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Gambichler T, Bui D, Domin B, Ardabili L, Devrim Y, Abu Rached N, Susok L. Comparison of clinical and laboratory data of adult patients with cutaneous IgA vasculitis and non-IgA vasculitis. Clin Exp Dermatol 2024; 49:859-865. [PMID: 38446988 DOI: 10.1093/ced/llae062] [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: 01/09/2024] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Immune complex vasculitides may be subdivided into adult IgA small vessel vasculitis (aIgA-SVV; i.e. adult Henoch-Schönlein purpura) and non-IgA-SVV (hypersensitivity vasculitis, etc.). OBJECTIVES To evaluate the clinical and laboratory parameters of inpatients fulfilling the diagnostic criteria for aIgA-SVV and non-IgA-SVV. METHODS Twenty-nine adults aged ≥ 20 years with aIgA-SVV [according to the European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Paediatric Rheumatology European Society (EULAR/PRINTO/PRES) criteria] and 53 adults with non-IgA-SVV (according to the 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides) were compared with respect to a variety of clinical and laboratory parameters by uni- and multivariable analyses. RESULTS Compared with patients with aIgA-SVV, the platelet-to-lymphocyte ratio was significantly higher in patients with non-IgA-SVV. Serum C3 levels and mean corpuscular haemoglobin concentration in patients with non-IgA-SVV were significantly lower compared with patients with aIgA-SVV. Proteinuria and haematuria were significantly more common in patients with aIgA SVV, and were significantly correlated with systemic immune-inflammation biomarkers only in patients with aIgA-SVV. In patients with aIgA-SVV, higher lactate dehydrogenase and C-reactive protein were strong independent predictors for the presence of proteinuria and proteinuria. In patients with non-IgA-SVV, female sex was a protective factor for proteinuria, while skin lesions on the upper extremities proved to be a significant independent predictor of haematuria. CONCLUSIONS We detected several clinical and laboratory differences between patients with aIgA-SVV and non-IgA-SVV. Distinct predictors for renal involvement were not observed in either group, indicating that aIgA-SVV and non-IgA-SVV are similar conditions but do not appear to represent the same entity.
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Affiliation(s)
- Thilo Gambichler
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
- Department of Dermatology, Christian Hospital Unna, Unna, Germany
- Department of Dermatology, Klinikum Dortmund GmbH, University Witten/Herdecke, Dortmund, Germany
| | - Duyên Bui
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Belanna Domin
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Larisa Ardabili
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Yusa Devrim
- Department of Dermatology, Klinikum Dortmund GmbH, University Witten/Herdecke, Dortmund, Germany
| | - Nessr Abu Rached
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Laura Susok
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
- Department of Dermatology, Klinikum Dortmund GmbH, University Witten/Herdecke, Dortmund, Germany
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Fathaddin AA. Evaluation of the histopathological spectrum of skin biopsies in patients with chronic kidney disease: A single-center experience. INDIAN J PATHOL MICR 2024; 67:318-323. [PMID: 38394406 DOI: 10.4103/ijpm.ijpm_162_23] [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: 02/27/2023] [Accepted: 09/04/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND AIM Patients with chronic kidney disease (CKD), particularly those with end-stage renal disease (ESRD), frequently experience skin problems. Here, we present and discuss the histopathology results of skin biopsies performed on renal patients at our facility. MATERIALS AND METHODS We retrospectively reviewed all histopathological reports and slides of skin biopsies taken from CKD patients for the last 5 years at the Pathology Department of King Saud University Medical City, King Saud University in Riyadh. DESIGN This is a retrospective cross-sectional study. RESULTS Patients were 19 (43.2%) males and 25 (56.8%) females, with a mean age of 53.4 19.8 years. Diabetic nephropathy, hypertensive nephropathy, and lupus nephritis were the three most common kidney pathologies (59.1%, 11.4%, and 11.4%, respectively). Seventeen patients (38.5%) were receiving hemodialysis. Acquired perforating collagenosis (APC), which was observed in 16 (36.4%) of our patients, was the most prevalent skin pathology, followed by bullous drug reactions in nine (20.5%), leukocytoclastic vasculitis (LCV) in eight (18.2%), calciphylaxis in six (13.6%), and prurigo nodularis in five (11.4%) patients. Erythematous plaques and papules were the most prevalent skin conditions at the time of presentation in 12 patients (27.3%), followed by pruritus in six (13.6%) and ulcerations in six (13.6%) patients. Collected data were analyzed using the Statistical Package for Social Sciences (SPSS) version 26.0. CONCLUSION A spectrum of skin conditions may be seen in CKD patients. The quality of life of CKD patients will be significantly improved by identifying and managing these conditions. Pathologists' familiarity with this spectrum is important, as a correct histopathologic diagnosis will lead to a better outcome.
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Affiliation(s)
- Amany A Fathaddin
- Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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3
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Ben Rejeb S, Beltaifa D, Ben Romdhane Y, Bellil K. Immunohistochemical analysis of myeloperoxidase expression in cutaneous leucocytoclastic vasculitis. J Immunoassay Immunochem 2024; 45:112-121. [PMID: 38258442 DOI: 10.1080/15321819.2024.2304836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Myeloperoxidase (MPO) is a pro-oxidant enzyme mainly found in the azurophilic granules of neutrophils. It not only displays a key role in the intracellular microbial killing process but also contributes to the extracellular clearance of several pathogens. This study aimed to detect MPO in cutaneous leukocytoclastic vasculitis (LCV) using immunohistochemistry. We retrospectively collected 22 confirmed cases of skin LCV diagnosed in our pathology department over 11 years (2012-2023). Immunohistochemistry was performed using anti-myeloperoxidase antibody (Leica clone 59A5) on the LeicaBond MAX automated system, following manufacturer's instructions. Two pathologists assessed immunohistochemical staining, scoring intensity as weak (+), moderate (++), or strong (+++). Patients' mean age was 56.9 years, with a male-to-female ratio of 1.18. Pathologically, vasculitis involved small blood vessels in all cases. Immunohistochemical analysis showed granular positive MPO staining in 59.1% of cases. Staining intensity was weak in 46.15%, moderate in 46.15%, and strong in 7.69%. Staining was patchy in 84.62% and diffuse in 15.38% of cases. MPO expression, detected in 59.1% of cutaneous LCV tissues, exhibited a patchy and peri-vascular distribution. It holds potential as a diagnostic marker for patients with early or minor histological changes.
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Affiliation(s)
- Sarra Ben Rejeb
- Pathology Department, Security Forces Hospital, Marsa, Tunisie
| | - Dorsaf Beltaifa
- Pathology Department, Security Forces Hospital, Marsa, Tunisie
| | | | - Khadija Bellil
- Pathology Department, Security Forces Hospital, Marsa, Tunisie
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Roble JG, Ligon SE, Langan KL. Leukocytoclastic Vasculitis Localized to the Uterine Cervix. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2024; 83:81-84. [PMID: 38456159 PMCID: PMC10915865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Patients with gynecologic vasculitis should be evaluated for systemic disease as prognosis and treatment can vary depending on systemic involvement versus isolated disease. Leukocytoclastic vasculitis is a rare, immune-mediated small-vessel vasculitis. Leukocytoclastic vasculitis of the uterine cervix with systemic involvement has not previously been reported. A 25-year-old female with abnormal cervical cancer screening presented for colposcopy. Biopsies were notable for dysplasia and concurrent leukocytoclastic vasculitis. The patient later recalled a recurrent rash of her lower extremities, suspicious for systemic disease. Patients with gynecologic vasculitis should be evaluated for systemic involvement because prognosis and treatment differ from that of isolated disease. Additionally, leukocytoclastic vasculitis of the uterine cervix may be associated with both hormonal contraception and infections such as human papillomavirus, and any resulting cervical dysplasia should be monitored for progression and treated accordingly.
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Affiliation(s)
- Jose G. Roble
- Department of Obstetrics and Gynecology, Tripler Army Medical Center, Honolulu, HI (JGR)
| | - Sarah E. Ligon
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (SEL, KLL)
| | - Kelly L. Langan
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (SEL, KLL)
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Feng H, Li S, Jie Y. Leucocytoclastic Vasculitis Presenting as Bilateral Ulcerative Keratitis: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231204358. [PMID: 37808226 PMCID: PMC10559690 DOI: 10.1177/11795476231204358] [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: 03/08/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023]
Abstract
Introduction Small artery disease caused by neutrophils and immune-mediated is known as leucocytoclastic vasculitis (LCV). Clinically, it manifests as palpable, asymptomatic purpuric papules on the limbs. Ocular manifestation is rare. Here, we describe a case of peripheral ulcerative keratitis (PUK) associated with LCV. Case presentation A 59-year-old man was referred to the hospital with blurred vision due to corneal perforation in his left eye. He complained of itchy nodules on his hands and lower legs for 15 years and the skin biopsy of the back of his hand revealed LCV 6 years ago, which suggested erythema elevatum diutinum. The patient was under treatment with anti-inflammatory and immunosuppressive drugs and physical features of LCV seen in him included erythema on his hands and legs. After receiving conjunctival flap covering surgery, the corneal perforation was resolved. Conjunctival flaps covered cornea that limited his vision to hand motion. Six months later, he was referred to our clinic again because of pain, redness, photophobia, and tearing in the right eye, presenting with PUK. Necrotic tissue was removed during surgery, which also included a conjunctival flap covering procedure. Following surgery, the symptoms were reduced, and the postoperative eye condition remained stable. Conclusion To our knowledge, it is the first case of PUK secondary to LCV which was diagnosed 6 years ago. This case demonstrates that PUK associated with LCV can be successfully treated by surgical interventions.
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Affiliation(s)
| | | | - Ying Jie
- Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing Tongren Eye Center, Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Lagacé F, D’Aguanno K, Prosty C, Laverde-Saad A, Cattelan L, Ouchene L, Oliel S, Genest G, Doiron P, Richer V, Jfri A, O’Brien E, Lefrançois P, Powell M, Moreau L, Litvinov IV, Muntyanu A, Netchiporouk E. The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications. J Cutan Med Surg 2023; 27:NP1-NP36. [PMID: 37401812 PMCID: PMC10486181 DOI: 10.1177/12034754231177582] [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: 01/05/2023] [Revised: 03/29/2023] [Accepted: 04/09/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress. OBJECTIVES AND PROJECT DESCRIPTION The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth. FUTURE IMPACT With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.
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Affiliation(s)
- François Lagacé
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | | | - Connor Prosty
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Alexandra Laverde-Saad
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Leila Cattelan
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Lydia Ouchene
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Sarah Oliel
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Genevieve Genest
- Division of Allergy and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Philip Doiron
- Division of Dermatology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Richer
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Abdulhadi Jfri
- Department of Dermatology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Elizabeth O’Brien
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Philippe Lefrançois
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Mathieu Powell
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Linda Moreau
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Ivan V. Litvinov
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Anastasiya Muntyanu
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Elena Netchiporouk
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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Guevara-Rodriguez N, Flores-Chang M, Chilakala A, Contreras J, Perdomo P, Liliya G. A rare adverse event of atorvastatin inducing leukocytoclastic vasculitis with ANCA-negative (Anti-Neutrophil cytoplasmic antibody) case report and literature review. Clin Case Rep 2023; 11:e7030. [PMID: 36873078 PMCID: PMC9981573 DOI: 10.1002/ccr3.7030] [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] [Received: 07/29/2022] [Revised: 01/19/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Leukocytoclastic vasculitis is an entity associated with drugs, infections, cryoglobulinemia, and connective tissue diseases but can also be idiopathic, systemic, or organ localized. Moreover, LCV associated with drugs is a rare disorder. When it is present usually has an elevation of anti-neutrophil cytoplasmic antibody, most likely anti-myeloperoxidase, which can be helpful to orient the diagnosis. We are presenting a 55-year-old female with a past medical history of diabetes mellitus (DM) and hyperlipidemia (HLD) who presented with a painful and pruritic rash localized in the abdomen and lower extremities that started 1 week after initiated atorvastatin for management of hyperlipidemia. This is the first case ever reported of leukocytoclastic vasculitis ANCA negative associated with atorvastatin, to our best knowledge.
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Affiliation(s)
| | - Mailing Flores-Chang
- Department of Medicine, Internal Medicine St. Barnabas Hospital Health System Bronx New York USA
| | - Akhila Chilakala
- CUNY School of Medicine, Medical school in New York City New York New York USA
| | - Jose Contreras
- Department of Medicine, Internal Medicine St. Barnabas Hospital Health System Bronx New York USA
| | - Paula Perdomo
- Department of Medicine, Internal Medicine St. Barnabas Hospital Health System Bronx New York USA
| | - Gandrabur Liliya
- Internal Medicine, Department of Rheumatology St. Barnabas Hospital Health System Bronx New York USA
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Ertekin SS, Koku Aksu AE, Leblebici C, Erdemir VA, Erdem O, Bal Avcı E, Gürel MS. Systemic disease in leukocytoclastic vasculitis: a focus on direct immunofluorescence findings. An Bras Dermatol 2023; 98:59-67. [PMID: 36369199 PMCID: PMC9837647 DOI: 10.1016/j.abd.2021.11.009] [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: 10/27/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Direct immunofluorescence (DIF) panels are usually ordered for clinically suspected cutaneous vasculitis, but their positivity rate is variable, and their prognostic significance is not clear to date. OBJECTIVE The study aims to investigate the systemic involvement rate in leukocytoclastic vasculitis (LCV) patients and the potential clinical and laboratory associations with systemic involvement, including DIF findings. METHODS A retrospective study of patients with histopathologically proven cutaneous LCV examined in the dermatology department between 2013 and 2017 was performed. RESULTS Of the 81 patients (mean age, 50.6 years), 42 (52%) were male. The mean time between the appearance of skin lesions and biopsy was 23.1 days, ranging from 2 to 180 days. DIF showed overall positivity of 90.1%, and C3 was the most frequent immunoreactant (82.7%). Any kind of extracutaneous involvement was present in 47 (58%) of patients, with renal involvement being the most frequent (53.1%), followed by articular (18.5%) and gastrointestinal (11.1%) involvement. The presence of renal disease was associated with the detection of IgG in the lesional skin (p = 0.017), and with the absence of IgM in the lesional skin (p = 0.032). There was a significant association between C3 deposition and joint involvement (p = 0.05). STUDY LIMITATIONS This is a single-center study with a retrospective design. CONCLUSION DIF seems to be a useful ancillary diagnostic tool in the evaluation of cutaneous vasculitis, but the relationship between DIF findings and systemic involvement needs to be further elucidated due to contradictory data in the current literature.
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Affiliation(s)
- Sümeyre Seda Ertekin
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey,Corresponding author.
| | - Ayşe Esra Koku Aksu
- Department of Dermatology, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Cem Leblebici
- Department of Pathology, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Vefa Aslı Erdemir
- Department of Dermatology, Göztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ozan Erdem
- Department of Dermatology, Başakşehir Çam and Sakura City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Elif Bal Avcı
- Department of Dermatology, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Salih Gürel
- Department of Dermatology, Göztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
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Kelly BG, Stratton DB, Mansour I, Tanriover B, Culpepper KS, Curiel-Lewandrowski C. Navigating the initial diagnosis and management of adult IgA vasculitis: A review. JAAD Int 2022; 8:71-78. [PMID: 35721303 PMCID: PMC9204729 DOI: 10.1016/j.jdin.2022.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Background IgA vasculitis in adults has not been thoroughly studied. This has left a practice gap related to the management and follow-up of a population that is at an increased risk of comorbidities and potentially poor outcomes. For this reason, it is important to synthesize evidence from the current literature because this can help direct the movement for more robust studies to clarify best practice recommendations. Objective We sought to create a narrative review for the practicing dermatologist when diagnosing and leading the care of IgA vasculitis in adult patients. Methods A broad literature search was performed with a focus on articles that were published after the introduction of the most updated European Alliance of Associations for Rheumatology/Pediatric Rheumatology International Trials Organization/Pediatric Rheumatology European Society criteria. Results The characteristics and management guidelines for IgA vasculitis in adults have been refined, although more rigorous studies are needed to develop best practice recommendations. Limitations Because of the lack of sufficient randomized controlled trials on IgA vasculitis in adults, this narrative review is composed of mostly observational, descriptive studies. Conclusion Adults with IgA vasculitis are at an increased risk of complicated disease course, necessitating formal diagnostic assessment and clear-cut follow-up recommendations to manage and prevent poor health outcomes related to various comorbidities.
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Affiliation(s)
- Brenna G. Kelly
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Iyad Mansour
- Division of Nephrology, University of Arizona, Tucson, Arizona
| | - Bekir Tanriover
- Division of Nephrology, University of Arizona, Tucson, Arizona
| | - Keliegh S. Culpepper
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Dermpath Diagnostics, Tucson, Arizona
| | - Clara Curiel-Lewandrowski
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Correspondence to: Clara Curiel-Lewandrowski, MD, Division of Dermatology, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724.
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Leukocytoclastic vasculitis presenting clinically as bullous pyoderma gangrenosum following leucovorin, fluorouracil and oxaliplatin chemotherapy: a rare case report and literature review. Anticancer Drugs 2022; 33:970-974. [PMID: 35946554 DOI: 10.1097/cad.0000000000001338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There are no published cases about bullous pyoderma gangrenosum induced by leucovorin, fluorouracil and oxaliplatin (FOLFOX) chemotherapy. With the increasing incidence of gastric and colorectal cancers and the increased usage of targeted therapies, some cutaneous adverse effects may become common. An 84-year-old male presented to our clinic with multiple ulcerative plaques covered with hemorrhagic crusts on both extremities after several FOLFOX chemotherapy sessions for gastric cancer and liver metastasis. Two weeks later, multiple bullae also appeared, especially on the acral areas. The histopathology examination was compatible with acute leukocytoclastic vasculitis. The FOLFOX chemotherapy regimen is increasingly administered considering the rising incidence of gastrointestinal cancers. Hence, our understanding of its possible side effects and complications must be heightened.
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Sakkab R, Fabrikant JM. Leukocytoclastic Vasculitis of the Foot and Ankle: A Case Report With Over Five-Year Follow-Up. Cureus 2022; 14:e25371. [PMID: 35765407 PMCID: PMC9233596 DOI: 10.7759/cureus.25371] [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] [Accepted: 05/25/2022] [Indexed: 11/12/2022] Open
Abstract
The estimated incidence of leukocytoclastic vasculitis of any etiology is between 15 and 30 people per million per year. Despite being a rare pathologic entity, leukocytoclastic vasculitis has many documented etiologies. Here, we report on a case of a 47-year-old man with liver cirrhosis who was admitted to our institution for diffuse palpable purpura of the distal lower extremities. Workup was largely negative for infectious and systemic causes. The patient received multiple days of intravenous antibiotics and consultations with infectious disease, dermatology, and podiatry. Skin biopsies confirmed a diagnosis of idiopathic leukocytoclastic vasculitis. A steroid taper was prescribed, and the patient had clinical resolution and healing of skin lesions. After 5.5 years after the vasculitic episode, the patient remained free of cutaneous lower extremity lesions. Medication-induced leukocytoclastic vasculitis and associations with systemic illness or malignancy were ruled out. In the lower extremities, misdiagnosis of cellulitis for noninfectious dermatologic conditions is common. Clinicians must have a wide differential and take a multidisciplinary approach to similar types of cases to reduce unnecessary antibiotic usage.
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Sarkar N, Palit A, Sethy M, Behera B, Dash S, Sahu DP. A Cross-Sectional Study to Correlate Serum Complement C3 and C4 Levels With Clinical and Pathological Severity in Cutaneous Small-Vessel Vasculitis. Cureus 2022; 14:e24845. [PMID: 35693365 PMCID: PMC9175591 DOI: 10.7759/cureus.24845] [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] [Accepted: 05/08/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction The role of serum C3 and C4 levels as a marker of disease activity in cutaneous small-vessel vasculitis (CSVV) has been sparsely studied, especially in India. The primary objective was to determine the correlation between clinico-histopathological severity and serum C3 and C4 levels in CSVV. The secondary objective was to determine the association between direct immunofluorescence (DIF) findings and serum C3 and C4 levels and clinico-histopathological findings. Method This prospective cross-sectional study included all the clinically diagnosed cases of CSVV that satisfied the pathological criteria for CSVV. A clinical disease activity grade and a histopathological severity grade were calculated in all patients (N=50). Results Serum C3 and C4 levels (n=44) were diminished in 4.5% of cases. There was no significant correlation between the serum C3 and C4 levels and the clinical and histopathological severity. DIF was positive in 60.0% of cases (n=45), and IgA was the predominant immune deposit (46.7%). No significant association was detected between the DIF findings and the serum C3 and C4 levels, histopathological severity, and clinical disease activity grade. Positive DIF findings were significantly associated with palpable purpura and cutaneous necrosis. A significant association was detected between gastrointestinal involvement and IgA positivity. Conclusion In CSVV, serum C3 and C4 may not be used as markers of disease severity, and a positive DIF finding may indicate an underlying gastrointestinal involvement.
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14
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Qaseem Y, Cassidy F, Aganovic L, Purysko A, Mirza S, Vahdat N. Renovascular involvement of systemic vascular disease: a pictorial review. Abdom Radiol (NY) 2022; 47:3531-3545. [PMID: 35796773 PMCID: PMC9261205 DOI: 10.1007/s00261-022-03591-5] [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: 02/10/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 01/18/2023]
Abstract
Like many solid organs, the kidneys are susceptible to a wide variety of systemic vascular diseases. Comprising a significant subset of these diseases are the vasculitides, broadly encompassing numerous inflammatory conditions of the blood vessels. However, many of these conditions are non-vasculitic and non-inflammatory, and differentiation of these entities is crucial to guide the initiation of proper therapy. These non-vasculitic diseases include coagulopathic conditions leading to vascular complications, hemolysis, and hematogenous processes that can affect multiple organ systems. These systemic diseases can result in both macrovascular and microvascular pathology, involving the arteries, veins, and smaller vessels, and management of these conditions can differ significantly depending upon the underlying pathophysiology. Because the clinical manifestations of these disease processes can be heterogeneous, ranging from renal dysfunction to life-threatening hemorrhage, proper recognition of these entities is essential to help guide clinicians to the correct diagnosis and prevent potentially disastrous complications. Many of these systemic vascular processes can be detected by non-invasive imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), and identification of their characteristic renal manifestations by radiologists is a critical component of patient care. This review covers a variety of these diseases and their imaging manifestations, to aid in their recognition and better equip radiologists to provide vital diagnostic information that can optimize patient care.
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Affiliation(s)
- Yousuf Qaseem
- grid.266100.30000 0001 2107 4242Department of Radiology, University of California San Diego Health, San Diego, CA USA
| | - Fiona Cassidy
- grid.266100.30000 0001 2107 4242Department of Radiology, University of California San Diego Health, San Diego, CA USA ,Department of Radiology, Veteran Administration Healthcare System, San Diego, CA USA
| | - Lejla Aganovic
- grid.266100.30000 0001 2107 4242Department of Radiology, University of California San Diego Health, San Diego, CA USA ,Department of Radiology, Veteran Administration Healthcare System, San Diego, CA USA
| | - Andrei Purysko
- grid.239578.20000 0001 0675 4725Department of Radiology, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Sara Mirza
- grid.266100.30000 0001 2107 4242Department of Radiology, University of California San Diego Health, San Diego, CA USA
| | - Noushin Vahdat
- grid.266100.30000 0001 2107 4242Department of Radiology, University of California San Diego Health, San Diego, CA USA ,Department of Radiology, Veteran Administration Healthcare System, San Diego, CA USA
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15
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Ireifej B, Weingarten M, Dhamrah U, Weingarten M, Hadi S. Leukocytoclastic Vasculitic Rash Following Second Dose of Moderna COVID-19 Vaccine. J Investig Med High Impact Case Rep 2022; 10:23247096211066283. [PMID: 35293793 PMCID: PMC8943294 DOI: 10.1177/23247096211066283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The immunization against coronavirus disease (COVID-19) via vaccination serves as a significant milestone in the fight against the pandemic. Rapid introduction of various COVID-19 vaccines to stem the spread of virus has researchers scrambling to document the adverse effects left in its wake. Thus far, there have been singular examples of cutaneous vasculitis associated with COVID-19. A history of vasculitis leaves little error to miss its inclusion in diagnostic differentials. It also invokes the physiologic possibility that afflicted patients possess a more susceptible landscape for recurrence that was then triggered by the vaccine when compared with those who lack similar history. In our case report, we build on those findings with one of the first documented examples of vaccination-induced vasculitic rash in a previously asymptomatic patient.
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Affiliation(s)
- Branden Ireifej
- Icahn School of Medicine at Mount Sinai-Elmhurst Hospital Center, New York, NY, USA
| | - Mark Weingarten
- Icahn School of Medicine at Mount Sinai-Elmhurst Hospital Center, New York, NY, USA
| | - Umaima Dhamrah
- Icahn School of Medicine at Mount Sinai-Elmhurst Hospital Center, New York, NY, USA
| | | | - Suhail Hadi
- Icahn School of Medicine at Mount Sinai-Elmhurst Hospital Center, New York, NY, USA
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16
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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Garcia RA, Gaznabi S, Musoke L, Osnard M, Balakumaran K, Armitage KB, Al-Kindi SG, Ginwalla M, Abu-Omar Y, Elamm CA. LVAD Vasculitis Case Series: Suggestion of a New Fatal LVAD-Related Phenomenon. JACC Case Rep 2021; 3:1013-1017. [PMID: 34317675 PMCID: PMC8311371 DOI: 10.1016/j.jaccas.2021.03.030] [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: 12/24/2020] [Revised: 03/10/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
Left ventricular assist devices (LVADs) are surgically implanted mechanical devices indicated for patients with advanced heart failure and are known to come with several complications. Here we present a case series, and review 1 documented report, of LVAD vasculitis, a presumed new LVAD immune/humoral related phenomenon. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Raul Angel Garcia
- Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
- Address for correspondence: Dr Raul Angel Garcia, Saint Luke’s Mid America Heart Institute, 4401 Wornall Road, CV Research 9th Floor, Kansas City, Missouri 64111, USA.
| | - Safwan Gaznabi
- Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lewis Musoke
- Department of Infectious Disease, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael Osnard
- Department of Internal Medicine, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kathir Balakumaran
- Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Keith B. Armitage
- Department of Infectious Disease, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sadeer G. Al-Kindi
- Department of Cardiovascular Medicine, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mahazarin Ginwalla
- Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Yasir Abu-Omar
- Department of Cardiothoracic Surgery, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chantal A. Elamm
- Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
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Fraticelli P, Benfaremo D, Gabrielli A. Diagnosis and management of leukocytoclastic vasculitis. Intern Emerg Med 2021; 16:831-841. [PMID: 33713282 PMCID: PMC8195763 DOI: 10.1007/s11739-021-02688-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
Leukocytoclastic vasculitis (LCV) is a histopathologic description of a common form of small vessel vasculitis (SVV), that can be found in various types of vasculitis affecting the skin and internal organs. The leading clinical presentation of LCV is palpable purpura and the diagnosis relies on histopathological examination, in which the inflammatory infiltrate is composed of neutrophils with fibrinoid necrosis and disintegration of nuclei into fragments ("leukocytoclasia"). Several medications can cause LCV, as well as infections, or malignancy. Among systemic diseases, the most frequently associated with LCV are ANCA-associated vasculitides, connective tissue diseases, cryoglobulinemic vasculitis, IgA vasculitis (formerly known as Henoch-Schonlein purpura) and hypocomplementemic urticarial vasculitis (HUV). When LCV is suspected, an extensive workout is usually necessary to determine whether the process is skin-limited, or expression of a systemic vasculitis or disease. A comprehensive history and detailed physical examination must be performed; platelet count, renal function and urinalysis, serological tests for hepatitis B and C viruses, autoantibodies (anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies), complement fractions and IgA staining in biopsy specimens are part of the usual workout of LCV. The treatment is mainly focused on symptom management, based on rest (avoiding standing or walking), low dose corticosteroids, colchicine or different unproven therapies, if skin-limited. When a medication is the cause, the prognosis is favorable and the discontinuation of the culprit drug is usually resolutive. Conversely, when a systemic vasculitis is the cause of LCV, higher doses of corticosteroids or immunosuppressive agents are required, according to the severity of organ involvement and the underlying associated disease.
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Affiliation(s)
- Paolo Fraticelli
- Dipartimento Di Scienze Cliniche E Molecolari, Clinica Medica, Università Politecnica Delle Marche, Via Tronto 10/A, 60127, Ancona, Italy.
| | - Devis Benfaremo
- Dipartimento Di Scienze Cliniche E Molecolari, Clinica Medica, Università Politecnica Delle Marche, Via Tronto 10/A, 60127, Ancona, Italy
| | - Armando Gabrielli
- Dipartimento Di Scienze Cliniche E Molecolari, Clinica Medica, Università Politecnica Delle Marche, Via Tronto 10/A, 60127, Ancona, Italy
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19
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Life-threatening manifestation of cutaneous leukocytoclastic vasculitis. Postepy Dermatol Alergol 2021; 38:335-337. [PMID: 34408600 PMCID: PMC8362755 DOI: 10.5114/ada.2021.106214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/16/2019] [Indexed: 01/31/2023] Open
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20
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Akhavanrezayat A, Hien DL, Pham BH, Nguyen HV, Tuong Ngoc TT, Al-Moujahed A, Uludag G, Karkhur S, Doan HL, Nguyen QD. Impending central retinal vein occlusion in patient with idiopathic cutaneous leukocytoclastic vasculitis. Am J Ophthalmol Case Rep 2020; 20:100934. [PMID: 33015410 PMCID: PMC7522751 DOI: 10.1016/j.ajoc.2020.100934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/16/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose To report a case of impending central retinal vein occlusion (CRVO) associated with idiopathic cutaneous leukocytoclastic vasculitis (LCV) that demonstrated significant resolution following treatment with intravenous (IV) methylprednisolone. Observations A 27-year-old man presented to a tertiary Uveitis Clinic with a five-day history of blurry vision in the right eye (OD). He had a history of a purpuric rash and arthralgias five years ago and a biopsy-confirmed diagnosis of LCV controlled with colchicine two years ago in India. Recently, he presented with a recurrent rash and severe abdominal pain. After being evaluated by rheumatology and gastroenterology, he was placed on Helicobacter pylori treatment and high dose oral prednisone, which improved his skin and gastrointestinal symptoms. At the first ophthalmic exam, his systemic findings included lower extremity purpura. His best-corrected visual acuity (BCVA) was 20/20 in both eyes (OU). Slit-lamp examination revealed no cells or flare in OU. Dilated fundus exam showed mild enlarged, tortuous veins, optic nerve hemorrhage, and intraretinal hemorrhages temporal to the macula in OD. Spectral-domain optical coherence tomography (SD-OCT) demonstrated multiple hyper-reflective, plaque-like lesions involving the inner nuclear layer, consistent with paracentral acute middle maculopathy (PAMM). The patient was diagnosed with impending central retinal vein occlusion (CRVO) in OD. Laboratory evaluations were unremarkable. Aspirin was initially started for the patient but was later held due to the worsening of retinal hemorrhage and retinal vein tortuosity at the one-week follow-up. The patient then received three doses of intravenous methylprednisolone, followed by systemic oral prednisone and mycophenolate mofetil. One month later, retinal hemorrhages, venous stasis, and skin manifestations resolved. Conclusion and importance Ocular involvement in LCV is rare and may present with different manifestations. The index case is the first report of impending CRVO in a patient with idiopathic LCV and without any other known risk factors for CRVO. Our report not only describes the unique course of LCV-related ocular involvement, but also introduces and underscores a potentially effective therapeutic plan.
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Affiliation(s)
| | - Doan Luong Hien
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Pham Ngoc Thach University of Medicine, Saigon, Viet Nam
| | - Brandon H Pham
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Huy Vu Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Than Trong Tuong Ngoc
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Pham Ngoc Thach University of Medicine, Saigon, Viet Nam
| | | | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Samendra Karkhur
- Department of Ophthalmology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Huy Luong Doan
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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21
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Micheletti RG, Pagnoux C. Management of cutaneous vasculitis. Presse Med 2020; 49:104033. [PMID: 32645416 DOI: 10.1016/j.lpm.2020.104033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Cutaneous vasculitis encompasses cutaneous components of systemic vasculitides, skin-limited variants of systemic vasculitides, such as IgA vasculitis or cutaneous polyarteritis nodosa, and single-organ cutaneous vasculitis, as individualized in 2012 in the Chapel Hill Consensus Conference Nomenclature. In this article, we focus on the management of skin-limited and single-organ vasculitides, often referred to, in clinical practice, as isolated "cutaneous leukocyctoclastic vasculitis", terms which may correspond to histological findings or descriptions, but are imprecise and not specific. Since most cases of isolated cutaneous vasculitis are self-limited and resolve spontaneously over 3 to 4 weeks, most patients require no systemic treatment. For those with severe, intractable, or chronic and recurring vasculitis, systemic therapy can be indicated and should be tailored to the severity of the disease. High-quality literature is lacking to guide management. Oral glucocorticoids may be required for a short period of time for painful, ulcerative, or otherwise severe disease in order to speed resolution. Among drugs which are reasonable longer-term options are colchicine, dapsone, azathioprine or hydroxychloroquine. Additional studies, including an ongoing multicenter randomized trial, are needed to determine the most effective therapies for skin-limited vasculitis.
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Affiliation(s)
- Robert G Micheletti
- Departments of Dermatology and Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 7 South, Room 724, Philadelphia, PA 19104, United States
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Ste 2-220, Toronto, Ontario, M5T 3L9, Canada.
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22
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Guzman AK, Balagula Y. Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment. Clin Dermatol 2020; 38:613-628. [PMID: 33341196 DOI: 10.1016/j.clindermatol.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.
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Affiliation(s)
- Anthony K Guzman
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Yevgeniy Balagula
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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23
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Gehlhausen JR, Wetter DA, Nelson C, Ramachandran S, McNiff JM, Ko CJ. A detailed analysis of the distribution, morphology, and histopathology of complex purpura in hospitalized patients: A case series of 68 patients. J Am Acad Dermatol 2020; 84:1188-1196. [PMID: 32376433 DOI: 10.1016/j.jaad.2020.04.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Purpura in inpatients commonly leads to dermatologic consultation. The differential diagnosis is broad and algorithms are intricate. OBJECTIVE We evaluated inpatient consultations for complex purpura to document the most common diagnoses and to validate the true diagnostic utility of histopathology, clinical morphology, and distribution. METHODS We reviewed a case series of 68 inpatients during a 4-year period with a dermatologic consultation for purpura and biopsy findings of vasculitis or microvascular occlusion. RESULTS Key features of complex purpura are nonbranching (round) versus branching (retiform) morphology, dependent versus acral or generalized distribution, and leukocytoclastic vasculitis versus microvascular occlusion (with emphasis on depth of involvement). Dependent nonbranching purpura with only superficial vessels involved by leukocytoclastic vasculitis was most often due to IgA vasculitis or cutaneous single-organ small-vessel vasculitis. In contrast, deeper involvement by leukocytoclastic vasculitis was suggestive of systemic disease (eg, antineutrophil cytoplasmic antibody-associated vasculitis). Branching purpura was concerning, with greater than 90% sensitivity and specificity for microvascular occlusion and associated high mortality (≈50%). The majority of patients who died had acral branching lesions. LIMITATIONS Small sample size, inpatients at a tertiary care center, and retrospective nature are some limitations. CONCLUSION Nonbranching dependent purpura corresponded to leukocytoclastic vasculitis, with the most common diagnoses being IgA vasculitis or skin-limited small-vessel vasculitis; patients with deep involvement often had systemic diseases. In this series, branching purpura was due to microvascular occlusion rather than medium-vessel vasculitis, and had associated high mortality.
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Affiliation(s)
- Jeff R Gehlhausen
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | - David A Wetter
- Mayo Clinic Department of Dermatology, Rochester, Minnesota
| | - Caroline Nelson
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | | | - Jennifer M McNiff
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut
| | - Christine J Ko
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut.
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24
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Abstract
PURPOSE OF REVIEW Cutaneous vasculitis reflects a spectrum ranging from skin limited to severe systemic forms. To date, there is still no generally acknowledged nomenclature for cutaneous vasculitis. This review aims to summarize the recent advances in the nomenclature of cutaneous vasculitis. RECENT FINDINGS The most widely adopted vasculitis classification system is the one of 2012 Revised Chapel Hill Consensus Conference (CHCC) which represent not such a classification but a nomenclature system that name vasculitis on the basis of the size of the vessel affected. The CHCC 2012 did not deal with the special features of cutaneous vasculitis and did not explicitly discuss the presence of skin-limited or skin-dominant forms of vasculitis. Therefore, a consensus group was formed to propose an Addendum to CHCC 2012, focusing on cutaneous vasculitis. The Addendum better clarify the main aspects of some single-organ vasculitis, including IgM/IgG vasculitis, nodular vasculitis, erythema elevatum et diutinum and recurrent macular vasculitis in hypergammaglobulinemia. Moreover, it differentiated normocomplementemic from hypocomplementemic urticarial vasculitis. Finally, it recognized cutaneous polyarteritis nodosa as a distinct subtype of polyarteritis nodosa. SUMMARY Classification criteria are useful tools to standardize names and definitions for cutaneous vasculitis; however, they do not represent diagnostic criteria. Collaborative efforts are still needed to get a shared classification and valid diagnostic criteria for cutaneous vasculitis.
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25
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Demographic, etiological and clinical characteristics of patients with leukocytoclastic vasculitis single center experience. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.572537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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26
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Golovach IY, Yehudina YD. [Peripheral nervous system lesion in systemic vasculitis - issues of diagnosis and treatment]. TERAPEVT ARKH 2019; 91:63-69. [PMID: 32598591 DOI: 10.26442/00403660.2019.12.000206] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Vasculitis is a clinically diverse group of diseases with histopathological signs of blood vessel inflammation, which contributes to vascular damage and ischemic damage to the affected tissues. Vasculitic neuropathy is a common complication of the primary systemic vasculitides, such as polyartertis nodosa and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, systemic diseases of the connective tissue - systemic lupus erythematosus and Sjogren syndrome, vasculitis associated with infection, most often viral hepatitis C and B and non - systemic vasculitis neuropathy. Vessels of medium and small caliber are involved in the pathological process in these diseases. With all vasculitis, except for those caused by the direct effect of the infectious trigger on the blood vessel walls, the main pathogenetic mechanism is an autoimmune process with the development of vasa nervorum vasculitis - small arteries and vessels that supply peripheral nerves, and the outcome - nerve ischemia. The classic clinical presentation is an acute or subacute painful multifocal neuropathy that has a predilection for the lower extremities, affects two or more named nerves, and progresses in a step wise manner. However, vasculitic neuropathy can manifest in a variety of ways, including asymmetric polyneuropathies and distal symmetric sensory neuropathies, and it also can be slowly progressive, particularly in cases of nonsystemic vasculitic neuropathy (NSVN), a form of vasculitis that clinically remains restricted to peripheral nerves. Nerve biopsy can help establish the diagnosis of a systemic vasculitis, particularly when other organ involvement is not clinically apparent, and is required for diagnosis of NSVN. Neuropathy due to systemic vasculitis should be treated in accordance with the recommendations for the treatment of the underlying disease. In NSVH, the main medicine of choice are glucocrticoids, and in severe/progressive cases, pulse therapy with cyclophosphamide.
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Affiliation(s)
- I Y Golovach
- Feofaniya Clinical hospital State Management of Affairs
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27
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Wollina U, Krönert C, Koch A, Schönlebe J, Vojvodic A, Lotti T. Erythema Elevatum Diutinum - Two Case Reports, Two Different Clinical Presentations, and a Short Literature Review. Open Access Maced J Med Sci 2019; 7:3039-3042. [PMID: 31850118 PMCID: PMC6910801 DOI: 10.3889/oamjms.2019.765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Erythema elevatum diutinum (EED) belongs to the spectrum of cutaneous leukocytoclastic vasculitides. EED is a very rare dermatosis presenting with reddish to browning papules and plaques. EED may be associated with infections, hematologic and autoimmune disorders. CASE REPORTS: We present two patients with EED, a 50-year-old woman and a 42-year-old man. While the woman shows an association with colitis ulcerosa, the man had an anti-thrombin deficiency. Treatment was started with oral corticosteroid and dapsone, respectively. In both cases, there was a partial and temporary response. CONCLUSIONS: EED is a rare vasculitis with an unusual clinical presentation and a chronic course. Response to treatment is unsatisfactory and in the long-term run sometimes frustrating.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - Claudia Krönert
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - André Koch
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - Jacqueline Schönlebe
- Institute of Pathology "Georg Schmorl", Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | | | - Torello Lotti
- Department of Dermatology, University of Rome "G. Marconi", Rome, Italy
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Pedro F, Abuowda Y, Craveiro N, Oliveira AA, Mestre A, Santos C. Vasculitis of small and large vessels, a casual association? ACTA ACUST UNITED AC 2018; 64:590-594. [PMID: 30365660 DOI: 10.1590/1806-9282.64.07.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/05/2017] [Indexed: 11/22/2022]
Abstract
The authors report a case of a 69-year-old man with idiopathic leukocytoclastic cutaneous vasculitis. For three years, the lesions recurred with progressive worsening and were associated with systemic manifestations of low-grade fever, weight loss and raised inflammatory markers. The patient latter presented a 6th cranial nerve involvement, raising the concern of a possible systemic vasculitis, which was latter evidenced by the development of deep vein thrombosis and angina pectoris. The treatment of the patient witch based on the decreasing of inflammatory activity, by using effective immunosuppressive therapy, with lower toxicity is more important than identifying the type of the vasculitis. This case illustrates the importance of awareness for the systemic involvement that can occur in up to 50% of patients with leukocytoclastic cutaneous vasculitis.
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Affiliation(s)
- Filipa Pedro
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
| | - Yahia Abuowda
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
| | - Nuno Craveiro
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
| | - Ana Alves Oliveira
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
| | - Ana Mestre
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
| | - Cristina Santos
- Internal Medicine Department - III, District Hospital of Santarem, Portugal
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Pastuszczak M, Celińska-Löwenhoff M, Sułowicz J, Wojas-Pelc A, Musiał J. Clinical study on single-organ cutaneous small vessels vasculitis (SoCSVV). Medicine (Baltimore) 2017; 96:e6376. [PMID: 28328827 PMCID: PMC5371464 DOI: 10.1097/md.0000000000006376] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Leukocytoclastic vasculitis (LCV) is a heterogenous group of disorders that may manifest as a mild disease isolated to the skin or be a part of life-threatening systemic vasculitis. According to the 2012 Chapel Hill Consensus Conference nomenclature, patients presenting symptoms of LCV confined only to the skin should be defined as suffering from a single-organ cutaneous small vessel vasculitis (SoCSVV). SoCSVV is a benign disease with a good clinical outcome but with a significant risk of relapse and skin ulcer formation.The aim of the current study was to characterize SoCSVV and to identify factors that may be associated with the risk of recurrence and skin ulcers.Medical records of patients with LCV hospitalized at the Department of Dermatology at University Hospital in Cracow in the years 2010 to 2015 were analyzed.A total of 24 patients fulfilled criteria of SoCSVV. Drugs and preceding infections were identified as precipitating factors in 40% and 20% of cases, respectively. Skin lesions other than palpable purpura (i.e., macules, urticarial vasculitis, or ulcers) were identified in almost half of the patients. Interestingly, the presence of macules independently increased the risk of skin ulcer formation (odds ratio = 16; 95% confidence interval: 1.5-176.6; P = 0.0075) in the multivariate logistic regression analysis. One-quarter of patients with SoCSVV experienced relapse during the 6-month follow-up. The greater number of affected skin areas was an independent risk factor of recurrence (odds ratio = 5; 95% confidence interval: 2-45; P = 0.02).SoCSVV was usually associated with drugs and preceding infections. The disease relapses in approximately one-quarter of the patients. The more severe the skin involvement in the course of SoCSVV, the higher is the risk of recurrence.
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Affiliation(s)
| | | | | | | | - Jacek Musiał
- 2nd Department of Medicine, Jagiellonian University Medical College, Cracow, Poland
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