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Tabibi P, Shiari R, Shafiee A, Rahmani K, Saravi N. Case report of streptococcal infection as a potential precipitating factor in cutaneous polyarteritis nodosa in pediatric patients. Clin Case Rep 2024; 12:e9038. [PMID: 38827940 PMCID: PMC11142904 DOI: 10.1002/ccr3.9038] [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: 04/23/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message This pediatric case report underscores the importance of maintaining a high clinical suspicion for polyarteritis nodosa (PAN) in patients presenting with atypical features, such as migratory arthritis and subcutaneous nodules. Importantly, it highlights the focus on the potential relationship between streptococcal infection and cutaneous PAN. Early recognition and prompt, aggressive treatment is critical, as PAN can be a life-threatening condition if left unmanaged. This case emphasizes the need for a multidisciplinary approach to effectively identify and manage this rare vasculitis disorder in the pediatric population. Abstract Polyarteritis nodosa (PAN) is a rare and life-threatening vasculitis with diverse clinical presentations, posing a diagnostic challenge. Early recognition and prompt intervention are crucial to prevent organ damage. We present the case of an 8-year-old boy who exhibited atypical symptoms including migratory arthritis, myalgia, digital discoloration and ischemic changes, and subcutaneous nodules. Initial concerns for septic arthritis were ruled out. A comprehensive evaluation revealed elevated inflammatory markers and a confirmatory skin biopsy demonstrating active leukocytoclastic vasculitis, are highly suggestive of a diagnosis of PAN. Notably, elevated ASO titers suggested a possible concurrent streptococcal infection. The aggressive treatment approach with high-dose aspirin, steroids, methotrexate, and tocilizumab is justified given the severity of the patient's symptoms and the nature of the disease process. This case underscores the importance of considering PAN in the differential diagnosis for children presenting with atypical features. Early diagnosis and prompt intervention, including addressing potential infectious triggers, are crucial for optimal outcomes in pediatric PAN.
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Affiliation(s)
- Pooneh Tabibi
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Reza Shiari
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Ali Shafiee
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Khosro Rahmani
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Niloofar Saravi
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
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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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Affiliation(s)
- Sabah Osmani
- University of New Mexico School of Medicine, Albuquerque, New Mexico
- Correspondence to: Sabah Osmani, BA, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106.
| | - Jiasen Wang
- University of New Mexico Department of Dermatology, Albuquerque, New Mexico
| | - Hillary Elwood
- University of New Mexico Department of Dermatology, Albuquerque, New Mexico
| | - Therese A. Holguin
- University of New Mexico Department of Dermatology, Albuquerque, New Mexico
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Abstract
Direct immunofluorescence (DIF) remains a valuable tool that may be underused because of perceived challenges in the interpretation, limitations, and processing of DIF specimens. The aim of this review is to provide a practical guide for appropriately incorporating DIF in a variety of clinical diseases, such as autoimmune blistering disorders. In vasculitis, the role of DIF continues to evolve, particularly in the setting of IgA vasculitis. Although typically not indicated for the workup of connective tissue disease, DIF may be helpful in cases with negative serologies, nondiagnostic histologic findings, or scarring alopecia. Practical pearls for biopsy technique, specimen handling, and storage are also discussed.
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Hoffman KP, Chung C, Parikh S, Kwatra SG, Trinidad J, Kaffenberger BH. Immunoglobulin A expression in adult cutaneous leukocytoclastic vasculitis and its effect on hospital outcomes. J Am Acad Dermatol 2020; 83:1511-1513. [PMID: 32585279 DOI: 10.1016/j.jaad.2020.06.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/11/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Kalyn P Hoffman
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Catherine Chung
- The Ohio State University Wexner Medical Center Division of Dermatology; The Ohio State University, Wexner Medical Center, Department of Pathology, Columbus, Ohio
| | - Samir Parikh
- The Ohio State University, Wexner Medical Center, Division of Nephrology, Columbus, Ohio
| | - Shawn G Kwatra
- Johns Hopkins University Department of Dermatology, Baltimore, Maryland
| | - John Trinidad
- The Ohio State University Wexner Medical Center Division of Dermatology
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Bağcı IS, Aoki R, Krammer S, Ruzicka T, Sárdy M, Hartmann D. Ex vivo confocal laser scanning microscopy: An innovative method for direct immunofluorescence of cutaneous vasculitis. JOURNAL OF BIOPHOTONICS 2019; 12:e201800425. [PMID: 31021054 DOI: 10.1002/jbio.201800425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/05/2019] [Accepted: 03/07/2019] [Indexed: 06/09/2023]
Abstract
Ex vivo confocal laser scanning microscopy (ex vivo CLSM) offers an innovative diagnostic approach through vertical scanning of skin samples with a resolution close to conventional histology. In addition, it enables fluorescence detection in tissues. We aimed to assess the applicability of ex vivo CLSM in the detection of vascular immune complexes in cutaneous vasculitis and to compare its diagnostic accuracy with direct immunofluorescence (DIF) microscopy. Eighty-two sections of 49 vasculitis patients with relevant DIF microscopy findings were examined using ex vivo CLSM following staining with fluorescent-labeled IgG, IgM, IgA, C3 and fibrinogen antibodies. DIF microscopy showed immunoreactivity of vessels with IgG, IgM, IgA, C3 and Fibrinogen in 2.0%, 49.9%, 12.2%, 59.2% and 44.9% of the patients, respectively. Ex vivo CLSM detected positive vessels with the same antibodies in 2.0%, 38.8%, 8.2%, 42.9% and 36.7% of the patients, respectively. The detection rate of positive superficial dermal vessels was significantly higher in DIF microscopy as compared to ex vivo CLSM (P < .05). Whereas, ex vivo CLSM identified positive deep dermal vessels more frequently compared to DIF microscopy. In conclusion, ex vivo CLSM could identify specific binding of the antibodies in vessels and showed a comparable performance to conventional DIF microscopy in diagnosing vasculitis.
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Affiliation(s)
- Işın S Bağcı
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Rui Aoki
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Krammer
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Ruzicka
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Miklós Sárdy
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Daniela Hartmann
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
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Neufeld M, Molyneux K, Pappelbaum KI, Mayer-Hain S, von Hodenberg C, Ehrchen J, Barratt J, Suzuki Y, Sunderkötter C. Galactose-deficient IgA1 in skin and serum from patients with skin-limited and systemic IgA vasculitis. J Am Acad Dermatol 2019; 81:1078-1085. [PMID: 30902725 DOI: 10.1016/j.jaad.2019.03.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/02/2019] [Accepted: 03/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND IgA vasculitis (IgAV) encompasses a systemic form involving kidneys, gut, skin, or joints, and a skin-limited form. One characteristic feature of systemic IgAV is deposition of galactose-deficient IgA1 (GD-IgA1) in kidneys (as in IgA nephropathy). The relevance of GD-IgA1 for cutaneous vasculitis is unknown. OBJECTIVE We investigated whether GD-IgA1 is deposited perivascularly in systemic and also skin-limited IgAV and whether its serum levels differ between both forms. METHODS In a case-control study, deposition of GD-IgA1 was analyzed immunohistochemically by KM55 antibody in skin biopsy specimens from 12 patients with skin-limited IgAV and 4 with systemic IgAV. GD-IgA1 levels were compared by enzyme-linked immunosorbent assay in sera from 15 patients each with skin-limited and systemic IgAV and from 11 healthy individuals. RESULTS All biopsy samples from systemic IgAV, and also from skin-limited IgAV, revealed perivascular GD-IgA1 deposition. The average GD-IgA1 concentration in serum was significantly higher in systemic IgAV than in skin-limited IgAV, despite overlap between the groups. LIMITATIONS Although high GD-IgA1 levels may be predictive of systemic IgAV, patient numbers were too low to determine cutoff values for systemic versus skin-limited IgAV. CONCLUSION Perivascular GD-IgA1 deposition is a prerequisite for systemic and skin-limited IgAV; however, high GD-IgA1 levels in some patients with systemic IgAV suggest a dose-dependent effect of GD-IgA1 in IgAV.
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Affiliation(s)
- Matthias Neufeld
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany; Department of Dermatology, University of Münster, Münster, Germany
| | - Karen Molyneux
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | - Karin I Pappelbaum
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany
| | - Sarah Mayer-Hain
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany
| | - Christina von Hodenberg
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany; Department of Dermatology, University of Münster, Münster, Germany
| | - Jan Ehrchen
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany; Department of Dermatology, University of Münster, Münster, Germany
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Cord Sunderkötter
- Department of Translational Dermatoinfectiology, University of Münster, Münster, Germany; Department of Dermatology and Venereology, University Hospital of Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
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Role of Direct Immunofluorescence in Cutaneous Small-Vessel Vasculitis: Experience From a Tertiary Center. Am J Dermatopathol 2018; 40:661-666. [DOI: 10.1097/dad.0000000000001170] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Feasel P, Billings SD, Bergfeld WF, Piliang MP, Fernandez AP, Ko JS. Direct immunofluorescence testing in vasculitis-A single institution experience with Henoch-Schönlein purpura. J Cutan Pathol 2017; 45:16-22. [DOI: 10.1111/cup.13054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/21/2017] [Accepted: 09/29/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Patrick Feasel
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Steven D. Billings
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Wilma F. Bergfeld
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Melissa P. Piliang
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Anthony P. Fernandez
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
| | - Jennifer S. Ko
- Departments of Pathology and Dermatology; Cleveland Clinic Foundation; Cleveland Ohio
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11
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Clinicopathologic correlation of 282 leukocytoclastic vasculitis cases in a tertiary hospital: a focus on direct immunofluorescence findings at the blood vessel wall. Immunol Res 2016; 65:395-401. [DOI: 10.1007/s12026-016-8850-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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12
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Yüksel S, Çağlar M, Evrengül H, Becerir T, Tepeli E, Ergin A, Çiçek EA, Aybek H, Yalçın N, Demirkan NÇ. Could serum pentraxin 3 levels and IgM deposition in skin biopsies predict subsequent renal involvement in children with Henoch-Schönlein purpura? Pediatr Nephrol 2015; 30:969-74. [PMID: 25543194 DOI: 10.1007/s00467-014-3026-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 11/26/2014] [Accepted: 12/01/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the potential of serum pentraxin 3 (PTX3) values as an early predictor of subsequent renal involvement in patients with Henoch-Schönlein purpura (HSP) with no abnormalities on urinary examination and in renal function tests at disease onset. METHODS This was a prospective cohort study which included 60 pediatric patients with HSP (age range 3-15 years) who were diagnosed between February 2011 and October 2012 and 60 age- and sex-matched healthy controls. The patients were followed up for at least 18 months. Clinical findings were recorded for all patients at first examination, and blood samples for routine laboratory parameters and PTX3 value as well as skin biopsy specimens were obtained from each subject. RESULTS Of the 60 patients with HSP, 29 (48.3 %) developed subsequent renal involvement, of whom four underwent kidney biopsy. The mean serum PTX3 level of patients with subsequent renal involvement was significantly higher than those of patients without renal involvement and of the controls (2.20 ± 1.30 vs. 1.36 ± 0.85 and 1.03 ± 0.7 ng/ml, respectively; p = 0.004). Immunofluorescence evaluation of skin biopsy revealed that in addition to immunoglobulin A (IgA) deposition, the IgM deposition was significantly associated with subsequent renal involvement (p = 0.008). CONCLUSIONS A high PTX3 level and IgM staining in skin biopsies from HSP patients may be harbingers of subsequent renal involvement.
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Affiliation(s)
- Selçuk Yüksel
- Department of Pediatric Nephrology, Pamukkale University School of Medicine, Denizli, Turkey,
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Clinical Significance of Immunoglobulin Deposition in Leukocytoclastic Vasculitis. Am J Dermatopathol 2014; 36:723-9. [DOI: 10.1097/dad.0000000000000122] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.
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Affiliation(s)
- Tracy V Ting
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4010, Cincinnati, OH 45229, USA.
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Nandeesh B, Tirumalae R. Direct immunofluorescence in cutaneous vasculitis: experience from a referral hospital in India. Indian J Dermatol 2013; 58:22-5. [PMID: 23372207 PMCID: PMC3555367 DOI: 10.4103/0019-5154.105280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Cutaneous vasculitis is commonly recognized and biopsied, owing to ease of access. Most biopsies are also subjected to direct immunofluorescence (DIF), though the rates of positivity vary. This is an attempt to assess the utility of DIF and glean data that will help optimize the test. Objective: To assess the diagnostic utility of DIF in cutaneous vasculitis. Materials and Methods: All cases of suspected cutaneous vasculitis submitted for DIF between 2004 and 2010 were included. Clinical data, histopathologic diagnosis, DIF findings and additional tests such as anti nuclear antibody (ANA), anti neutrophil cytoplasmic antibody (ANCA) (where done) were noted. Results: There were 198 patients in the study group, with a female predominance. Purpura was the commonest clinical presentation. Extracutaneous involvement was noted in 29% of patients’ i.e., joint pain, abdominal pain and hematuria. Leukocytoclastic vasculitis was the commonest histologic diagnosis. DIF showed an overall positivity of 39% (n = 77) with C3 in 26% (n = 52) and IgA in 23% (n = 46) cases. Forty one cases of suspected Henoch Schonlein Purpura (HSP) showed IgA positivity. The timing of biopsy ranged from <3 days to six months, with 38% being done within seven days. DIF was positive in 86% of biopsies performed within seven days of onset of lesions. Sixty percent of patients with extracutaneous manifestations showed deposits. Vascular deposits were also noted in dermatitis herpetiformis, dematomyositis and prurigo. Conclusion: DIF positivity is strongly influenced by the timing of the biopsy and the presence of extracutaneous features. Its clinical value is greatest in patients with HSP, being contributory in 90% of cases. Vascular deposits may be seen in non-vasculitic conditions and need clinicopathologic correlation.
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Affiliation(s)
- Bn Nandeesh
- Department of Pathology, St. John's Medical College, Bangalore, India
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Gota CE, Calabrese LH. Diagnosis and treatment of cutaneous leukocytoclastic vasculitis. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.12.79] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Magro CM, Roberts-Barnes J, Crowson AN. Direct Immunofluorescence Testing in the Diagnosis of Immunobullous Disease, Collagen Vascular Disease, and Vascular Injury Syndromes. Dermatol Clin 2012; 30:763-98, viii. [DOI: 10.1016/j.det.2012.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Linskey KR, Kroshinsky D, Mihm MC, Hoang MP. Immunoglobulin-A–associated small-vessel vasculitis: A 10-year experience at the Massachusetts General Hospital. J Am Acad Dermatol 2012; 66:813-22. [DOI: 10.1016/j.jaad.2011.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/07/2011] [Accepted: 06/09/2011] [Indexed: 10/17/2022]
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Kroshinsky D, Stone JH, Nazarian RM. Case records of the Massachusetts General Hospital. Case 22-2011. A 79-year-old man with a rash, arthritis, and ocular erythema. N Engl J Med 2011; 365:252-62. [PMID: 21774714 DOI: 10.1056/nejmcpc1100929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, and the Harvard Medical School, Boston, USA
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The use of C3d and C4d immunohistochemistry on formalin-fixed tissue as a diagnostic adjunct in the assessment of inflammatory skin disease. J Am Acad Dermatol 2009; 59:822-33. [PMID: 19119098 DOI: 10.1016/j.jaad.2008.06.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Revised: 06/03/2008] [Accepted: 06/13/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Direct immunofluorescent (DIF) testing defines an important diagnostic adjunct in the classification of various inflammatory skin conditions; it requires fresh tissue, a laboratory equipped to perform the procedure, and a pathologist skilled in its interpretation. Although advances have been made in the development of antibodies that can be applied to paraffin-embedded tissue, there has been no reported success on the application of paraffin tissue-based immunohistochemistry as a potential substitute for DIF testing on skin biopsy material. OBJECTIVE We applied C3d and C4d immunohistochemistry on paraffin-embedded, formalin-fixed tissue to define a potential application of these two antibodies as a diagnostic adjunct in the evaluation of various inflammatory skin diseases. DESIGN A natural language search identified cases submitted for both light microscopic and DIF studies from July 2006 to August 2007. We prospectively included similar cases encountered from August 2007 to March 2008. We correlated the C3d and C4d staining pattern with the DIF and light microscopic findings. RESULTS All cases of scarring discoid lupus erythematosus (LE) (20/20) and systemic LE (5/5) showed prominent granular C3d along the dermoepidermal junction (DEJ) and a positive lupus band test result in the latter by DIF. All systemic LE cases demonstrated granular DEJ C4d with C3d or C4d in blood vessels (BV). There was a negative lupus band test result without DEJ C3d or C4d in all cases of subacute cutaneous lupus erythematosus (SCLE) (15/15). There were, however, deposits of C4d within epidermal keratinocytes (7/7), corresponding to IgG decoration of keratinocytes by DIF and the presence of anti-Ro antibodies. Dermatomyositis cases showed prominent mural C3d and C4d in BV corresponding to C5b-9 by DIF (12/12) and one case of hydroxyurea-induced dermatomyositis lacked this staining. Although by DIF all dermatomyositis cases had a negative lupus band test result, 25% of cases showed staining for C3d along the DEJ (3/9). Bullous pemphigoid cases demonstrated homogenous DEJ C3d (17/17) whereas C4d was characteristically negative; there was 100% concordance with linear IgG and C3d by DIF. Eighty two percent of pemphigus cases demonstrated prominent intercellular C3d and C4d, roughly mirroring the intercellular pattern for IgG and complement seen by DIF (9/11). Porphyria cases showed homogeneous and granular C3d (11/11) and C4d (7/11), mirroring the vascular immunoglobulin and C5b-9 by DIF. All cases of urticarial (5), leukocytoclastic (6), and lymphocytic (1) vasculitis exhibited prominent mural C3d and C4d in BV, whereas Henoch-Schönlein purpura (10/10) showed primarily mural BV C3d without C4d, with IgA by DIF. Three cases of relapsing polychondritis showed C3d and C4d within chondrocyte nuclei (3/3), in contrast to negative staining in chondrodermatitis nodularis helicis (0/2). Hypersensitivity reactions were negative for C3d and C4d. LIMITATIONS The small sample size in each category is a limitation. The lack of literature precedent with regard to immunohistochemical assessment of extracellular antigens on paraffin-embedded tissue in skin samples is another limitation of this study. CONCLUSIONS When correlated with the light microscopic and clinical findings, the C3d and C4d assay has significant application in the assessment of select inflammatory skin diseases including vasculopathic conditions, collagen vascular disease, and autoimmune vesiculobullous disorder. It may prompt further DIF testing or, in some instances, may even define a reasonable substitute for DIF and/or add to the morphologic assessment of a biopsy specimen submitted for routine light microscopic assessment primarily in the setting of autoimmune vesiculobullous disease and collagen vascular disease.
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Abstract
Identification of vasculitis by skin biopsy represents the diagnostic gold standard. Skin biopsies should be taken from fresh lesions or from margin of an ulceration and should contain all layers of the skin including subcutis. Classification of vasculitis is based on histological criteria considering the size of the predominantly affected vessel, the distribution of vasculitis in the dermis and subcutis, and the predominant inflammatory cell-type. In cutaneous vasculitis, small and medium-sized vessels of the arterial and/or venous system are predominant affected. Vasculitis of the larger-sized blood vessels is based on inflammatory cells within the wall of the vessel; in small vessel vasculitis, additional features include fibrin within the vessel wall and/or an intraluminal thrombus and/or perivascular and interstitial infiltrates of neutrophils, nuclear dust and extravasated erythrocytes are required for the diagnosis of vasculitis. Leukocytoclastic vasculitis is the most common form of cutaneous vasculitis. An correct diagnosis requires careful correlation of medical history, the clinical, serological, imaging and direct immunofluorescence data, and histologic findings.
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Xu LY, Esparza EM, Anadkat MJ, Crone KG, Brasington RD. Cutaneous manifestations of vasculitis. Semin Arthritis Rheum 2008; 38:348-60. [PMID: 18355896 DOI: 10.1016/j.semarthrit.2008.01.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 12/11/2007] [Accepted: 01/05/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To discuss the clinical features, diagnostic evaluation, and treatment options for cutaneous vasculitis. METHODS The literature in the PubMed database was reviewed regarding the presentation, pathophysiology, clinical workup, and treatment of cutaneous vasculitis. RESULTS Available classification criteria of vasculitis are based on histopathologic criteria or clinicohistologic features. These have been designed more for research purposes than for clinical application. Skin findings such as palpable purpura, nodules, urticaria, ulcers, and infarction are clues to the presence of vasculitis. Pathologic findings of fibrinoid necrosis, infiltration by neutrophils or lymphocytes, and deposition of complement and immunoglobulin may be helpful in reaching a specific diagnosis. However, there is considerable overlap across different conditions. CONCLUSIONS The correct diagnosis of cutaneous manifestations of vasculitis requires an understanding of vasculitis classification, recognition of specific clinical patterns, and the ability to interpret histopathologic data.
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Affiliation(s)
- Lisa Y Xu
- Rheumatology and Dermatology, Department of Internal Medicine and Lauren V. Ackerman Laboratory of Surgical Pathology, Washington University School of Medicine, St. Louis, MO, USA
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23
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Al-Mutairi N. Spectrum of cutaneous vasculitis in adult patients from the Farwaniya region of Kuwait. Med Princ Pract 2008; 17:43-8. [PMID: 18059100 DOI: 10.1159/000109589] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the clinical profile, etiologic factors, disease associations, and the laboratory profile of adult patients with cutaneous leukocytoclastic vasculitis (LV) presenting to the Dermatology Department at Farwaniya Hospital, Kuwait. SUBJECTS AND METHODS The medical records of 57 adult patients (>18 years) with biopsy-proven cutaneous LV from January 2004 to June 2006 at Farwaniya Hospital were reviewed. RESULTS Of the 57 patients studied, 21 (36.8%) were classified as having primary cutaneous small vessel vasculitis. The most common type of skin lesions found was palpable purpura seen in 29 (50.9%) patients. No possible cause for the cutaneous vasculitis could be identified in 21 patients. Extracutaneous involvement was seen in 32 (56.1%) patients of which 29 had joint involvement. The most frequent laboratory abnormality was an elevated erythrocyte sedimentation rate (ESR). Altered laboratory evaluation in the form of leukocytosis, raised antistreptolysin O titers and urine abnormalities were found in association with systemic vasculitis. IgA deposits were present in 33 patients. Risk factors for chronicity of cutaneous LV were female sex, advanced age, unidentified etiology, absence of fever and presence of joint involvement. CONCLUSION The commonest type of LV in Kuwait is primary cutaneous small vessel vasculitis. The most frequent laboratory abnormality associated with LV was increased ESR.
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Brandt HRC, Arnone M, Valente NYS, Criado PR, Sotto MN. Vasculite cutânea de pequenos vasos: etiologia, patogênese, classificação e critérios diagnósticos - Parte I. An Bras Dermatol 2007. [DOI: 10.1590/s0365-05962007000500002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Vasculite é a inflamação da parede dos vasos. Pode variar em gravidade desde doença autolimitada de um único órgão até doença grave com risco de morte por falência de múltiplos órgãos. Existem várias causas, embora só se apresente por poucos padrões histológicos de inflamação vascular. Vasos de qualquer tipo e em qualquer órgão podem ser afetados, resultando em ampla variedade de sinais e sintomas. Diferentes vasculites com apresentações clínicas indistinguíveis têm evolução e tratamento muito diferentes. Essa condição representa desafio para o médico, incluindo classificação, diagnóstico, exames laboratoriais pertinentes, tratamento e seguimento adequado. Neste artigo são revistos a classificação, a etiologia, a patogênese e os critérios diagnósticos das vasculites cutâneas.
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Abstract
Vasculitis presents with a range of clinical manifestations, many of which affect the skin. Diagnosing and classifying vasculitis can prove challenging. Particularly given the lack of unified criteria that are both useful as a research tool and clinically relevant. Also, vasculitis may be secondary to a wide range of conditions, making the prompt recognition and treatment of associated disorders essential for appropriate patient management. This article will highlight the classification, pathogenesis, clinical presentation, diagnosis, evaluation, and treatment of the cutaneous vasculitides.
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Affiliation(s)
- Tatiana M Grzeszkiewicz
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA 94305-5334, USA
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26
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Abstract
A broad and diverse spectrum of vasculitic syndromes exists. These syndromes affect the skin with varying levels of associated systemic manifestations, running the gamut from a self-limited, localized, cutaneous phenomenon to rapidly progressive, multiorgan disease. The majority of cases of cutaneous vasculitis will show a neutrophilic small vessel vasculitis that can be either a primary (idiopathic) disorder (eg, cutaneous leukocytoclastic angiitis) or a secondary disorder that is associated with drugs, infection (eg, streptococcal infection, viral hepatitis), or underlying disease (eg, connective tissue disease, malignancy). Biopsy is the gold standard for the diagnosis of cutaneous vasculitis and also necessary for the detection of cutaneous vascular immune complexes by direct immunofluorescence. Based on the type of vessel disrupted by inflammation (small and/or muscular), the distribution of vasculitis in the dermis and subcutis, and predominate inflammatory cell-type mediating vessel wall damage, a list of relevant differential diagnoses can be generated. This histologic information coupled with extravascular findings such as tissue eosinophilia, tissue neutrophilia, and/or granulomas, plus pathophysiologic markers such as direct immunofluorescent examination for immune complexes and serologic evaluation for antineutrophil cytoplasmic antibodies allows for more accurate diagnosis of specific vasculitic entities. Herein, we review both primary and secondary vasculitic syndromes that affect the skin and show a small vessel neutrophilic mediated vasculitis.
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Affiliation(s)
- J Andrew Carlson
- Divisions of Dermatology and Dermatopathology, Albany Medical College, Albany, NY 12208, USA.
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27
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Abstract
Vasculitis is histologically defined as inflammatory cell infiltration and destruction of blood vessels. Vasculitis is classified as primary (idiopathic, eg, cutaneous leukocytoclastic angiitis, Wegener's granulomatosis) or secondary, a manifestation of connective tissue diseases, infections, adverse drug eruptions, or a paraneoplastic phenomenon. Cutaneous vasculitis, manifested as urticaria, purpura, hemorrhagic vesicles, ulcers, nodules, livedo, infarcts, or digital gangrene, is a frequent and often significant component of many systemic vasculitic syndromes such as lupus or rheumatoid vasculitis and antineutrophil cytoplasmic antibody-associated primary vasculitic syndromes such as Churg-Strauss syndrome. In most instances, cutaneous vasculitis represents a self-limited, single-episode phenomenon, the treatment of which consists of general measures such as leg elevation, warming, avoidance of standing, cold temperatures and tight fitting clothing, and therapy with antihistamines, aspirin, or nonsteroidal anti-inflammatory drugs. More extensive therapy is indicated for symptomatic, recurrent, extensive, and persistent skin disease or coexistence of systemic disease. For mild recurrent or persistent disease, colchicine and dapsone are first-choice agents. Severe cutaneous and systemic disease requires more potent immunosuppression (prednisone plus azathioprine, methotrexate, cyclophosphamide, cyclosporine, or mycophenolate mofetil). In cases of refractory vasculitis, plasmapheresis and intravenous immunoglobulin are viable considerations. The new biologic therapies that work via cytokine blockade or lymphocyte depletion such as tumor alpha inhibitor infliximab and the anti-B-cell antibody rituximab, respectively, are showing benefit in certain settings such as Wegener's granulomatosis, antineutrophil cytoplasmic antibody-associated vasculitis, Behçet's disease, and cryoglobulinemic vasculitis.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, MC-81, NY 12208, USA.
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28
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Barnadas MA, Curell R, Alomar A. Direct immunofluorescence in granuloma faciale: a case report and review of literature. J Cutan Pathol 2006; 33:508-11. [PMID: 16872475 DOI: 10.1111/j.1600-0560.2006.00451.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 49-year-old male presented at our department with erythematous brownish plaques in the malar areas and left cheek of 9 years' evolution. Histopathological study revealed a dense, predominantly perivascular, inflammatory infiltrate in the reticular dermis. The infiltrate was composed of abundant neutrophils, lymphocytes, histiocytes, and eosinophils. Leukocytoclasia and fibrin in some vessel walls were also observed. The patient was diagnosed with granuloma faciale (GF). Direct immunofluorescence (DIF) study showed heavy immunoglobulin G (IgG) and less intense deposits of IgA, IgM, C(3) and C(1q) surrounding superficial and deep vessels of the reticular dermis. Perivascular and diffuse fibrinogen deposits were also present. No deposits were detected at the dermoepidermal junction. Our findings lend support to the hypothesis that classical pathway activation of complement may be involved in the development of vasculitis in GF.
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Affiliation(s)
- M A Barnadas
- Department of Dermatology, Hospital de la Sta. Creu i St. Pau, Barcelona, Spain.
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Carlson JA, Ng BT, Chen KR. Cutaneous Vasculitis Update: Diagnostic Criteria, Classification, Epidemiology, Etiology, Pathogenesis, Evaluation and Prognosis. Am J Dermatopathol 2005; 27:504-28. [PMID: 16314707 DOI: 10.1097/01.dad.0000181109.54532.c5] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vasculitis, inflammation of the vessel wall, can result in mural destruction with hemorrhage, aneurysm formation, and infarction, or intimal-medial hyperplasia and subsequent stenosis leading to tissue ischemia. The skin, in part due to its large vascular bed, exposure to cold temperatures, and frequent presence of stasis, is involved in many distinct as well as un-named vasculitic syndromes that vary from localized and self-limited to generalized and life-threatening with multi-organ disease. To exclude mimics of vasculitis, diagnosis of cutaneous vasculitis requires biopsy confirmation where its acute signs (fibrinoid necrosis), chronic signs (endarteritis obliterans), or past signs (acellular scar of healed arteritis) must be recognized and presence of extravascular findings such as patterned fibrosis or collagenolytic granulomas noted. Although vasculitis can be classified by etiology, many cases have no identifiable cause, and a single etiologic agent can elicit several distinct clinicopathologic expressions of vasculitis. Therefore, the classification of cutaneous vasculitis is best approached morphologically by determining vessel size and principal inflammatory response. These histologic patterns roughly correlate with pathogenic mechanisms that, when coupled with direct immunofluorescent examination, anti-neutrophil cytoplasmic antibody (ANCA) status, and findings from work-up for systemic disease, allow for specific diagnosis, and ultimately, more effective therapy. Herein, we review cutaneous vasculitis focusing on diagnostic criteria, classification, epidemiology, etiology, pathogenesis, and evaluation of the cutaneous vasculitis patient.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, Albany, New York 12208, USA.
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30
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Sais G, Vidaller A. Role of direct immunofluorescence test in cutaneous leukocytoclastic vasculitis. Int J Dermatol 2005; 44:970-1; author reply 971. [PMID: 16336539 DOI: 10.1111/j.1365-4632.2004.02462.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Eedy DJ, English JSC. Updates from the British Association of Dermatologists 84th annual meeting, 6-9 July 2004, Belfast, U.K. Br J Dermatol 2005; 152:13-28. [PMID: 15656796 DOI: 10.1111/j.1365-2133.2005.6413.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Herein is a synopsis of the main research and clinical findings presented at the British Association of Dermatologists meeting held during 6-9 July 2004, in Belfast, U.K. The conference highlighted the progress that has been made in understanding the increasing biological, epidemiological and therapeutic advances that have been made recently in the field of dermatology. The authors highlight the more important advances or summaries, but this is not meant as a substitute for reading the conference proceedings and related references quoted in this article.
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Affiliation(s)
- D J Eedy
- Craigavon Area Hospital Group Trust, 68 Lurgan Road, Portadown, BT63 5QQ, UK.
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