Systemic granulomatous necrotizing vasculitis in a MPO-ANCA-positive patient

A Ruptured Jejunal Arterial Aneurysm in a Young Woman Undergoing Chronic Hemodialysis Due to Myeloperoxidase-antineutrophil Cytoplasmic Antibody-associated Vasculitis

A 21-year-old woman was admitted to our hospital because of massive intestinal bleeding. She started hemodialysis due to myeloperoxidase antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at 18 years of age. Her ANCA titers remained stable; however, her C-reactive protein increased on 5 mg/day prednisolone before admission. Computed tomography angiography revealed a ruptured jejunal arterial aneurysm. Transcatheter arterial embolization, blood transfusion and the reinforcement of steroid therapy resolved her symptoms of AAV. Our case of a young patient with AAV and medium-sized arterial vasculitis is rare and emphasizes that the ANCA titer does not always rise, especially in patients with nonrenal vasculitis flare-ups.

Fatal hemoperitoneum due to rupture of mesenteric artery in remission state of microscopic polyangiitis, concomitant with severe hypertension and posterior reversible encephalopathy syndrome: an autopsy case report

Microscopic polyangiitis (MPA) is a type of necrotizing vasculitis associated with high levels of myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA). While generally associated with renal dysfunction, MPA can also cause intraabdominal hemorrhage in rare cases. A 66-year-old man was admitted to our hospital for renal dysfunction, numbness, and weight loss for 3 months. He had no significant medical history. Renal biopsy revealed crescentic glomerulonephritis with necrotizing vasculitis, which was associated with a high serum titer of MPO-ANCA, leading to a diagnosis of MPA. Remission-induction treatment with glucocorticoids and rituximab was initiated, which improved the patient's general condition and renal failure. His blood pressure was elevated and was controlled by amlodipine treatment. Two months after discharge, he visited the emergency department because of chest pain. A diagnosis of acute cardiovascular syndrome was suggested; however, his cardiac artery was not stenotic. The patient's blood pressure was high despite antihypertensive therapy, and he developed posterior reversible encephalopathy syndrome (PRES). Despite intensive treatment, the patient died 3 days later. An autopsy revealed that the cause of death was hypovolemic shock due to massive intra-abdominal hemorrhage from the ruptured mesenteric artery involved in vasculitis. In cases of MPA with sudden-onset chest or abdominal pain, a ruptured intra-abdominal artery should be considered. Secondary hypertension associated with vasculitis should be carefully managed to prevent hemorrhagic complications and PRES.

A novel autoantibody against moesin in the serum of patients with MPO-ANCA-associated vasculitis

BACKGROUND

Antineutrophil cytoplasmic autoantibody (ANCA) directed against myeloperoxidase (MPO), a diagnostic criterion in MPO-ANCA-associated vasculitis (MPO-AAV), does not always correlate with disease activity. Here, we detected autoantibodies against moesin, which was located on the surface of stimulated endothelial cells, in the serum of patients.

METHODS

The anti-moesin autoantibody titer was evaluated by ELISA. Seventeen kinds of cytokines/chemokines were measured by a Bio-Plex system.

RESULTS

Serum creatinine in the anti-moesin autoantibody-positive group was higher than that in the negative group. Additionally, interferon (IFN)-γ, macrophage chemotactic peptide-1 (MCP-1), interleukin (IL)-2, IL-7, IL-12p70, IL-13, granulocyte/macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor were significantly higher in the positive group. Furthermore, IL-7 and IL-12p70 levels correlated with the anti-moesin autoantibody titer. Based on these findings and the binding of anti-moesin IgG to neutrophils and monocytes, we detected the secretion of cytokines/chemokines such as IFN-γ, MCP-1 and GM-CSF from these cells.

CONCLUSIONS

The anti-moesin autoantibody existed in the serum of patients with MPO-AAV and was associated with the production of inflammatory cytokines/chemokines targeting neutrophils with a cytoplasmic profile, which suggests that the anti-moesin autoantibody has the possibility to be a novel autoantibody developing vasculitis via neutrophil and endothelial cell activation.

Gynecologic vasculitis: an analysis of 163 patients

Gynecologic vasculitis (GynV) has been reported as part of systemic vasculitis (SGynV) and as single-organ (isolated gynecologic) vasculitis (IGynV). In the current study, we analyzed the clinical and histologic characteristics of patients with GynV and sought to identify features that differentiate the isolated from the systemic forms of the disease. We used pathology databases from our institution and an English-language literature search (PubMed) to identify affected patients with biopsy-proven GynV. Using a standardized format for data gathering and analysis, we recorded clinical manifestations, laboratory and histologic features, and surgical and medical therapies. Patients were analyzed as 2 subsets: IGynV and SGynV.A total of 163 patients with GynV were included (152 from the literature and 11 from the Cleveland Clinic pathology database). The incidence of vasculitis among all gynecologic surgeries in our institution over 16 years was 0.15%. Half of the patients presented with vaginal bleeding. Other less common presentations included the finding of an asymptomatic abdominal mass, uterine prolapse, atypical cervical smear, and pelvic pain. Constitutional and musculoskeletal symptoms were reported in 24% of patients. One hundred fifteen (70.6%) patients had IGynV, and 48 (29.4%) had SGynV. Compared to patients with SGynV, those with IGynV were younger (median age, 51 yr; range, 18-80 yr vs. median, 68 yr; range, 32-83 yr; p = 0.0001) and presented more often with vaginal bleeding (57% vs. 25%; p = 0.0002) and less frequently with asymptomatic pelvic masses (6% vs. 35%; p = 0.0001). IGynV was less often associated with constitutional or musculoskeletal symptoms (7% vs. 74%; p = 0.0001). Patients with IGynV were much less likely to have abnormal erythrocyte sedimentation rates (26% vs. 97%; p = 0.0001) and anemia (17% vs. 80%; p = 0.0001) than patients with SGynV. None of the patients with IGynV received corticosteroids, whereas almost all patients with SGynV received corticosteroids and about one-third also received cytotoxic therapy. In IGynV, the site most often involved was the uterus, particularly the cervix, whereas in SGynV lesions were more often multifocal, affecting mainly ovaries, fallopian tubes, and myometrium. Nongranulomatous inflammation occurred in most patients with IGynV, while the predominant histologic pattern noted in SGynV was granulomatous.While vasculitis was the only lesion in 32% of the resected specimens, leiomyomas (18.4%) and endometrial carcinoma (8.3%) were the most frequent concomitant benign and malignant (nonvasculitic) lesions, respectively. Except for benign ovarian abnormalities, which were more frequent in SGynV than in IGynV (21% vs. 4%; p = 0.001), other benign (50%) and malignant (18%) conditions were similarly present in both groups. Among SGynV patients, giant cell arteritis was diagnosed in 29 of the 48 (60.4%) patients, and one-third presented without symptoms of vascular involvement or polymyalgia rheumatica. In summary, GynV is rare and most often occurs as a single-organ disease. It is usually an incidental finding in the course of surgery. The isolated form is associated with the absence of systemic symptoms and normal acute phase reactants, and does not require systemic therapy. Among systemic vasculitides, giant cell arteritis is the most frequently reported form of systemic vasculitis with gynecologic involvement.

Extensive pancreatic necrosis in microscopic polyangiitis

We encountered an 84-year-old woman with microscopic polyangiitis who was found to have pancreatitis on autopsy. The patient was admitted to Yamanashi University Hospital because of fever and progressive renal failure. She was diagnosed with anti-myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA)-related microscopic polyangiitis (MPA) and was treated successfully with prednisolone pulse therapy. Two months later, she was found unconscious at home and was transferred to hospital, where she died of cardiac arrest after 6 days. Autopsy revealed systemic vasculitis with fibrinoid necrosis (with the most severe form found in the pancreas), interstitial pneumonia, and crescentic glomerulonephritis. A review of the literature revealed that pancreatic involvement in vasculitis, although rare, is one of the complications of MPA; however, the present study is the first report to focus on the pancreatic involvement of MPA. We recommend that nephrologists consider the possibility of pancreatic involvement in this disease.