Infection-associated vasculitides

New-onset systemic vasculitis following SARS-CoV-2 infection and vaccination: the trigger, phenotype, and outcome

The global health crisis caused by the COVID-19 pandemic overwhelmed the capacity of healthcare systems to cope with the rapidly spreading infection and its associated complications. Among these complications, autoimmune phenomena such as systemic vasculitis emerged as a significant challenge. Both the SARS-CoV-2 virus and the vaccines developed to combat it appeared to induce clinical manifestations resembling various types of systemic vasculitis, affecting large, medium, and small vessels. These virus- or vaccine-induced vasculitides exhibited a distinct natural history and course from de novo vasculitis, as they were more responsive to steroid therapy and some mild cases even resolved spontaneously. Notably, there have been no confirmed cases of SARS-CoV-2 infection or vaccination triggering variable vessel vasculitis like Behcet's disease or Kawasaki disease. IgA vasculitis, which is predominantly a pediatric condition, was more prevalent in adults after COVID-19 infection and they had a favorable outcome with glucocorticoid treatment. The impact of immunosuppression, especially B-cell-depleting agents, on the immunogenicity of the vaccine was evident, but there was no significant increase in the incidence of SARS-CoV-2 infection in these patients compared to the general population. Considering their relatively benign course, these post-COVID or post-vaccine vasculitides seem to be amenable to 0.8 to 1 mg/kg prednisolone or equivalent, which could be gradually tapered. The need for immunosuppression and the duration of steroid therapy should be determined on an individual basis. While the world still reels from the perils of a deadly pandemic, the aftermath continues to haunt. Our narrative review aims to explore the effects of COVID and the vaccine on systemic vasculitis, as well as the effect of disease and immunosuppression on the immunogenicity of the COVID vaccine.

Spectrum of Large- and Medium-Vessel Vasculitis in Adults: Neoplastic, Infectious, Drug-Induced, Autoinflammatory, and Primary Immunodeficiency Diseases

Purpose of Review

To provide a comprehensive review of drugs and neoplastic, infectious, autoinflammatory, and immunodeficiency diseases causing medium- to large-vessel vasculitis in adults with emphasis on information essential for the initial diagnostic process.

Recent Findings

Entities with medium- to large-vessel vasculitis as clinical manifestations have been described recently (e.g., adenosine deaminase-2 deficiency, VEXAS-Syndrome), and vasculitis in established autoinflammatory or immunodeficiency diseases is increasingly being identified.

Summary

In the diagnostic process of medium- to large-vessel vasculitis in adults, a large variety of rare diseases should be included in the differential diagnosis, especially if diagnosis is made without histologic confirmation and in younger patients. Although these disorders should be considered, they will undoubtedly remain rare in daily practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11926-022-01083-5.

Vasculitis flare after COVID-19: report of two cases in patients with preexistent controlled IgA vasculitis and review of the literature

COVID-19 has been related to several autoimmune diseases, triggering the appearance of autoantibodies and endothelial dysfunction. Current evidence has drawn attention to vasculitis-like phenomena and leukocytoclastic vasculitis in some COVID-19 patients. Moreover, it has been hypothesized that COVID-19 could induce flares of preexisting autoimmune disorders. Here, we present two patients with previously controlled IgA vasculitis who developed a renal and cutaneous flare of vasculitis after mild COVID-19, one of them with new-onset ANCA vasculitis. These patients were treated with glucocorticoids and immunosuppressants achieving successful response. We also provide a focused literature review and conclude that COVID-19 may be associated with triggering of vasculitis and could induce flares of previous autoimmune diseases.

Vasculitis Secondary to Pulmonary Bacterial Infection: A Case Report

Vasculitides are a heterogeneous group of primary disorders which may occur secondary to a variety of conditions. Among them, vasculitis caused by bacterial infection is rare. Here, we present images of CT scans and histology from a 22-year-old young Chinese man with vasculitis secondary to bacterial infection, which is a difficult disease to diagnose. This patient had been diagnosed with antineutrophil-cytoplasmic-antibody-negative vasculitis with pulmonary and renal involvement and was treated with glucocorticoids combined with immunosuppressive agents. However, during his follow up we found that multiple patchy shadows and cavities in both lungs and renal lesions had fluctuated, and the improvement of chest imaging was always related to antibiotic treatment. In addition, renal histology showed capillary loop necrosis and extensive crescent formation, and electron microscopy revealed scattered subepithelial hump-like deposits, which favored the diagnosis of infection over idiopathic vasculitis. Therefore, vasculitis secondary to infection was confirmed. The subsequent therapy response supported our diagnosis. This case is important; since vasculitis secondary to infection is uncommon, our case provides a model for the diagnosis of vasculitis secondary to infection.

Immunoglobulin A vasculitis induced by atypical pneumonia infection with Chlamydophila pneumonia

Infections are a common trigger for IgA vasculitis. Among the bacteria that cause atypical pneumonia, Mycoplasma pneumoniae infection has strongly been associated with IgA vasculitis, with Chlamydophila pneumoniae reported with IgA vasculitis in only one case. Though IgA vasculitis is a self-limiting disease, patients with infection-related vasculitis have shown to benefit from early identification and treatment with antimicrobial therapy. Here, we report a case of IgA vasculitis due to C. pneumoniae infection in a 19-year-old male who presented with an acute onset of rash, that was later followed by symptoms of cough and fever.

Pathogens in Vasculitis: Is It Really Idiopathic?

Vasculitis is an autoimmune disease characterized by the infiltration of leukocytes in blood vessels. An increasing number of studies on human and animal models have implicated various microorganisms in the pathogenesis of vasculitis. Previous studies have shown the presence of infectious agents, including viruses, bacteria, and fungi, in diseased vessels. However, despite continued research, the link between infection and vasculitis is not fully understood, possibly owing to the lack of appropriate animal models that mirror human disease and the technical limitations of pathogen detection in blood vessels. Among the pathogen-induced animal models, Candida albicans water-soluble fraction (CAWS)-induced coronary arteritis is currently considered one of the representative models of Kawasaki (KD) disease. Advances in metagenomic next-generation sequencing have enabled the detection of all nucleic acids in tissue, which can help identify candidate pathogens, including previously unidentified viruses. In this review, we discuss the findings from reports on pathogen-associated vasculitis in animal models and humans, with a specific focus on the investigation of the pathogenesis of vasculitis. Further studies on animal models and microbes in diseased vessels may provide important insights into the pathogenesis of vasculitis, which is often considered an idiopathic disease.

Aortitis - An Interdisciplinary Challenge

The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.

Pulmonary manifestations of systemic vasculitis in childhood

The systemic vasculitides are a heterogenous group of rare conditions with an incompletely understood aetiology. Any of the systemic vasculitides may cause respiratory disease, but some conditions are more likely to affect the pulmonary system, often through pulmonary infarction and diffuse alveolar haemorrhage. These conditions are often difficult to diagnose due to their rarity and significant clinical overlap with common respiratory conditions. Prompt diagnosis and management can significantly reduce morbidity and mortality.

The systemic vasculitides are often difficult to diagnose due to their rarity and significant clinical overlap with common respiratory conditions. Prompt diagnosis and management can reduce associated morbidity and mortality.https://bit.ly/36M5tTB

Bacterial-Infection-Associated Polyarteritis Nodosa Presenting as Acute, Rapidly Progressive Multiple Hepatic Artery Aneurysms

A 26-year-old male soldier was clinically characterized by transient fever, persistent right upper quadrant pain, hypertension, and elevated inflammatory biomarkers associated with bacterial infection. On the fifteenth day after the onset of symptoms, he had typical CT findings in polyarteritis nodosa involving only the hepatic arteries. Transcatheter arterial coil embolization of the right hepatic artery was performed due to ruptured hepatic aneurysms. Combination therapy with antibiotics and antihypertensives was administrated after embolization. The intrahepatic aneurysms completely vanished and inflammatory biomarkers returned to normal on the tenth day after embolization. The current case highlights the diagnosis and treatment of bacterial-infection-associated polyarteritis nodosa involving only the hepatic arteries, coexisting with hypertension.

An interesting case of small vessel pathology following coronavirus infection

Vasculitis is a descriptive term for a wide variety of conditions characterised by inflammation of the blood vessels that may occur as a primary process or secondary to an underlying disease. Occlusive vasculopathy is a different clinical entity characterised by skin changes and ulceration of the lower extremities because of thrombosis of the small vessels of the dermis and is usually associated with pre-thrombotic conditions. Both conditions can be confirmed or excluded by skin biopsy. We report the case of a 63-year-old woman presenting with upper and lower respiratory tract symptoms followed by a vasculitic rash on both legs. The patient underwent extensive radiological and laboratory investigations that were negative apart from positive coronavirus OC43. A biopsy of the skin was performed. Considering the clinical presentation and the investigations performed, the diagnosis of small vessel vasculopathy following coronavirus OC43 has been suggested by the authors.

Anti-Rheumatic Drugs for the Fight Against the Novel Coronavirus Infection (SARSCoV-2): What is the Evidence?

SARS-CoV-2 is a positive-sense single-stranded RNA virus that causes the COVID-19 infection. Spike proteins are the most important proteins found on its capsule using the host's ACE2 receptors to invade respiratory cells. The natural course of the COVID-19 infection is variable, from asymptomatic to severe and potentially fatal. A small percentage of the severely infected patients will end up in an intensive care unit for ventilatory support. Elderly male patients with pre-existing medical conditions and smokers are at a disproportionate high risk to develop severe complications. Studies have shown that deaths occur due to a dysregulated immune system that overreacts, producing a plethora of cytokines, leading to the so-called "cytokine storm" phenomenon. In this direction, many drugs that are used in the everyday practice of Rheumatologists have been used. Indeed, pro-inflammatory cytokines such as the IL-1 and IL-6 have been shown to be the pivotal cytokines expressed, and anti-cytokine treatment has been tried so far with various results. In addition, hydroxychloroquine, an antimalarial drug, has been shown to reduce COVID-19 symptoms. Other drugs have also been used, such as intravenous pulses of immunoglobulins, and colchicine. Robust clinical trials are needed in order to find the suitable treatment. Current data indicate that hydroxychloroquine and cytokine targeting therapies may prove helpful in the fight of SARS-CoV-2 in appropriately selected patients.

Update on vasculitis: an overview and dermatological clues for clinical and histopathological diagnosis - part I

The term vasculitis refers to the inflammation of vessel walls. It may range in severity from a self-limited disorder in one single organ to a life-threatening disease due to multiple organ failure. It has many causes, although they result in only a few histological patterns of vascular inflammation. Vessels of any type and in any organ can be affected, a fact that results in a broad variety of signs and symptoms. Different vasculitides with indistinguishable clinical presentations have quite different prognosis and treatments. This condition presents many challenges to physicians in terms of classification, diagnosis, appropriate laboratory workup, and treatment. Moreover, it compels a careful follow-up. This article reviews the Chapel-Hill 2012 classification, etiology, recent insights in pathophysiology, some important dermatological clues for the diagnosis and summarizes treatment of some of these complex vasculitis syndromes.