTD group (75%, p = 0.001). Renal presentation was comparable between groups, including the pathological analysis of renal biopsies. Patients of CTD group presented a higher rate of non-renal relapse (25% versus 7.7%, p = 0.037), and experienced more frequently a venous thrombotic event (31.2% versus 10%, p = 0.021). No difference between groups was observed according to major outcomes. CONCLUSION Association between CTD and ANCA-GN is not a rare condition and predominantly affects females. While AAV presentation is not significantly different, CTD patients experience more frequently non-renal relapse and venous thrombotic events.
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Li C, Wang JJ, Zhou ML, Liang DD, Yang J, Zhu HX, Hu WX, Zhang HT. Differences in clinico-pathological characteristics and outcomes between proteinase 3-ANCA positivity and myeloperoxidase-ANCA positivity in lupus nephritis. Lupus 2019; 28:1111-1119. [PMID: 31291845 DOI: 10.1177/0961203319861680] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Owing to the low prevalence of anti-neutrophil cytoplasmic antibodies (ANCA) in lupus nephritis (LN), there is no study about the differences between proteinase 3 (PR3)-ANCA positivity and myeloperoxidase (MPO)-ANCA positivity in LN until now. METHODS Here we perform a retrospective study to determine whether there are differences in clinic-pathological characteristics and renal outcomes between PR3-ANCA-positive LN patients and MPO-ANCA-positive LN patients. RESULTS A total of 26 (27.4%) PR3-ANCA-positive LN patients and 69 (72.6%) MPO-ANCA-positive LN patients (p < 0.001) were eligible for this study. Compared with PR3-ANCA-positive LN patients, MPO-ANCA-positive LN patients had significantly higher levels of serum creatinine (109.6 µmol/l vs. 74.3 µmol/l, p = 0.02), lower titers of antinuclear antibodies (ANA) (128 vs. 256, p = 0.01), and higher serum concentrations of C3 and C4 (0.54 g/l vs. 0.36 g/l, p = 0.002; 0.12 g/l vs. 0.06 g/l, p < 0.001; respectively). Furthermore, the MPO-ANCA-positive group had higher scores for chronicity index (p = 0.007), including interstitial fibrosis (p = 0.001) and tubular atrophy (p = 0.03) on biopsy specimens. The renal survival rates for MPO-ANCA-positive LN patients were 94.1% at 1 year, 83.2% at 5 years and 79.6% at 10 years; these values were worse when compared with those of the PR3-ANCA-positive group, which were 100%, 100% and 100%, respectively. CONCLUSION MPO-ANCA-positive LN patients had more severely impaired baseline renal function and less active lupus serology. More severely chronic pathological changes, including interstitial fibrosis and tubular atrophy on renal specimens, occurred in MPO-ANCA-positive LN patients. We found that MPO-ANCA-positive LN patients had worse renal outcomes.
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Affiliation(s)
- C Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J-J Wang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - M-L Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - D-D Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J Yang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - H-X Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - W-X Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - H-T Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Fukue R, Takeno M, Miyamoto D, Shirai Y, Nagahama K, Shimizu A, Kuwana M. Rapid progression to end-stage renal disease in a young female with mixed immunopathological features of lupus and ANCA-associated vasculitis. Int J Rheum Dis 2019; 22:956-958. [PMID: 30968562 DOI: 10.1111/1756-185x.13573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ryosuke Fukue
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Miyamoto
- Department of Nephrology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yuichiro Shirai
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Kiyotaka Nagahama
- Department of Analytic Human Pathology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan.,Department of Pathology, Kyorin University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Systemic Lupus Erythematosus (SLE) and Antineutrophil Cytoplasmic Antibody-Associated Vasculitis (AAV) Overlap Syndrome: Case Report and Review of the Literature. Case Rep Rheumatol 2019; 2019:5013904. [PMID: 30723567 PMCID: PMC6339764 DOI: 10.1155/2019/5013904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/02/2018] [Accepted: 12/12/2018] [Indexed: 11/17/2022] Open
Abstract
We report here the first case of systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis overlap syndrome (SLE/AAV) who had granulomatous polyangiitis (GPA) as the initial presentation. SLE/AAV overlap syndrome is an uncommon entity recently described in the literature. Prior reported patients with SLE/AAV overlap syndrome presented with SLE and microscopic polyangiitis (MPA). Our patient initially presented with granulomatous gastric ulcer and later developed respiratory failure. She was diagnosed with GPA. While on maintenance treatment with azathioprine 150 mg/day, she developed hematuria and proteinuria which turned out to be from class V lupus nephritis instead of relapse of vasculitis. Currently, the patient is doing well after treatment with rituximab. Although rare, this entity should be recognized and need to be treated appropriately.
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40
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Doutre MS. [What's new in internal medicine?]. Ann Dermatol Venereol 2018; 145 Suppl 7:VIIS24-VIIS31. [PMID: 30583754 DOI: 10.1016/s0151-9638(18)31286-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
What's new in internal medicine will be dedicated to three topics: i) inflammatory myopathies constituting a heterogenous group of diseases whose clinical manifestations, immunological abnormalities, treatment response and outcomes vary widely; ii) alterations of gut microbiota contributing to the occurrence or development of a range of conditions, including autoimmune diseases for which further work is necessary to understand the correlation of dysbiosis with these diseases; iii) the reciprocal relationship between obesity, metabolic syndrome, atherosclerosis and autoimmune diseases. New data concerning systemic sclerosis, cutaneous vasculitis, adult Still's disease, autoantibodies anti DFS70, Epstein Barr virus and autoimmune diseases were also highlighted.
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Affiliation(s)
- M-S Doutre
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, 1, rue Jean-Burget, 33000 Bordeaux, France.
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41
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ANCA-Associated Necrotizing Glomerulonephritis Overlapping with Mesangial Proliferative Lupus Nephritis Refractory to Plasmapheresis, Steroid Pulse Therapy, and a Combination of Mycophenolate Mofetil and Rituximab. Case Rep Rheumatol 2018; 2018:3076806. [PMID: 30581646 PMCID: PMC6276453 DOI: 10.1155/2018/3076806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/05/2018] [Indexed: 12/11/2022] Open
Abstract
Necrotizing glomerulonephritis (GN) associated with antineutrophil cytoplasmic antibody (ANCA) has been increasingly recognized in the context of class III or IV lupus nephritis (LN), hereafter designated as ANCA-associated necrotizing LN. While this subset of GN appears to portend an unfavorable renal outcome, it is not clear whether it represents a distinct entity and benefits from a more aggressive therapy. We report a 78-year-old woman who presented with rapidly progressive GN and was found to have a double-stranded DNA (dsDNA) antibody, hypocomplementemia, antiphospholipid antibody, and strongly positive myeloperoxidase antibody. Renal pathology showed necrotizing and crescentic GN on a background of mesangial proliferative GN. Her kidney disease did not improve despite the treatment with plasmapheresis, three doses of methylprednisolone pulse therapy followed by prednisone at 1 mg/kg/day, rituximab, and mycophenolate mofetil. This case not only reinforces the notion that ANCA-associated necrotizing LN is associated with high dsDNA antibody, hypocomplementemia, and worse renal outcome but also adds new insight into the full spectrum of this emerging disease entity by demonstrating that the concurrence of ANCA-associated vasculitis is not specific for class III or IV LN but can also be seen on a background of class II LN.
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42
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Khorolsky C, Castellano A, Comstock D, Brinster NK, See SY, Garner BF. Systemic lupus erythematosus and antineutrophilic cytoplasmic antibody-associated vasculitis overlap syndrome complicated by subarachnoid hemorrhage: case-based review. Rheumatol Int 2018; 38:2329-2335. [PMID: 30327865 DOI: 10.1007/s00296-018-4169-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 10/01/2018] [Indexed: 12/01/2022]
Abstract
Systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) overlap syndrome is an inflammatory disorder with a mixed presentation that is characterized by clinical features of both SLE and AAV. Although renal disease predominates, any organ system in the body may be affected. Neurologic manifestation in patients with SLE-AAV overlap syndrome is rare and has only been previously documented as cerebral ischemia. We report a patient with SLE-AAV overlap syndrome diagnosed based on clinical, serologic and biopsy-proven histologic findings who presented with subarachnoid hemorrhage (SAH) secondary to ruptured right anterior cerebral artery aneurysm. To the authors' knowledge, this is the first reported case of SLE-AAV overlap syndrome diagnosed in a patient with a SAH due to an intracranial aneurysm. Neurologic involvement in patients with SLE-AAV overlap syndrome is uncommon and has not been well-studied. Clinicians who encounter patients with neurologic signs that present with symptoms and a serologic profile that correspond to both SLE and AAV criteria, should consider the association between SLE-AAV overlap syndrome and a hemorrhagic stroke, specifically SAH.
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Affiliation(s)
- Ciril Khorolsky
- Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA.
| | - Andrew Castellano
- Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - David Comstock
- Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Nooshin K Brinster
- Department of Pathology, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Sein Y See
- Department of Nephrology, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Bruce F Garner
- Department of Rheumatology, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
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Martín-Nares E, Zuñiga-Tamayo D, Hinojosa-Azaola A. Prevalence of overlap of antineutrophil cytoplasmic antibody associated vasculitis with systemic autoimmune diseases: an unrecognized example of poliautoimmunity. Clin Rheumatol 2018; 38:97-106. [PMID: 30006919 DOI: 10.1007/s10067-018-4212-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 12/24/2022]
Abstract
We aimed to estimate the frequency of overlap of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with systemic autoimmune diseases. Retrospective single-center study to identify patients with AAV diagnosis and concomitant autoimmune systemic diseases, simultaneously, before or after the diagnosis of AAV. Sociodemographic characteristics, such as comorbidities; follow-up time; type of AAV; disease duration; relapses; treatment and response; clinical, serological, and histological characteristics; disease activity and damage; prognosis; dialysis requirements, and death were assessed. Twenty-eight of two hundred and forty-seven patients (11.3%) with AAV had a concomitant diagnosis of autoimmune disease. The predominant AAV type was renal-limited vasculitis (39%), followed by granulomatosis with polyangiitis (29%), mycroscopic polyangiitis (25%), and eosinophilic granulomatosis with polyangiitis (7%). Mean age at AAV diagnosis was 50 ± 17 years and 24/28 were ANCA positive. The main clinical manifestations were renal (79%), otorhinolaryngologic (43%), and pulmonary and peripheral neuropathy (32%). Sixteen patients (57%) experienced partial or total remission at a median follow-up of 34 months, and four patients (14%) died. The most frequent autoimmune disease overlapped was rheumatoid arthritis (39%), followed by Sjögren's syndrome and systemic sclerosis (14%), mixed connective tissue disease (11%), systemic lupus erythematosus and juvenile idiopathic arthritis (7%), and ankylosing spondylitis and IgG4-related disease (4%). In nine patients (32%), both diagnoses were simultaneous; in the rest, median time elapsed between the autoimmune disease and AAV diagnosis was 173 months. The prevalence of overlap AAV with other autoimmune diseases was low. The most common AAV phenotype was renal-limited vasculitis, and the most frequent overlap disease was rheumatoid arthritis.
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Affiliation(s)
- Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico
| | - Diego Zuñiga-Tamayo
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico.
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Curtiss P, Liebman T, Khorolsky C, Brinster N, Beasley J, Lo Sicco K. Systemic lupus erythematosus and antineutrophil cytoplasmic antibody-associated vasculitis: An emerging overlap syndrome with cutaneous manifestations. JAAD Case Rep 2018; 4:493-496. [PMID: 29984294 PMCID: PMC6031565 DOI: 10.1016/j.jdcr.2018.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Paul Curtiss
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Tracey Liebman
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Ciril Khorolsky
- Department of Internal Medicine, NYU Lutheran Medical Center, Brooklyn, New York
| | - Nooshin Brinster
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Jenna Beasley
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Kristen Lo Sicco
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
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Liebowitz J, Fine D, Seo P, Petri M, Machireddy K, Haque U, Manno R, Timlin H. Pauci-immune Glomerulonephritis in Systemic Lupus Erythematosus (SLE). Cureus 2018; 10:e2949. [PMID: 30202678 PMCID: PMC6128587 DOI: 10.7759/cureus.2949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Glomerulonephritis (GN) in lupus is generally an immune complex glomerulonephritis from the deposition of immunoglobulin and complements. Pauci-immune GN is the most common cause of rapidly progressive GN and is frequently associated with an anti-nuclear cytoplasmic antibody (ANCA). We report a patient with a history of systemic lupus erythematosus who presented with worsening proteinuria and was subsequently diagnosed with pauci-immune GN on renal biopsy, in the absence of ANCA.
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Affiliation(s)
- Jason Liebowitz
- Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Derek Fine
- Nephrology, Johns Hopkins Bayview Medical Center, Baltimore, USA
| | - Philip Seo
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michelle Petri
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Uzma Haque
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Rebecca Manno
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Homa Timlin
- Medicine, The Johns Hopkins University School of Medicine, Essex, USA
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A Cross-Sectional Study of the Association between Autoantibodies and Qualitative Ultrasound Index of Bone in an Elderly Sample without Clinical Autoimmune Disease. J Immunol Res 2018; 2018:9407971. [PMID: 29854851 PMCID: PMC5952466 DOI: 10.1155/2018/9407971] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/05/2018] [Accepted: 03/17/2018] [Indexed: 12/15/2022] Open
Abstract
Bone loss is characteristic of the ageing process and a common complication of many autoimmune diseases. Research has highlighted a potential role of autoantibodies in pathologic bone loss. The confounding effects of immunomodulatory drugs make it difficult to establish the contribution of autoantibodies amongst autoimmune disease sufferers. We attempted to examine the relationship between autoantibodies and bone mass in a population of 2812 elderly participants without clinical autoimmune disease. Serum samples were assayed for a panel of autoantibodies (anti-nuclear, extractable nuclear antigen, anti-neutrophil cytoplasmic, thyroid peroxidase, tissue transglutaminase, anti-cardiolipin, rheumatoid factor, and cyclic citrullinated peptide). Bone mass was measured using quantitative ultrasound (QUS) of the calcaneus. The relationship between each autoantibody and bone mass was determined using linear regression models. Anti-nuclear autoantibodies were the most prevalent, positive in approximately 11%, and borderline in roughly 23% of our sample. They were also the only autoantibody observed to be significantly associated with QUS index in the univariate analysis (n = 1628; r = -0.20; 95% CI: -0.40-0.00; p = 0.046). However, statistical significance was lost after adjustment for various other potential confounders. None of the other autoantibodies was associated with QUS index in either univariate or multivariate analysis. We are limited by the cross-sectional nature of the study and the low prevalence of autoantibodies in our nonclinical sample.
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Amann K. Do ANCAs make the difference in lupus nephritis? Kidney Int 2017; 92:1048-1050. [DOI: 10.1016/j.kint.2017.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
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Wang L, Hao C, Deng Y, Liu Y, Hu S, Peng Y, He M, Fu J, Liu M, Chen J, Chen X. Screening epitopes on systemic lupus erythematosus autoantigens with a peptide array. Oncotarget 2017; 8:85559-85567. [PMID: 29156741 PMCID: PMC5689631 DOI: 10.18632/oncotarget.20994] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/28/2017] [Indexed: 11/29/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a common autoimmune disease. Many autoantibodies are closely associated with SLE. However, the specific epitopes recognized and bound by these autoantibodies are still unclear. This study screened the binding epitopes of SLE-related autoantibodies using a high-throughput screening method. Epitope prediction on 12 SLE-related autoantigens was performed using the Immune Epitope Database and Analysis Resource (IEDB) software. The predicted epitopes were synthesized into peptides and developed into a peptide array. Serum IgG from 50 SLE patients and 25 healthy controls was detected using the peptide array. The results were then validated using an enzyme-linked immunosorbent assay (ELISA). The diagnostic efficiency of each epitope was analyzed using a ROC curve. Seventy-three potential epitopes were screened for using the IEDB software after the epitopes on the 12 SLE-related autoantigens were analyzed. Peptide array screening revealed that the levels of the autoantibodies recognized and bound by 4 peptide antigens were significantly upregulated in the serum of SLE patients (P < 0.05). The ELISA results showed that the 4 antigens with significantly increased serum autoantibodies levels in SLE patients were acidic ribosomal phosphoprotein (P0)-4, acidic ribosomal phosphoprotein (P0)-11, DNA topoisomerase 1 (full length)-1, and U1-SnRNP 68/70 KDa-1 (P < 0.05), and the areas under the ROC curve for diagnosing SLE on the basis of these peptides were 0.91, 0.90, 0.93, and 0.91, respectively. Many autoantibodies specifically expressed in the serum of patients with SLE can be detected by specific peptide fragments and may be used as markers in clinical auxiliary diagnoses.
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Affiliation(s)
- Lin Wang
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Chenjun Hao
- Obstetrics and gynecology, Guangzhou Panyu Hexian Memorial Hospital, 511400 Guangzhou, China
| | - Yongqiu Deng
- Obstetrics and gynecology, Guangzhou Panyu Hexian Memorial Hospital, 511400 Guangzhou, China
| | - Yanbo Liu
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Shiliang Hu
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Yangang Peng
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Manna He
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Jinhu Fu
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Ming Liu
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Jia Chen
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
| | - Xiaoming Chen
- Department of Rheumatology, Shaoyang Central Hospital, 422000 Shaoyang, China
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Howell DN. Renal biopsy in patients with systemic lupus erythematosus: Not just lupus glomerulonephritis! Ultrastruct Pathol 2017; 41:135-146. [DOI: 10.1080/01913123.2017.1282068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- David N. Howell
- Department of Pathology, Duke University, Durham, NC, USA
- Durham Veterans Affairs Medical Centers, Durham, NC, USA
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ANTIMIELOPEROXIDASE POSITIVO EM PACIENTE COM DIAGNÓSTICO RECENTE DE LES. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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