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Kuske L, Khalifa A, Wibisono A, Bräsen JH, Witte T. MPO-ANCA-positive granulomatosis with polyangiitis and concurrent IgG4-related disease with periaortitis and tubulointerstitial nephritis: A case report of a new overlap syndrome? Int J Rheum Dis 2023; 26:1821-1825. [PMID: 36973170 DOI: 10.1111/1756-185x.14680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition that was first recognized as a unique disease entity in the early 2000s. Its diagnosis is based on specific pathologic, serologic, and clinical features, and the exclusion of several differential diagnoses, such antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, emerging evidence suggests that these 2 conditions may overlap in some cases. Here, we report a new case of overlapping IgG4-RD and AAV. The patient was diagnosed with IgG4-RD owing to the presence of periaortitis and IgG4 positive tubulointerstitial nephritis. Myeloperoxidase (MPO)-ANCA positivity, chronic paranasal sinusitis, and glomerulonephritis with granuloma led to a concurrent diagnosis of MPO-ANCA-positive granulomatosis with polyangiitis. Our case supports the hypothesis that diagnoses of IgG4-RD and AAV are not mutually exclusive but can overlap. It can be assumed that an overlap with IgG4-RD typically affects the granulomatous form of AAV, suggesting a common pathophysiological pathway for these 2 conditions.
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Affiliation(s)
- Luise Kuske
- Department of Rheumatology, Medical School Hannover, Hannover, Germany
| | | | - Alexander Wibisono
- Department of Nuclear Medicine, Medical School Hannover, Hannover, Germany
| | | | - Torsten Witte
- Department of Rheumatology, Medical School Hannover, Hannover, Germany
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Żabińska M, Kościelska-Kasprzak K, Krajewska J, Bartoszek D, Augustyniak-Bartosik H, Krajewska M. Immune Cells Profiling in ANCA-Associated Vasculitis Patients-Relation to Disease Activity. Cells 2021; 10:1773. [PMID: 34359942 PMCID: PMC8307495 DOI: 10.3390/cells10071773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 12/05/2022] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are a group of necrotizing multiorgan autoimmune vasculitides that predominantly affect small blood vessels and are associated with the presence of ANCAs. The aim was to assess regulatory and effector cell populations accompanied by the suPAR biomarker level and link the so-defined immune state to the AAV disease activity. The research involved a multicomponent description of an immune state encompassing a range of B and T cell subsets such as transitional/regulatory B cells (CD19+CD24++CD38++), naïve B cells (CD19+CD24INTCD38INT), Th17 cells, T regulatory cells (CD4+CD25+FoxP3+) and cytotoxic CD4+CD28- cells by flow cytometry. The suPAR plasma level was measured by ELISA. The results indicate that AAV is associated with an increased suPAR plasma level and immune fingerprint characterized by an expansion of Th17 cells and T cells lacking the costimulatory molecule CD28, accompanied by a decrease of regulatory populations (Tregs and transitional B cells) and NK cells. Decreased numbers of regulatory T cells and transitional B cells were shown to be linked to activation of the AAV disease while the increased suPAR plasma level-to AAV-related deterioration of kidney function. The observed immune fingerprint might be a reflection of peripheral tolerance failure responsible for development and progression of ANCA-associated vasculitides.
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Affiliation(s)
- Marcelina Żabińska
- Department of Nephrology and Transplantation Medicine, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland; (K.K.-K.); (D.B.); (H.A.-B.); (M.K.)
| | - Katarzyna Kościelska-Kasprzak
- Department of Nephrology and Transplantation Medicine, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland; (K.K.-K.); (D.B.); (H.A.-B.); (M.K.)
| | - Joanna Krajewska
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland;
| | - Dorota Bartoszek
- Department of Nephrology and Transplantation Medicine, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland; (K.K.-K.); (D.B.); (H.A.-B.); (M.K.)
| | - Hanna Augustyniak-Bartosik
- Department of Nephrology and Transplantation Medicine, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland; (K.K.-K.); (D.B.); (H.A.-B.); (M.K.)
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Faculty of Medicine, Wroclaw Medical University, 50-367 Wrocław, Poland; (K.K.-K.); (D.B.); (H.A.-B.); (M.K.)
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Abstract
The diagnosis of primary central and peripheral nerve vasculitides should be established with certainty if suspected before commencing potent immunosuppressive therapy. The aim of induction therapy is to rapidly control the underlying inflammatory response and stabilize the blood-brain and blood-nerve barriers, followed by maintenance immunosuppression tailored to the likeliest humoral and cell-mediated autoimmune inflammatory vasculitic processes.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY, USA; School of Public Health, City University of New York, New York, NY, USA.
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Aging in Primary Systemic Vasculitis: Implications for Diagnosis, Clinical Manifestations, and Management. Drugs Aging 2018; 36:53-63. [DOI: 10.1007/s40266-018-0617-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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6
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Smith RM. Update on the treatment of ANCA associated vasculitis. Presse Med 2015; 44:e241-9. [PMID: 26021670 DOI: 10.1016/j.lpm.2015.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 11/28/2022] Open
Abstract
The introduction of glucocorticoids and cyclophosphamide has transformed ANCA associated vasculitis (AAV) from a fatal to a largely treatable condition. Over the past 40 years, considerable progress has been made in refining immunosuppressive regimens with a focus on minimising toxicity. As knowledge of the pathogenesis of AAV grows, it is mirrored by the availability of biological agents. Lymphocyte and cytokine targeted agents have been evaluated for the treatment of AAV and are entering the routine therapeutic arena with the potential to improve patient outcomes. Rituximab has transformed management of AAV in the past decade. However, there remains unmet need in the treatment of AAV; the majority of patients will relapse within five years of diagnosis despite maintenance immunosuppression; a small number of patients remain refractory to current therapies and treatment toxicity continues to contribute to mortality and chronic disability. As in rare diseases, treatment advances in vasculitis depend on international collaborative research networks to both establish an evidence base for newer agents and develop recommendations for optimal patient management.
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Affiliation(s)
- Rona M Smith
- Addenbrooke's Hospital, Department of renal medicine, Box 57, Hills Road, Cambridge CB20QQ, United Kingdom.
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Todd SK, Pepper RJ, Draibe J, Tanna A, Pusey CD, Mauri C, Salama AD. Regulatory B cells are numerically but not functionally deficient in anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology (Oxford) 2014; 53:1693-703. [PMID: 24729396 DOI: 10.1093/rheumatology/keu136] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES B cells are central to the pathology of ANCA-associated vasculitis (AAV), a disease characterized by autoantibodies and effectively treated by rituximab. In addition to promoting inflammation, a subset of B cells act to suppress harmful autoimmune responses (Breg). The balance of effector and regulatory B cell subsets in AAV is not known. This study was conducted to assess the relative frequency of these subsets during different states of disease activity. METHODS B memory (Bmem), naive (Bnaive) and regulatory (Breg) subsets were defined by their relative expression of CD24 and CD38. Function was assessed by cytokine production and suppressive action on CD4(+) Th1 activation evaluated in a co-culture system. RESULTS Compared with healthy controls, the frequency of Breg (CD24(hi)CD38(hi)) was significantly reduced during disease remission in both proteinase 3 (PR3)- and MPO-ANCA patients and during acute disease in PR3-ANCA patients, while the frequency of memory cells (CD24(hi)CD38(lo)) was reduced during active disease and restored during remission. Breg cell frequency showed a positive correlation, while Bmem had an inverse correlation with IL-10 production in vitro. B and T cell co-cultures revealed that memory and naive B cell subsets augmented Th1 activation in vitro, which was prevented by Breg, and this pattern did not differ between remission AAV patients and controls. CONCLUSION In remission there is a numerical, but not functional, deficiency in Breg and preservation of Bmem associated with reduced IL-10 production and increased Th1 activation in vitro. This imbalance may contribute to the high rate of relapse observed in AAV, especially in PR3-ANCA patients.
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Affiliation(s)
- Sarah Katrina Todd
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Ruth J Pepper
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Juliana Draibe
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Anisha Tanna
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Charles D Pusey
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Claudia Mauri
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK
| | - Alan D Salama
- UCL Centre for Nephrology, Royal Free Hospital, Renal and Vascular Inflammation Group, Imperial College London, Hammersmith Hospital and Centre for Rheumatology, University College London, London, UK.
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Serum from patients with systemic vasculitis induces alternatively activated macrophage M2c polarization. Clin Immunol 2014; 152:10-9. [PMID: 24631966 DOI: 10.1016/j.clim.2014.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/23/2014] [Accepted: 02/25/2014] [Indexed: 01/23/2023]
Abstract
Anti-neutrophil cytoplasmic antibody associated vasculitides (AAV) are conditions defined by an autoimmune small vessel inflammation. Dying neutrophils are found around the inflamed vessels and the balance between infiltrating neutrophils and macrophages is important to prevent autoimmunity. Here we investigate how sera from AAV patients may regulate macrophage polarization and function. Macrophages from healthy individuals were differentiated into M0, M1, M2a, M2b or M2c macrophages using a standardized protocol, and phenotyped according to their expression surface markers and cytokine production. These phenotypes were compared with those of macrophages stimulated with serum from AAV patients or healthy controls. While the healthy control sera induced a M0 macrophage, AAV serum promoted polarization towards the M2c subtype. No sera induced M1, M2a or M2b macrophages. The M2c subtype showed increased phagocytosis capacity compared with the other subtypes. The M2c polarization found in AAV is consistent with previous reports of increased levels of M2c-associated cytokines.
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9
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Smith RM, Jones RB, Jayne DRW. Progress in treatment of ANCA-associated vasculitis. Arthritis Res Ther 2012; 14:210. [PMID: 22569190 PMCID: PMC3446448 DOI: 10.1186/ar3797] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Autoantibodies to neutrophil cytoplasmic antigen-associated vasculitis (AAV) is characterised by inflammation of blood vessels. The introduction of immunosuppressive therapy with glucocorticoids and cyclophosphamide transformed AAV from a fatal condition to a largely treatable condition. Over the past 30 years, considerable progress has been made refining immunosuppressive regimens with a focus on minimising toxicity. There is, however, a high unmet need in the treatment of AAV. A proportion of patients are refractory to current therapies; 50% experience a relapse within 5 years and treatment toxicity contributes to mortality and chronic disability. As knowledge of the pathogenesis of vasculitis grows, it is mirrored by the availability of biological agents, which herald a revolution in the treatment of vasculitis. Lymphocyte-targeted and cytokine-targeted agents have been evaluated for the treatment of AAV and are entering the routine therapeutic arena with the potential to improve patient outcomes. As rare diseases, treatment advances in vasculitis depend on international collaborative research networks both to establish an evidence base for newer agents and to develop recommendations for patient management.
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Affiliation(s)
- Rona M Smith
- Department of Renal Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB20QQ, UK.
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10
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Saleem R, Oliver M, Rowbottom A, Solomon L. Antineutrophil cytoplasmic antibodies: two cases of changing antigenic specificity. Ann Clin Biochem 2012; 49:295-9. [PMID: 22362085 DOI: 10.1258/acb.2011.011100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The transformation of the antineutrophil cytoplasmic antibody (ANCA) specificity in the absence of specific drug treatment has not been reported in the literature. A few studies have suggested changes in the epitopes recognized by the ANCAs. We describe two patients who switched from myeloperoxidase-positive to PR3 (proteinase 3)-positive ANCA during the course of their disease process and subsequently remained unchanged. One patient developed ulcerative colitis following the appearance of PR3-ANCA while the other remains quiescent. Regular follow-up and close monitoring of ANCA specificity are essential. A change of specificity may indicate the development of a new ANCA-related disease.
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Affiliation(s)
- Rehana Saleem
- Department of Immunology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, UK
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Homeister JW, Willis MS. The Molecular Biology and Treatment of Systemic Vasculitis in Children. MOLECULAR AND TRANSLATIONAL VASCULAR MEDICINE 2012. [PMCID: PMC7121654 DOI: 10.1007/978-1-61779-906-8_2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Primary systemic vasculitides are rare in childhood but are associated with significant morbidity and mortality. The cause of the majority of vasculitides is unknown, although it is likely that a complex interaction between environmental factors, such as infections and inherited host responses, triggers the disease and determines the vasculitis phenotype. Several genetic polymorphisms in vasculitides have now been described, which may be relevant in terms of disease predisposition or development of disease complications. Treatment regimens continue to improve with the use of different immunosuppressive medications and newer therapeutic approaches such as biologic agents. This chapter reviews recent studies shedding light on the pathogenesis of vasculitis with emphasis on molecular biology where known, and summarizes current treatment strategies. We discuss new emerging challenges particularly with respect to the long-term cardiovascular morbidity for children with systemic vasculitis and emphasize the importance of future international multicenter collaborative studies to further increase and standardize the scientific base investigating and treating childhood vasculitis.
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Affiliation(s)
- Jonathon W. Homeister
- grid.410711.20000 0001 1034 1720, The University of North Carolina, McAllister Heart Institute, 101 Manning Drive, Chapel Hill, 27599-7525 USA
| | - Monte S. Willis
- grid.410711.20000 0001 1034 1720, The University of North Carolina, McAllister Heart Institute, 103 Mason Farm Road, Chapel Hill, 27599-7525 USA
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Hervier B, Hamidou M, Haroche J, Durant C, Mathian A, Amoura Z. Systemic lupus erythematosus associated with ANCA-associated vasculitis: an overlapping syndrome? Rheumatol Int 2011; 32:3285-90. [PMID: 21805174 DOI: 10.1007/s00296-011-2055-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/10/2011] [Indexed: 01/12/2023]
Abstract
Systemic lupus erythematosus (SLE) and small-sized vessel vasculitis are usually two distinguishable autoimmune diseases. However, a vasculitis may be found in the course SLE but rarely corresponds to an ANCA-associated vasculitis (AAV). We report four cases of de novo SLE associated with AAV, our aim being to discuss the clinical significance of this association. We included four patients fulfilling the criteria for both SLE and AAV and followed in two different university hospitals between 1996 and 2009. In light of a 20-year literature review (25 described clinical cases), we discussed the etiopathogeny of such an association. All patients presented a severe renal involvement (creatininemia ranging from 120 to 370 μmol/l) and thrombopenia (ranging from 45,000 to 137,000 platelets/mm(3)). The other main clinical symptoms were arthritis (n = 3), serositis (n = 2) and intra-alveolar hemorrhage (n = 2). An inflammatory syndrome was noticed at diagnosis in all cases. ANCAs were MPO-ANCAs in all cases. Two out of these four patients were also diagnosed with antiphospholipid syndrome. The frequency of this association seems not fortuitous. Although the etiopathogenic mechanisms of such an association remain to be more precisely described, several clinical, histological and immunological features support the hypothesis of the existence of a SLE-AAV overlapping syndrome. Moreover, clinicians must be aware of such an overlapping syndrome, notably because its initial presentation can be very severe.
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Affiliation(s)
- B Hervier
- Internal Medicine Department, National Reference Centre for Lupus and Antiphospholipid Syndrome, CHU Pitié-Salpétrière, 83 Boulevard de l'hôpital, 75013 Paris, France.
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Rimbert M, Hamidou M, Braudeau C, Puéchal X, Teixeira L, Caillon H, Néel A, Audrain M, Guillevin L, Josien R. Decreased numbers of blood dendritic cells and defective function of regulatory T cells in antineutrophil cytoplasmic antibody-associated vasculitis. PLoS One 2011; 6:e18734. [PMID: 21494636 PMCID: PMC3073002 DOI: 10.1371/journal.pone.0018734] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 03/14/2011] [Indexed: 01/07/2023] Open
Abstract
Background Dendritic cells (DC) and regulatory cells (Treg) play pivotal roles in controlling both normal and autoimmune adaptive immune responses. DC are the main antigen-presenting cells to T cells, and they also control Treg functions. In this study, we examined the frequency and phenotype of DC subsets, and the frequency and function of Treg from patients with ANCA-associated vasculitis (AAV). Methodology/Principal Findings Blood samples from 19 untreated patients with AAV during flares and before any immunosuppressive treatment were analyzed, along with 15 AAV patients in remission and 18 age-matched healthy controls. DC and Treg numbers, and phenotypes were assessed by flow cytometry, and in vitro suppressive function of Treg was determined by co-culture assay. When compared to healthy volunteers, absolute numbers of conventional and plasmacytoid DC were decreased in AAV patients. During the acute phase this decrease was significantly more pronounced and was associated with an increased DC expression of CD62L. Absolute numbers of Treg (CD4+CD25highCD127low/− Tcells) were moderately decreased in patients. FOXP3 and CD39 were expressed at similar levels on Treg from patients as compared to controls. The suppressive function of Treg from AAV patients was dramatically decreased as compared to controls, and this defect was more pronounced during flares than remission. This Treg functional deficiency occurred in the absence of obvious Th17 deviation. Conclusion In conclusion, these data show that AAV flares are associated with both a decrease number and altered phenotype of circulating DC and point to a role for Treg functional deficiency in the pathogenesis of AAV.
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Affiliation(s)
- Marie Rimbert
- CHU Nantes, Laboratoire d'Immunologie, Nantes, France
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes, France
- INSERM, UMR643, Nantes, France
- Université de Nantes, Faculté de Médecine, Nantes, France
| | - Mohamed Hamidou
- Université de Nantes, Faculté de Médecine, Nantes, France
- CHU Nantes, Service de Médecine Interne, Nantes, France
| | - Cécile Braudeau
- CHU Nantes, Laboratoire d'Immunologie, Nantes, France
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes, France
| | | | - Luis Teixeira
- AP-HP, Hôpital Cochin, Service de Médecine Interne, Paris, France
- Université Paris Descartes, Paris, France
| | | | - Antoine Néel
- Université de Nantes, Faculté de Médecine, Nantes, France
- CHU Nantes, Service de Médecine Interne, Nantes, France
| | - Marie Audrain
- CHU Nantes, Laboratoire d'Immunologie, Nantes, France
| | - Loic Guillevin
- AP-HP, Hôpital Cochin, Service de Médecine Interne, Paris, France
- Université Paris Descartes, Paris, France
| | - Régis Josien
- CHU Nantes, Laboratoire d'Immunologie, Nantes, France
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Nantes, France
- INSERM, UMR643, Nantes, France
- Université de Nantes, Faculté de Médecine, Nantes, France
- * E-mail:
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Biology and immunopathogenesis of vasculitis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00150-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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ANCA-associated vasculitides-lessons from the adult literature. Pediatr Nephrol 2010; 25:1397-407. [PMID: 20358231 DOI: 10.1007/s00467-010-1496-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/29/2010] [Accepted: 02/01/2010] [Indexed: 02/08/2023]
Abstract
Anti-neutrophil cytoplasmic antigen antibody (ANCA)-associated disease is a rare manifestation of primary systemic vasculitis in paediatric patients but one that carries significant morbidity, potential long-term disability and early mortality. It therefore requires a high index of suspicion, targeted investigation, prompt treatment and long-term follow-up with specialist input at every stage. The well-recognised diversity and overlap in clinical, laboratory and histopathological features of the ANCA-associated systemic vasculitides continue to hamper accurate diagnosis, confounding epidemiological data and necessitating a blanket approach to treatment, which is largely extrapolated from studies in adult patients and carries significant side-effects. Herein we summarise current knowledge of the epidemiology, pathogenesis, principal manifestations, investigation and evidence-based management, extrapolated from adult studies, of these disorders. We also discuss recent efforts towards classification of the childhood vasculitides that emphasise the value of histological diagnosis. Progress in our understanding of the pathophysiology underlying ANCA-associated disease should lead to targeted, safer and more effective therapies for these conditions. Nonetheless, many questions remain outstanding, and academic paediatricians face real challenges in identifying and collating the few cases they encounter into study cohorts. Meeting this challenge will require international collaboration, not only among paediatricians but also with the specialists taking over care of these patients as they reach adulthood.
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Pierrot-Deseilligny Despujol C, Pouchot J, Pagnoux C, Coste J, Guillevin L. Predictors at diagnosis of a first Wegener's granulomatosis relapse after obtaining complete remission. Rheumatology (Oxford) 2010; 49:2181-90. [PMID: 20675708 DOI: 10.1093/rheumatology/keq244] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Although in most patients with WG, induction therapy leads to complete remission (CR), the high relapse rate remains a major problem. This study was undertaken to identify potential predictors of these relapses. METHODS WG outcomes of patients included in two randomized trials were analysed. Patients were categorized into a predominant form of the disease using a scoring system composed of three granulomatous criteria (ear, nose and throat manifestations; lung nodules; and orbital pseudotumour) and three vascular criteria (serum creatinine >125 µmol/l, haematuria or proteinuria and alveolar haemorrhage). RESULTS Among 174 patients, 152 (87%) entered CR with CSs and CYC. The risk of death was higher for the vascular form [odds ratio (OR) 3.5 (95% CI 1.1, 11.4)]. With a median follow-up of 50 months, 66 out of 152 patients experienced a relapse (5-year relapse rate: 49%). Multivariate analysis retained the following variables at diagnosis as independent predictors of relapse: specific cardiac involvement [hazard ratio (HR) 2.9 (95% CI 1.3, 6.5)], ANCA with cytoplasmic-labelling pattern (c-ANCA) [HR 2.1 (95% CI 1.1, 4.3)] and higher age [HR 1.4 (95% CI 1.1, 1.7)]. Conversely, severe renal insufficiency was associated with a lower relapse rate [HR 0.4 (95% CI, 0.2-0.8)]. Comparing predominant granulomatous vs predominant vascular disease, relapses were more frequent and earlier with decreasing risk over time. CONCLUSIONS Increased risk of first WG relapse after initial remission appears to be related to heart involvement, age and c-ANCA positivity at onset. Predominant granulomatous presentation disease seems to be associated with poorer outcomes after CR. These findings may help adapt treatment strategies.
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Natural autoantibodies to myeloperoxidase, proteinase 3, and the glomerular basement membrane are present in normal individuals. Kidney Int 2010; 78:590-7. [PMID: 20592714 DOI: 10.1038/ki.2010.198] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCAs) have a pathogenic role in ANCA-associated vasculitis. The origin of ANCAs and anti-glomerular basement membrane (GBM) antibodies, however, is unknown. In this study, we determined whether natural autoantibodies against myeloperoxidase (MPO), proteinase 3 (PR3), and GBM were present in each of 10 healthy Chinese and Swedish individuals, negative for all three antigens by routine ELISA. Antibodies were purified from isolated IgG by antigen-specific affinity columns. Natural anti-GBM autoantibodies gave a linear staining pattern along the GBM of human renal sections. On ethanol-fixed granulocytes, both natural anti-MPO and anti-PR3 autoantibodies gave cytoplasmic staining. The titers of natural anti-MPO/PR3 autoantibodies were significantly lower than those from patients with vasculitis. In competition ELISA, the binding of natural anti-MPO autoantibodies could be inhibited by MPO, but not by PR3 or noncollagenous domains from type IV collagen. The same specificity results were found for natural anti-PR3 and anti-GBM autoantibodies. Overall, individuals of the Chinese origin had more natural autoantibodies than did those of the Swedish origin, but no other differences were found. Hence, our study shows that healthy individuals have masked circulating, noncross-reactive, antigen-specific natural autoantibodies against MPO, PR3, and GBM in their serum and IgG fractions. Further studies are needed to determine their role if any in the etiology of ANCA-associated vasculitis and anti-GBM disease.
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Georgin-Lavialle S, Aouba A, Mouthon L, Londono-Vallejo JA, Lepelletier Y, Gabet AS, Hermine O. The telomere/telomerase system in autoimmune and systemic immune-mediated diseases. Autoimmun Rev 2010; 9:646-51. [PMID: 20435169 DOI: 10.1016/j.autrev.2010.04.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 04/22/2010] [Indexed: 12/22/2022]
Abstract
Telomeres are specialized nucleoproteic structures that cap and protect the ends of chromosomes. They can be elongated by the telomerase enzyme, but in telomerase negative cells, telomeres shorten after each cellular division because of the end replicating problem. This phenomenon leads ultimately to cellular senescence, conferring to the telomeres a role of biological clock. Oxidative stress, inflammation and increased cell renewal are supplementary environmental factors that accelerate age-related telomere shortening. Similar to other types of DNA damage, very short/dysfunctional telomeres activate a DNA response pathway leading to different outcomes: DNA repair, cell senescence or apoptosis. During the last 10 years, studies on the telomere/telomerase system in autoimmune and/or systemic immune-mediated diseases have revealed its involvement in relevant physiopathological processes. Here, we present a literature review of telomere and telomerase homeostasis in systemic inflammatory diseases including systemic lupus erythematosus, rheumatoid arthritis and granulomatous diseases. The available data indicate that both telomerase activity and telomere length are modified in various systemic immune-mediated diseases and appear to be connected with premature immunosenescence. Studies on the telomere/telomerase system open new research avenues for the basic understanding and for therapeutic approaches of these pathologies.
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Affiliation(s)
- Sophie Georgin-Lavialle
- Department of Adult Haematology, Necker Enfants-Malades Hospital, Mastocytosis Reference Center, Paris Descartes University, Paris, France
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McKinney EF, Lyons PA, Carr EJ, Hollis JL, Jayne DRW, Willcocks LC, Koukoulaki M, Brazma A, Jovanovic V, Kemeny DM, Pollard AJ, MacAry PA, Chaudhry AN, Smith KGC. A CD8+ T cell transcription signature predicts prognosis in autoimmune disease. Nat Med 2010; 16:586-91, 1p following 591. [PMID: 20400961 PMCID: PMC3504359 DOI: 10.1038/nm.2130] [Citation(s) in RCA: 282] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 03/05/2010] [Indexed: 12/31/2022]
Abstract
Autoimmune diseases are common and debilitating, but their severe manifestations could be reduced if biomarkers were available to allow individual tailoring of potentially toxic immunosuppressive therapy. Gene expression-based biomarkers facilitating such tailoring of chemotherapy in cancer, but not autoimmunity, have been identified and translated into clinical practice. We show that transcriptional profiling of purified CD8(+) T cells, which avoids the confounding influences of unseparated cells, identifies two distinct subject subgroups predicting long-term prognosis in two autoimmune diseases, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), a chronic, severe disease characterized by inflammation of medium-sized and small blood vessels, and systemic lupus erythematosus (SLE), characterized by autoantibodies, immune complex deposition and diverse clinical manifestations ranging from glomerulonephritis to neurological dysfunction. We show that the subset of genes defining the poor prognostic group is enriched for genes involved in the interleukin-7 receptor (IL-7R) pathway and T cell receptor (TCR) signaling and those expressed by memory T cells. Furthermore, the poor prognostic group is associated with an expanded CD8(+) T cell memory population. These subgroups, which are also found in the normal population and can be identified by measuring expression of only three genes, raise the prospect of individualized therapy and suggest new potential therapeutic targets in autoimmunity.
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Affiliation(s)
- Eoin F. McKinney
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Paul A. Lyons
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Edward J. Carr
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Jane L. Hollis
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - David R. W. Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Lisa C. Willcocks
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Maria Koukoulaki
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Alvis Brazma
- European Bioinformatics Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SD, UK
| | - Vojislav Jovanovic
- Immunology Programme and Department of Microbiology, Centre for Life Sciences, National University of Singapore, Singapore
| | - D. Michael Kemeny
- Immunology Programme and Department of Microbiology, Centre for Life Sciences, National University of Singapore, Singapore
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Oxford, United Kingdom
| | - Paul A. MacAry
- Immunology Programme and Department of Microbiology, Centre for Life Sciences, National University of Singapore, Singapore
| | - Afzal N. Chaudhry
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
| | - Kenneth G. C. Smith
- Cambridge Institute for Medical Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, CB2 0XY, UK
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Chavele KM, Shukla D, Keteepe-Arachi T, Seidel JA, Fuchs D, Pusey CD, Salama AD. Regulation of myeloperoxidase-specific T cell responses during disease remission in antineutrophil cytoplasmic antibody-associated vasculitis: The role of Treg cells and tryptophan degradation. ACTA ACUST UNITED AC 2010; 62:1539-48. [DOI: 10.1002/art.27403] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Catania P, Pela I. Vasculitis in a boy with ESRD following influenza vaccination. Vaccine 2010; 28:877-8. [DOI: 10.1016/j.vaccine.2009.10.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 10/28/2009] [Indexed: 02/01/2023]
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Gatenby PA, Lucas RM, Engelsen O, Ponsonby AL, Clements M. Antineutrophil cytoplasmic antibody-associated vasculitides: could geographic patterns be explained by ambient ultraviolet radiation? ACTA ACUST UNITED AC 2009; 61:1417-24. [PMID: 19790114 DOI: 10.1002/art.24790] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This ecological study describes and quantifies the association between ambient ultraviolet (UV) radiation levels, including daily winter vitamin D effective UV radiation levels and the incidence of the 3 antineutrophil cytoplasmic antibody-associated vasculitides (AAVs): Wegener's granulomatosis (WG), microscopic polyangiitis (MPA), and Churg-Strauss syndrome (CSS). Latitudinal variation in occurrence of the AAVs, especially WG, has been previously reported. For other autoimmune diseases such as multiple sclerosis and type 1 diabetes mellitus, inverse associations with latitude are hypothesized to indicate a causative role for low UV radiation exposure, possibly acting via vitamin D status. METHODS Published epidemiologic studies provided data on incident cases, total population of study regions, age-specific incidence rates, and study location. From these data and online age-specific population data, we calculated crude incidence rates, the expected number of cases (to control for possible age confounding), and measures of ambient UV radiation. Negative binomial regression models were used to calculate the incidence rate ratio (IRR) for a 1,000 joules/m(2) increase in ambient UV radiation. RESULTS The incidence of WG and CSS increased with increasing latitude and decreasing ambient UV radiation, with a stronger and more consistent effect across different UV radiation measures for WG, e.g., for average daily ambient clear sky erythemal UV radiation (WG: IRR 0.64 [95% confidence interval (95% CI) 0.44-0.94], P = 0.02; CSS: IRR 0.67 [95% CI 0.43-1.05], P = 0.08; MPA: IRR 1.16 [95% CI 0.92-1.47], P = 0.22). There was no apparent latitudinal variation in MPA incidence. CONCLUSION Our findings are consistent with a protective immunomodulatory effect of ambient UV radiation on the onset of WG and CSS. We discuss possible mechanisms, including the effect of vitamin D on the immune system.
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Affiliation(s)
- Paul A Gatenby
- Australian National University, Canberra, ACT, Australia.
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Kamesh L, Heward JM, Williams JM, Gough SCL, Chavele KM, Salama A, Pusey C, Savage COS, Harper L. CT60 and +49 polymorphisms of CTLA 4 are associated with ANCA-positive small vessel vasculitis. Rheumatology (Oxford) 2009; 48:1502-5. [PMID: 19815671 DOI: 10.1093/rheumatology/kep280] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate whether single nucleotide polymorphisms (SNPs) within cytotoxic T-lymphocyte antigen-4 (CTLA-4) are associated with ANCA-associated small vessel vasculitis (SVV). METHODS The CTLA-4 CT60 (exon 4), +49 (exon 1) and -318 (promoter region) genotypes were determined by PCR and restriction fragment length polymorphism (RFLP) in 222 white Caucasians of UK origin with SVV and 670 ethnically matched controls. RESULTS The CTLA-4 exon 1 (+49) and 4 (CT60) polymorphisms are associated with SVV (+49: chi(2) = 10.965, P = 0.004; CT60: chi(2) = 12.017, P = 0.002). Both disease-susceptible and disease-protective haplotypes have been identified in this cohort, and their frequencies are similar in the subtypes of WG and microscopic polyangiitis. CONCLUSION This study provides further evidence that CTLA-4, a susceptibility locus for a number of common autoimmune diseases, may also be involved in the development of ANCA-associated SVV.
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Affiliation(s)
- Lavanya Kamesh
- Renal Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Analysis of T-cell receptor usage in myeloperoxidase−antineutrophil cytoplasmic antibody-associated renal vasculitis. Clin Exp Nephrol 2009; 14:36-42. [DOI: 10.1007/s10157-009-0230-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 09/09/2009] [Indexed: 10/20/2022]
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Abstract
Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA) are primary systemic small vessel vasculitides, associated with a positive C/PR3-ANCA in WG and P/MPO-ANCA in MPA. The most prominently involved organs are the upper (only in WG) and lower respiratory tract and the kidneys. The diagnostic work-up is an interdisciplinary approach assessing disease stage and extent. Treatment is adapted to disease stage and extent and relies on a combination of a cytotoxic plus a tapering regimen of corticosteroids. Induction of remission in "early systemic" disease can be achieved with low-dose methotrexate. In severe generalized vasculitis cyclophosphamide (CYC) is the mainstay of therapy, in rapidly progressive glomerulonephritis in combination with plasmapheresis. After 3-6 months of induction CYC is switched to a maintenance treatment with azathioprine. Alternatives are leflunomide, mycophenolate or methotrexate (creatinine < 150 micromol/l). Age > or = 50 at diagnosis, renal dysfunction and pulmonary involvement are associated with higher mortality rates. The relapse rate is approximately 50% within 5 years, being higher in WG than MPA.
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Hruskova Z, Rihova Z, Mareckova H, Jancova E, Rysava R, Zavada J, Merta M, Löster T, Tesar V. Intracellular cytokine production in ANCA-associated vasculitis: low levels of interleukin-10 in remission are associated with a higher relapse rate in the long-term follow-up. Arch Med Res 2009; 40:276-84. [PMID: 19608017 DOI: 10.1016/j.arcmed.2009.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Dysregulation of cell-mediated immune response likely plays a role in the pathogenesis of anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV), but it has not yet been fully established. The aim of this study was to assess the intracellular cytokine production in patients with AAV at different stages of the disease, in particular, in relation to the long-term prognosis. METHODS We included 69 patients with AAV and 24 healthy controls. Using flow cytometry, the following intracellular cytokines (IC) were measured in all patients: interferon-gamma (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), interleukin-2 and interleukin-4 in CD3+T cells and interleukin-10 (IL-10) and interleukin 12 (IL-12) in monocytes. Patients were then prospectively followed for a median of 43 months and cytokine production was related to the long-term prognosis. RESULTS When compared to healthy controls, increased IL-12 production was observed in AAV patients, both active (p<0.01) and in remission (p<0.05). In remission, increased IFN-gamma production was also found (p<0.01). IL-10 production was higher in active patients than in patients in remission (p<0.05) but did not differ from controls. Patients in remission who developed a relapse during follow-up had significantly lower IL-10 production than those without relapse (p<0.01). Results of this prospective study of IC production in AAV confirm findings of previous studies measuring circulating cytokine levels. CONCLUSIONS Activation of the immune system in AAV patients is noticeable even in remission. Patients with AAV display increased IL-12 production, which seems to be counterbalanced by IL-10. Low IL-10 levels in remission are associated with a higher relapse rate in the long-term follow-up.
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Affiliation(s)
- Zdenka Hruskova
- Department of Nephrology, 1st Faculty of Medicine and General Teaching Hospital, Charles University, Prague, Czech Republic.
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Kälsch AI, Peters A, Buhl B, Breedijk A, Prem K, Schmitt WH, Weiss C, Heeringa P, Kallenberg C, Birck R, Yard BA. Retinoid X receptor beta polymorphisms do not explain functional differences in vitamins D and A response in Antineutrophil cytoplasmic antibody associated vasculitis patients. Autoimmunity 2009; 42:467-74. [DOI: 10.1080/08916930902960347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Wilde B, van Paassen P, Damoiseaux J, Heerings-Rewinkel P, van Rie H, Witzke O, Tervaert JWC. Dendritic cells in renal biopsies of patients with ANCA-associated vasculitis. Nephrol Dial Transplant 2009; 24:2151-6. [PMID: 19193740 DOI: 10.1093/ndt/gfp019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Dendritic cells (DCs) maintain immune tolerance and are able to initiate immune responses. Their involvement in ANCA-associated vasculitis (AAV) is unknown. In this study, the participation of DC subsets is investigated in renal biopsies of AAV patients. METHOD A total of 25 patients with biopsy-proven AAV and five healthy controls (HC) with normal renal histology were included. Renal biopsies were stained for mature (CD208), immature (CD209), plasmacytoid (CD303) and Langerhans (CD1a) DC subsets. Furthermore, T-cells were stained using a T-cell marker (CD3). The interstitial cellular infiltrate was graded semi-quantitatively from 0+ (= absence of cells) to 3+ (= numerous cells). Within the glomeruli, an absolute count was performed for positive cells. RESULTS CD208+ and CD209+ cells were found within patients' glomeruli but not in HC (1 +/- 0.3 versus 0.08 +/- 0.1 cells/glom; 2 +/- 0.3 versus 0.1 +/- 0.07 cells/glom). An average of 0.3 +/- 0.1 cell/glom expressed CD3 in patients while few cells were found in HC (0.1 +/- 0.7 cell/glom). Focal interstitial cellular infiltrates were observed in patients' biopsies but not in HC. Interstitial infiltration with CD3+ and CD209+ cells was assessed at an average of 1+, but some glomeruli and tubuli were surrounded by CD3+ and CD209+ cells forming clusters. Serial sections revealed that CD209+ cells were present in CD3+ rich areas. CONCLUSION Both mature and immature glomerular DCs are found in renal biopsies of patients with AAV. Immature DCs cluster with T-cells in interstitial infiltrates in these biopsies. Since DCs form aggregates in T-cell areas, we hypothesize that these cells interact with each other and are involved in lymphoid neogenesis.
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Affiliation(s)
- Benjamin Wilde
- Division of Clinical and Experimental Immunology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
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Wilde B, Dolff S, Cai X, Specker C, Becker J, Totsch M, Costabel U, Durig J, Kribben A, Tervaert JWC, Schmid KW, Witzke O. CD4+CD25+ T-cell populations expressing CD134 and GITR are associated with disease activity in patients with Wegener's granulomatosis. Nephrol Dial Transplant 2008; 24:161-71. [DOI: 10.1093/ndt/gfn461] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Kälsch AI, Soboletzki M, Schmitt WH, van der Woude FJ, Hochhaus A, Yard BA, Birck R. Imatinib mesylate, a new kid on the block for the treatment of anti-neutrophil cytoplasmic autoantibodies-associated vasculitis? Clin Exp Immunol 2008; 151:391-8. [PMID: 18190601 DOI: 10.1111/j.1365-2249.2007.03572.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Persistent T cell activation is a common finding in anti-neutrophil cytoplasmic autoantibodies (ANCA)-associated systemic vasculitis (AAV) patients. Because imatinib, a selective inhibitor of the ABL, ARG, PDGFR and c-KIT tyrosine kinases, inhibits T cell activation, this study was conducted to evaluate the potential use of imatinib for the treatment AAV patients refractory to conventional therapy. In particular, we investigated the inhibition of T cell activation by this drug and its efficacy on activated T cells from anti-neutrophil cytoplasmic autoantibodies (ANCA)-associated systemic vasculitides (AASV) patients. T cell stimulation has been induced by anti-CD3/anti-CD28 antibodies or by phorbol myristate acetate (PMA)/ionomycin. T cell proliferation was analysed by tritiumthymidine incorporation. Cell cycle progression was determined by propidium iodide staining using fluorescence activated cell sorter (FACS) analysis and by RNAse protection assay (RPA). Cytokine levels were assessed by enzyme-linked immunosorbent assay. T cell proliferation was inhibited significantly by imatinib, due most probably to cell cycle arrest in the G1-phase. This was paralleled by inhibition in the expression of cyclin-dependent kinases 1 and 2 mRNA. The expression of CD25 in naive and memory T cells was decreased significantly by imatinib in activated T cells. Similarly, conversion from naive to memory T cells after T cell activation was impaired by imatinib. Imatinib did not influence interleukin-2 and tumour necrosis factor-alpha production but increased interferon-gamma production. These observed effects of imatinib were similar in T cells from AASV patients and from healthy individuals. Imatinib might be an alternative therapeutical option for AASV patients refractory to conventional therapy.
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Affiliation(s)
- A-I Kälsch
- Fifth Medical Department, University Hospital Mannheim, Medical Faculty of Mannheim of the University of Heidelberg, Germany
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Abstract
Wegener's Granulomatosis (WG) is closely associated with antineutrophil cytoplasmic autoantibodies (ANCA), particularly those directed to proteinase 3 (PR3). ANCA directed to myeloperoxidase (MPO) are associated with microscopic polyangiitis (MPA) and the Churg Strauss syndrome. PR3-ANCA associated vasculitis differs from MPO-ANCA associated vasculitis particularly in the occurrence of granulomatous inflammation and more widespread disease in the former condition. Studies in experimental animals strongly suggest a pathogenic role for MPO-ANCA, but this is less clear for PR3-ANCA. Here, we review pathogenic pathways in PR3-ANCA associated vasculitis focussing on unique patterns of PR3 expression on the neutrophil membrane in WG, as surface expression of PR3 is a prerequisite for stimulation by PR3-ANCA; (PR3-specific) cellular immunity in WG; and the role of Staphylococcus aureus carriage in this disease. These factors, together, may explain, at least in part, differences in clinical expression between MPO-ANCA and PR3-ANCA associated vasculitis.
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Affiliation(s)
- C G M Kallenberg
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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Ferraro AJ, Hassan B, Savage CO. Pathogenic mechanisms of anti-neutrophil cytoplasm antibody-associated vasculitis. Expert Rev Clin Immunol 2007; 3:543-55. [PMID: 20477159 DOI: 10.1586/1744666x.3.4.543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides are rare autoimmune diseases that can often be life threatening. They particularly affect the kidneys and lungs but can also affect many other organs. Various hypotheses have been proposed to explain the loss of tolerance against ANCA antigens (present in granules of neutrophils and monocytes); however, clear mechanisms remain elusive. Clinical observation, in vitro studies and newly developed animal models implicate ANCAs in disease pathogenesis and relevant mechanisms are now being characterized. Abnormalities in patient's T-cell populations exist and the increasingly recognized role of B cells in ANCA-associated vasculitis is also discussed.
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Affiliation(s)
- Alastair J Ferraro
- Birmingham University, Division of Immunity and Infection, Medical School, Birmingham B15 2TT, UK.
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Selamet U, Kovaliv YB, Savage CO, Harper L. ANCA-associated vasculitis: new options beyond steroids and cytotoxic drugs. Expert Opin Investig Drugs 2007; 16:689-703. [PMID: 17461741 DOI: 10.1517/13543784.16.5.689] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Small vessel vasculitic syndromes--Wegener's granulomatosis, microscopic polyangiitis and renal limited vasculitis (which are associated with circulating antineutrophil cytoplasmic autoantibodies)--are an important cause of renal failure. Present immunosuppressive regimens that are based on cyclophosphamide have significantly increased survival rates. However, these treatments are toxic, increase the risk of infection and do not cure disease. Therefore, newer approaches are required. Understanding disease pathogenesis has allowed rational use for newer therapies such as rituximab, which depletes B cells. Unfortunately, blockade of promising targets such as TNF-alpha, which was thought to be a pivotal cytokine in inflammation, has not shown benefit in a randomised controlled trial. Better understanding of the pathogenesis of the disease is the key to the development of novel targeted therapies, which are urgently required to improve patient prognosis. Gene therapy with targeted delivery of specific proteins is an exciting future prospect.
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Affiliation(s)
- Umut Selamet
- University of Birmingham, Division of Immunity and Infection, The Medical School, Edgbaston, Birmingham, B15 2TT, UK
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Kallenberg CGM, Heeringa P, Stegeman CA. Mechanisms of Disease: pathogenesis and treatment of ANCA-associated vasculitides. ACTA ACUST UNITED AC 2007; 2:661-70. [PMID: 17133251 DOI: 10.1038/ncprheum0355] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 10/16/2006] [Indexed: 01/13/2023]
Abstract
Wegener's granulomatosis and microscopic polyangiitis are idiopathic systemic vasculitides strongly associated with antineutrophil cytoplasmic autoantibodies (ANCA). In Wegener's granulomatosis, ANCA are mostly directed against proteinase 3 (PR3), whereas in microscopic polyangiitis ANCA are directed against myeloperoxidase; increases in levels of these autoantibodies precede or coincide with clinical relapses in many cases. In vitro, ANCA can further activate primed neutrophils to release reactive oxygen species and lytic enzymes, and, in conjunction with neutrophils, can damage and lyse endothelial cells. Patients with Wegener's granulomatosis or microscopic polyangiitis have an increased percentage of neutrophils that constitutively express PR3 on their membrane. These neutrophils can be stimulated by ANCA, without priming. In vivo, transfer of splenocytes from myeloperoxidase-deficient mice immunized with mouse myeloperoxidase into wild-type mice resulted in pauci-immune systemic vasculitis. A similar experiment in PR3-deficient mice did not cause significant vasculitic lesions. Together, clinical, in vitro and in vivo experimental data support a pathogenic role for ANCA in Wegener's granulomatosis and microscopic polyangiitis, although this role is more evident for myeloperoxidase-specific ANCA than for PR3-specific ANCA. Several controlled trials have led to an evidence-based approach for the treatment of ANCA-associated vasculitis, and further studies, based on new insights into pathogenesis, are in progress.
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Affiliation(s)
- Cees G M Kallenberg
- Department of Rheumatology and Clinical Immunology, University Medical Center, University of Groningen, 9700 RB Groningen, The Netherlands.
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van Paassen P, Tervaert JWC, Heeringa P. Mechanisms of vasculitis: how pauci-immune is ANCA-associated renal vasculitis? Nephron Clin Pract 2007; 105:e10-6. [PMID: 17108705 DOI: 10.1159/000096960] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Indexed: 12/31/2022] Open
Abstract
Both the innate and the acquired immune system are involved in the pathophysiology of renal vasculitis. However, anti-neutrophil cytoplasmic antibody (ANCA)-associated renal vasculitis is characterized by a 'pauci-immune' pattern of immunofluorescence during kidney biopsy, indicating the relative lack of immunoglobulin and complement deposition within the kidney. On the other hand, evidence is accumulating that ANCA, autoantibodies against constituents of primary granules of neutrophils and the lysosomes of monocytes, play a pathogenic role in renal vasculitis. In this review we will discuss both in vitro and in vivo experimental data providing compelling evidence that ANCA are a primary pathogenic factor in renal vasculitis, mainly by augmenting leukocyte-endothelial interactions. We will also address novel data, pointing at the role of, in addition to ANCA, non-specific proinflammatory signals. Finally, we propose a working hypothesis of the pathogenesis of ANCA-associated renal vasculitis.
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Affiliation(s)
- P van Paassen
- Department of Clinical and Experimental Immunology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, The Netherlands.
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Parambil JG, Keogh KA, Fervenza FC, Ryu JH. Microscopic Polyangiitis Associated With Thymoma, Exacerbating After Thymectomy. Am J Kidney Dis 2006; 48:827-31. [PMID: 17060003 DOI: 10.1053/j.ajkd.2006.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Accepted: 07/10/2006] [Indexed: 11/11/2022]
Abstract
A variety of autoimmune diseases has been associated with thymoma, and thymectomy does not always induce remission of these disorders. This case report describes a 50-year-old man who presented with migratory polyarthritis and an anterior mediastinal mass that proved to be a thymoma. Five months after thymectomy, the patient presented with worsening polyarthritis, hematuria, and azotemia. Based on elevated titers of antineutrophil cytoplasmic antibodies directed against myeloperoxidase and renal biopsy showing crescentic necrotizing glomerulonephritis, microscopic polyangiitis was diagnosed. After remission-induction therapy with prednisone and cyclophosphamide, articular symptoms and renal manifestations resolved. Microscopic polyangiitis was not associated previously with thymoma, and this case broadens the spectrum of autoimmune disorders seen with this tumor. Progressive disease seen after thymectomy in this patient has potential implications regarding the pathophysiological characteristics of microscopic polyangiitis and management of patients with this clinical association.
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Affiliation(s)
- Joseph G Parambil
- Division of Pulmonary and Critical Care Medicine, Desk East 18, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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38
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Abstract
Hewins et al. show that IL-18 is expressed in the kidneys of patients with ANCA-associated glomerulonephritis, and that IL-18 primes neutrophils via p38 MAPK. These findings suggest a role for IL-18, including IL-18-induced T(H)1 polarization and IFN-gamma production, in the progression of ANCA disease.
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Affiliation(s)
- B M Pressler
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Shovman O, Gilburd B, Zandman-Goddard G, Sherer Y, Shoenfeld Y. Pathogenic role and clinical relevance of antineutrophil cytoplasmic antibodies in vasculitides. Curr Rheumatol Rep 2006; 8:292-8. [PMID: 16839508 DOI: 10.1007/s11926-006-0012-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Within the last year, a growing body of evidence for a distinct role of antineutrophil cytoplasmic antibodies (ANCA) in the pathogenesis of ANCA-associated vasculitides (AAV) has developed. An experimental model of myeloperoxidase (MPO)-ANCA-associated vasculitis provided direct and convincing in vivo evidence that MPO-ANCA are primary pathogenic factors in small-vessel vasculitis by augmenting of leukocyte-vessel wall interaction and leukocyte-mediated vascular injury. Determination of bacterial lipopolysaccharide (LPS) effects on disease severity in a mouse model of anti-MPO-induced glomerulonephritis showed that ANCA and other proinflammatory stimuli of infectious origin acted in synergism in the development of destructive inflammation.
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Affiliation(s)
- Ora Shovman
- Department of Medicine B, Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel
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Morgan MD, Harper L, Williams J, Savage C. Anti-neutrophil cytoplasm-associated glomerulonephritis. J Am Soc Nephrol 2006; 17:1224-34. [PMID: 16624931 DOI: 10.1681/asn.2005080882] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Wegener's granulomatosis, microscopic polyangiitis, and renal limited vasculitis are associated with circulating anti-neutrophil cytoplasm antibodies and are an important cause of rapidly progressive glomerulonephritis. This review gives an account of recent advances in the understanding of the pathogenesis underlying these conditions and how these may lead to future treatments. Consideration is given to recent clinical trials in the management of anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitides.
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Affiliation(s)
- Matthew David Morgan
- Division of Immunity and Infection, The Medical School, University of Birmingham, Vincent Drive, Birmingham, United Kingdom
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41
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Moosig F, Schoch R, Kneba M. [T-large granular lymphocyte leukaemia. An important differential diagnosis to Felty's syndrome]. Z Rheumatol 2006; 65:447-51. [PMID: 16450150 DOI: 10.1007/s00393-005-0013-4] [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: 05/09/2005] [Accepted: 08/16/2005] [Indexed: 10/25/2022]
Abstract
T-Large Granular Lymphocyte (T-LGL) leukaemia is a rare clonal disease characterized by neutropenia and/or anaemia. Because of its strong association with rheumatoid arthritis (RA), T-LGL leukaemia is an important differential diagnosis to Felty's syndrome. This differentiation might be especially difficult since, in severe RA with extraarticular manifestations, there is often an expanded memory effector T-cell population which can hardly be separated from T-LGL leukaemia cells by means of immunophenotyping. The main criterion for T-LGL leukaemia is the detection of a clonal T-cell-receptor rearrangement by PCR. First-line therapy consists of weekly low-dose methotrexate. Alternatively, other immunosuppressives or cytotoxic agents can be useful. There are very limited data from therapy studies. The German CLL study group has initiated a protocol using parenteral low-dose methotrexate as first-line therapy and fludarabine as second-line medication.
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Affiliation(s)
- F Moosig
- Medizinische Klinik des Universitätsklinikum Schleswig-Holstein, Campus Kiel.
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