1
|
Al Saadi R, AlQassimi S, Abuzakouk M, Alduaij A. Severe Mononeuritis Multiplex in Eosinophilic Granulomatous Polyangiitis: A Case Report. Cureus 2024; 16:e57283. [PMID: 38690466 PMCID: PMC11058583 DOI: 10.7759/cureus.57283] [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] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
This report describes a 48-year-old man who presented with a month history of weakness and paraesthesia associated with severe pain of all four limbs. Initially diagnosed and treated as Guillain Barre syndrome due to the severity of his extremity weakness, it was later discovered to be eosinophilic granulomatous polyangiitis (EGPA). Mononeuritis multiplex should not be underestimated or overlooked in the setting of diagnosing EGPA and requires prompt treatment with biologics to limit the permanent consequences on patient's quality of life with regard to developing limb weakness and pain. Although peripheral neuropathy, namely, mononeuritis multiplex, is not the most common feature of EGPA, it is important to consider it in order not to delay treatment with biologic agents that as seen in our patient can both halt the progress of the disease as well as give the patient a better quality of life.
Collapse
Affiliation(s)
- Reem Al Saadi
- Internal Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| | - Sarah AlQassimi
- Internal Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| | | | - Ahmed Alduaij
- Pathology, National Reference Laboratory, Abu Dhabi, ARE
- Pathology and Laboratory Medicine Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| |
Collapse
|
2
|
Tracy JA. Autoimmune Axonal Neuropathies. Continuum (Minneap Minn) 2023; 29:1378-1400. [PMID: 37851035 DOI: 10.1212/con.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article reviews autoimmune axonal neuropathies, their characteristic clinical features, disease and antibody associations, appropriate ancillary testing, treatment, and prognosis. LATEST DEVELOPMENTS In 2021, the American College of Rheumatology and the Vasculitis Foundation released new summary guidelines for the treatment of antineutrophil cytoplasmic autoantibody-associated vasculitides. In addition, novel autoantibodies have been recently identified; they are often paraneoplastic and associated with axonal neuropathies. ESSENTIAL POINTS Recognition of autoimmune axonal neuropathies is important because of the potential for effective treatment to either reverse deficits or slow the progression of disease. It is necessary to properly assess for associations with other systemic disorders (eg, systemic vasculitis, connective tissue disease, neoplasm) so that adequate treatment for both neurologic and non-neurologic aspects of the disease can be initiated.
Collapse
|
3
|
Emmi G, Bettiol A, Gelain E, Bajema IM, Berti A, Burns S, Cid MC, Cohen Tervaert JW, Cottin V, Durante E, Holle JU, Mahr AD, Del Pero MM, Marvisi C, Mills J, Moiseev S, Moosig F, Mukhtyar C, Neumann T, Olivotto I, Salvarani C, Seeliger B, Sinico RA, Taillé C, Terrier B, Venhoff N, Bertsias G, Guillevin L, Jayne DRW, Vaglio A. Evidence-Based Guideline for the diagnosis and management of eosinophilic granulomatosis with polyangiitis. Nat Rev Rheumatol 2023; 19:378-393. [PMID: 37161084 DOI: 10.1038/s41584-023-00958-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 05/11/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of several organs. The diagnosis and management of EGPA are often challenging and require an integrated, multidisciplinary approach. Current practice relies on recommendations and guidelines addressing the management of ANCA-associated vasculitis and not specifically developed for EGPA. Here, we present evidence-based, cross-discipline guidelines for the diagnosis and management of EGPA that reflect the substantial advances that have been made in the past few years in understanding the pathogenesis, clinical subphenotypes and differential diagnosis of the disease, as well as the availability of new treatment options. Developed by a panel of European experts on the basis of literature reviews and, where appropriate, expert opinion, the 16 statements and five overarching principles cover the diagnosis and staging, treatment, outcome and follow-up of EGPA. These recommendations are primarily intended to be used by healthcare professionals, pharmaceutical industries and drug regulatory authorities, to guide clinical practice and decision-making in EGPA. These guidelines are not intended to limit access to medications by healthcare agencies, nor to impose a fixed order on medication use.
Collapse
Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Gelain
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ingeborg M Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, the Netherlands
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy
| | - Stella Burns
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- University of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Jan W Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, University of Lyon, IVPC, INRAE, ERN-LUNG, Lyon, France
| | - Eugenia Durante
- APACS, Associazione Pazienti con Sindrome di Churg Strauss, Arosio, Italy
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Alfred D Mahr
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marcos Martinez Del Pero
- Vasculitis and Lupus Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- ENT Department, West Suffolk Hospital, Bury St Edmunds, UK
| | - Chiara Marvisi
- Rheumatology Unit, Università di Modena e Reggio Emilia, Modena, Italy
| | | | - Sergey Moiseev
- Tareev Clinic of Internal Disease, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster/Kiel, Germany
| | - Chetan Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Thomas Neumann
- Department of Rheumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Iacopo Olivotto
- Meyer Children Hospital and Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research, Hannover Medical School, Hannover, Germany
| | - Renato A Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Renal Unit, ASST-Monza, Monza, Italy
| | - Camille Taillé
- Reference center for rare respiratory diseases, Bichat Hospital, AP-HP-Nord, University Paris Cité, Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Université de Paris, Paris, France
| | - Nils Venhoff
- Clinic for Rheumatology and Clinical Immunology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Crete, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Internal Medicine, Cochin Hospital, AP-HP, University of Paris, Paris, France
| | - David R W Jayne
- University of Cambridge, Box 118, Addenbrooke's Hospital, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
| |
Collapse
|
4
|
[Peripheral neuropathies during systemic diseases: Part II (vasculitis)]. Rev Med Interne 2023; 44:174-180. [PMID: 36925342 DOI: 10.1016/j.revmed.2023.01.003] [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: 11/07/2022] [Accepted: 01/08/2023] [Indexed: 03/15/2023]
Abstract
Primary systemic vasculitides, mainly of the small and medium-sized vessels, are frequently associated with peripheral neuropathies. When the disease is already known, the appearance of a neuropathy should suggest a specific injury, especially when associated with other systemic manifestations. Conversely, when neuropathy is inaugural, close collaboration between neurologists and internists is necessary to reach a diagnosis. A standardized electro-clinical investigation specifying the topography, the evolution and the mechanism of the nerve damage enables the positive diagnosis of the neuropathy. Several elements orient the etiological diagnosis and allow to eliminate the main differential diagnosis: non systemic vasculitic neuropathy. The existence of associated systemic manifestations (glomerular or vascular nephropathy, interstitial lung disease, intra-alveolar hemorrhage, ENT involvement…), biological markers (ANCA, cryoglobulinemia, rheumatoid factor), and invasive examinations allowing histological analysis (neuromuscular biopsy) are all useful tools for.
Collapse
|
5
|
White J, Dubey S. Eosinophilic granulomatosis with polyangiitis: A review. Clin Exp Rheumatol 2023; 22:103219. [PMID: 36283646 DOI: 10.1016/j.autrev.2022.103219] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/19/2022] [Indexed: 12/27/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, multi-system, inflammatory disease, belonging to the group of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Previously known as Churg-Strauss syndrome, EGPA is characterised by late-onset asthma, eosinophilia and vasculitis affecting small-to-medium vessels. This disease behaves differently in many aspects to the other AAV and is often excluded from AAV studies. The disease is poorly understood and, due to it rarity and unique manifestations, there has been limited research progress to optimise our understanding of its complex pathogenesis and ability to develop management options - although the success of interleukin-5 inhibitors such as Mepolizumab has been a welcome development. The pathophysiology also appears to be different to other forms of AAV and hence management strategies that work for AAV may not fully apply to this condition. There is no current standard therapy for EGPA although corticosteroids are almost universally used for treatment alongside other agents and encouraging modes of treatment continue to evolve beyond glucocorticoid immunosuppression (including interleukin-5 inhibition). There is therefore a significant ongoing unmet need for efficacious steroid-sparing immunosuppressing agents. The prognosis also diverges from other forms of AAV, and we discuss the pathophysiology, clinical features and diagnosis, management and prognosis in this article.
Collapse
Affiliation(s)
- Jpe White
- St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, United Kingdom
| | - S Dubey
- Dept of Rheumatology, Oxford University Hospitals NHS FT, Windmill Road, Oxford OX3 7LD, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7HE, United Kingdom.
| |
Collapse
|
6
|
Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
Collapse
Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
7
|
Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
Collapse
Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| |
Collapse
|
8
|
Vasculitic Tibial Mononeuropathy Associated with Inherited Immune Dysregulation: A Review of Tibial Mononeuropathies with Electrodiagnostic Considerations. Case Rep Neurol Med 2021; 2021:7161757. [PMID: 34804620 PMCID: PMC8604612 DOI: 10.1155/2021/7161757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
Compressive tibial mononeuropathies are uncommon and can be caused by conditions including posterior compartment syndrome, soleal sling syndrome, and tarsal tunnel syndrome. Therefore, it is critical to consider noncompressive etiologies when a tibial mononeuropathy is suspected. This is a patient with a history of rare inherited immune dysregulation that presented to the electrodiagnostic laboratory with severe neuropathic pain in the right foot associated with plantarflexion weakness, concerning for a tibial mononeuropathy. However, the patient's clinical presentation and results on electrodiagnostic testing were not consistent with any of the above entities. Therefore, noncompressive etiologies of tibial mononeuropathies such as vasculitis had to be considered. The patient subsequently underwent sural nerve biopsy which confirmed small-vessel vasculitis as the cause of the tibial mononeuropathy. She was then started on appropriate immunosuppressive treatment which resulted in significant pain relief and was discharged home. This case highlights the importance of considering noncompressive causes of tibial nerve injury. Compressive and vasculitic tibial mononeuropathies along with their electrodiagnostic considerations are reviewed. Furthermore, this case highlights the critical role of the electromyographer and ability to maximize the impact on patient care through a solid foundation in anatomy, pathophysiology, and electrodiagnosis blended with clinical acumen.
Collapse
|
9
|
Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
Collapse
Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
| |
Collapse
|
10
|
Abstract
PURPOSE This article describes the neurologic manifestations of systemic autoimmune diseases. RECENT FINDINGS Systemic autoimmune diseases can be associated with a wide spectrum of neurologic comorbidities involving the central and peripheral nervous systems. Systemic lupus erythematosus (SLE) can be associated with a number of manifestations predominantly affecting the central nervous system (CNS), whereas peripheral neuropathy is less common. Sjögren syndrome can be associated with peripheral neuropathy in 10% of cases and CNS disease in 2% to 5% of cases. The risk of stroke is increased in SLE, rheumatoid arthritis, temporal arteritis, psoriatic arthritis, and ankylosing spondylitis. Systemic vasculitides present most commonly with mononeuritis multiplex but can also affect the CNS. Cognitive dysfunction is a common symptom among patients with systemic autoimmune diseases, most commonly seen in patients with SLE or Sjögren syndrome. SUMMARY Neurologic manifestations of systemic autoimmune disease are important to recognize, as they may often be the presenting manifestation leading to diagnosis of the systemic disease or may be associated with increased morbidity, other complications, or mortality. Timely diagnosis and institution of appropriate treatment, often requiring multidisciplinary care, is essential to minimize morbidity and decrease the risk of permanent neurologic deficits.
Collapse
|
11
|
Medvedev I, Podzolkov VI, Ishina TI, Pisarev MV. Case Report: A 64-Year-Old Man with 10-Year History of Eosinophilic Granulomatosis with Polyangiitis with Bronchiectasis and Severe Klebsiella pneumonia. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929224. [PMID: 33582702 PMCID: PMC7893373 DOI: 10.12659/ajcr.929224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/30/2020] [Accepted: 12/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare and severe progressive disease with multiple clinical manifestations and organ damage. Usually, it requires long-term monitoring of the state of many organs due to the gradual character of its manifestations. CASE REPORT We report a case of a long-term follow-up of a patient with eosinophilic granulomatosis with polyangiitis with emphasis on specific clinical features in this patient. A 64-year-old man was being followed up for 10 years. The initial diagnosis was allergic bronchial asthma; however, as new clinical signs and symptoms developed, the diagnosis of EGPA became obvious. A positive treatment response was seen, mainly manifested as reduced polyneuropathy. Meanwhile, bronchial asthma remained uncontrolled and bronchiectasis and Klebsiella pneumoniae colonization developed despite the combination treatment with prednisolone and methotrexate. Furthermore, the patient suffered a cerebral ischemic infarction. During the last hospital admission, severe uncontrolled bronchial asthma complicated with pneumonia resulted in the patient's death. CONCLUSIONS This clinical case shows the gradual development of EGPA with multiple-organ involvement, including respiratory manifestations and peripheral and central nervous system damage. Immunosuppressive treatment combined with complications of EGPA could have contributed to severe pneumonia development and death of the patient.
Collapse
Affiliation(s)
- Ivan Medvedev
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Valery I. Podzolkov
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Tatiana I. Ishina
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Mikhail V. Pisarev
- Laboratory for the Study of Advanced Simulation Technologies, V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation
| |
Collapse
|
12
|
Trivioli G, Terrier B, Vaglio A. Eosinophilic granulomatosis with polyangiitis: understanding the disease and its management. Rheumatology (Oxford) 2021; 59:iii84-iii94. [PMID: 32348510 DOI: 10.1093/rheumatology/kez570] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/15/2019] [Indexed: 12/14/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis is characterized by asthma, blood and tissue eosinophilia and small-vessel vasculitis. The clinical presentation is variable, but two main clinic-pathologic subsets can be distinguished: one hallmarked by positive ANCA and predominant 'vasculitic' manifestations (e.g. glomerulonephritis, purpura and mononeuritis multiplex) and the other by negative ANCA and prominent 'eosinophilic' manifestations (e.g. lung infiltrates and cardiomyopathy). The pathogenesis is not fully understood but probably results from the interplay between T and B cells and eosinophils. Eosinophilic granulomatosis with polyangiitis must be differentiated from several conditions, including hypereosinophilic syndromes and other small-vessel vasculitides. The overall survival is good; however, patients frequently relapse and have persistent symptoms. The recently developed monoclonal antibodies targeting B cells and eosinophilopoietic cytokines such as IL-5 are emerging as valid alternatives to conventional immunosuppressive therapies. In this review, we discuss the essential features of eosinophilic granulomatosis with polyangiitis, with particular respect to the most relevant issues concerning clinical presentation and management.
Collapse
Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Descartes, Paris 5, Paris, France
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
| |
Collapse
|
13
|
Chang HC, Chou PC, Lai CY, Tsai HH. Antineutrophil Cytoplasmic Antibodies and Organ-Specific Manifestations in Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:445-452.e6. [PMID: 32771687 DOI: 10.1016/j.jaip.2020.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a rare and often severe systemic vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). EGPA can affect multiple organ systems, but the relationships between ANCA status and the organ-specific manifestations of EGPA in previous reports were inconsistent. OBJECTIVE To investigate the association of the ANCA status with organ-specific manifestations in EGPA. METHODS We performed a systematic review of studies published before March 16, 2020, in the PubMed, Embase, Web of Science, and Cochrane Library databases. The primary outcome was the association of ANCA status with organ-specific involvements of EGPA. Odds ratios (ORs) and 95% CIs were calculated using a random-effects model. RESULTS A total of 24 cross-sectional studies with 2527 patients with EGPA, including 921 ANCA-positive patients and 1606 ANCA-negative patients, were included in the meta-analysis. The significant results of pooled analyses revealed that compared with patients with EGPA with negative ANCA status, patients with EGPA with positive ANCA status had higher risks of peripheral neuropathy (OR, 1.701), renal involvement (OR, 5.097), and cutaneous purpura (OR, 1.746) and lower risks of pulmonary infiltrates (OR, 0.589) and cardiac involvement (OR, 0.427). The pooled analysis also revealed no significant association of ANCA status with asthma and involvements of the central nervous system, gastrointestinal tract, or skin. CONCLUSIONS This study provides more evidence that patients with EGPA may exhibit different features of disease based on their ANCA status.
Collapse
Affiliation(s)
- Hua-Ching Chang
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Pai-Chien Chou
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Thoracic Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yu Lai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiou-Hsin Tsai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
14
|
[Granulomatosis with polyangiitis and neurological disease onset]. DER NERVENARZT 2020; 91:1138-1141. [PMID: 32725492 PMCID: PMC7704493 DOI: 10.1007/s00115-020-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
15
|
Tauseef A, Asghar MS, Amir M, Zafar M, Anum A, Alvi H, Dawood M, Rasheed U, Akram M, Ahmed N. Microscopic polyangiitis: an incidental finding in a patient with stroke. J Community Hosp Intern Med Perspect 2020; 10:50-54. [PMID: 32128059 PMCID: PMC7034484 DOI: 10.1080/20009666.2020.1718479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/30/2019] [Indexed: 10/31/2022] Open
Abstract
Microscopic polyangiitis (MPA) is a primary systemic vasculitis characterized by inflammation
of small-sized vessels associated with the presence of anti-neutrophilic cytoplasmic
antibodies. We report a case of a 39-year-old female diagnosed with microscopic polyangiitis as
an incidental finding who presented with signs and symptoms of a stroke at a young age.
Usually, it presents with fever, malaise, skin rash, weight loss, mononeuritis multiplex, and
arthralgia/myalgia. Very rarely, it can involve meninges to cause meningeal vasculitis which
can present as a febrile seizure. The most frequent neurological manifestation is peripheral
neuropathy. Cerebral infarction or hemorrhage as an isolated finding is very rarely observed in
the patient with MPA as was seen in our patient.
Collapse
Affiliation(s)
- Abubakar Tauseef
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | | | - Mariam Amir
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Maryam Zafar
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Ayesha Anum
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Haris Alvi
- Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Mustafa Dawood
- Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Mohammed Akram
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Nisar Ahmed
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| |
Collapse
|
16
|
Golovach IY, Yehudina YD. [Peripheral nervous system lesion in systemic vasculitis - issues of diagnosis and treatment]. TERAPEVT ARKH 2019; 91:63-69. [PMID: 32598591 DOI: 10.26442/00403660.2019.12.000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Vasculitis is a clinically diverse group of diseases with histopathological signs of blood vessel inflammation, which contributes to vascular damage and ischemic damage to the affected tissues. Vasculitic neuropathy is a common complication of the primary systemic vasculitides, such as polyartertis nodosa and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, systemic diseases of the connective tissue - systemic lupus erythematosus and Sjogren syndrome, vasculitis associated with infection, most often viral hepatitis C and B and non - systemic vasculitis neuropathy. Vessels of medium and small caliber are involved in the pathological process in these diseases. With all vasculitis, except for those caused by the direct effect of the infectious trigger on the blood vessel walls, the main pathogenetic mechanism is an autoimmune process with the development of vasa nervorum vasculitis - small arteries and vessels that supply peripheral nerves, and the outcome - nerve ischemia. The classic clinical presentation is an acute or subacute painful multifocal neuropathy that has a predilection for the lower extremities, affects two or more named nerves, and progresses in a step wise manner. However, vasculitic neuropathy can manifest in a variety of ways, including asymmetric polyneuropathies and distal symmetric sensory neuropathies, and it also can be slowly progressive, particularly in cases of nonsystemic vasculitic neuropathy (NSVN), a form of vasculitis that clinically remains restricted to peripheral nerves. Nerve biopsy can help establish the diagnosis of a systemic vasculitis, particularly when other organ involvement is not clinically apparent, and is required for diagnosis of NSVN. Neuropathy due to systemic vasculitis should be treated in accordance with the recommendations for the treatment of the underlying disease. In NSVH, the main medicine of choice are glucocrticoids, and in severe/progressive cases, pulse therapy with cyclophosphamide.
Collapse
Affiliation(s)
- I Y Golovach
- Feofaniya Clinical hospital State Management of Affairs
| | | |
Collapse
|
17
|
Sharma A, Rajan R, Modi M, Pinto B, Dhooria A, Rathi M, Mittal T, Kumar S, Sharma K, Dhir V, Nada R, Minz RW, Singh S. Neurological Manifestations Do not Affect Cumulative Survival in Indian Patients with Antineutrophil Cytoplasmic Antibody Associated Vasculitis. Neurol India 2019; 67:1043-1047. [PMID: 31512630 DOI: 10.4103/0028-3886.266234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Neurological manifestations are an important cause of morbidity in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). It is not clear whether or not they are indicative of a severe disease course with multiple organ involvement and shortened survival. Aims and Objectives To characterize the neurological manifestations of AAV and analyze their relationship with other organ system and cumulative survival. Methods This was a retrospective single-center cohort study of AAV patients at a tertiary care hospital in North India. Data was collected from medical records regarding clinical history, neurological examination, Birmingham Vasculitis Activity Score (BVAS), serology, electrophysiology, imaging, and histopathological examination findings of patients. Results Ninety-two patients of systemic vasculitis were identified, 67 with granulomatosis with polyangiitis (GPA), 14 with microscopic polyangiitis, 8 with Churg-Strauss syndrome (CSS), and 3 with undifferentiated AAV. The median BVAS at presentation was 18.0 (interquartile range (IQR): 12.0). The median duration of follow-up was 31.3 months (IQR: 40.5). A total of 45.7% patients had neurological manifestations among which 23.8% presented with neurological complaints. Peripheral neuropathy was the most common manifestation noted in 23.9% of the patients. Among patients with GPA, 40.3% had neurological involvement (seen in 33.3% patients at presentation). Patients with nervous system disease were more likely to have associated musculoskeletal manifestations (P = 0.046) and less likely to have renal involvement (P = 0.017). The estimated cumulative survival of the subgroup with neurological involvement was 95.1 months from the time of diagnosis, which was not significantly different from the cohort without neurological involvement (113.8 months, P = 0.631). Conclusion Neurological morbidity commonly accompanies systemic vasculitis. Nervous system disease does not affect the survival significantly in these patients.
Collapse
Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Roopa Rajan
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Benzeeta Pinto
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aadhaar Dhooria
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarun Mittal
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Susheel Kumar
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kusum Sharma
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
18
|
Overall Disability Sum Score for Clinical Assessment of Neurological Involvement in Eosinophilic Granulomatosis With Polyangiitis. J Clin Rheumatol 2019; 24:197-202. [PMID: 29652700 DOI: 10.1097/rhu.0000000000000713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study was to verify the application of Overall Disability Sum Score (ODSS) for standardized clinical assessment of neurological involvement in patients with eosinophilic granulomatosis with polyangiitis (EGPA) and its correlation with treatment response and long-term outcomes. METHODS Consecutive EGPA patients referred to our tertiary vasculitis center were retrospectively evaluated. Patients' neurological damage and disability were systematically assessed with Vasculitis Damage Index and ODSS. RESULTS Fifty EGPA patients were included in the study with a median follow-up of 75 months (9-180 months). Twenty-five (50%) developed peripheral neuropathy, 17 (68%) presented mononeuritis multiplex, whereas 8 (32%) had symmetric polyneuropathy. Patients with neurological involvement were older (56.3 ± 13.4 vs. 44.4 ± 12.1 years, P < 0.0009), more frequently antineutrophil cytoplasmic antibody positive (48% vs. 16%, P = 0.015), and were more likely to have renal involvement (24% vs. 0%, P = 0.022). An early clinical response to therapy was observed within 6 months of treatment, resulting in a significant decrease in ODSS, which fell from the baseline value of 4.2 ± 2.4 to 2.9 ± 1.5 (P = 0.0001), whereas only a slow decreasing pattern was noted over the long-term period. However, all subjects developed neurological impairment and disability despite remission from active vasculitis. Patients with ODSS of greater than 3 at baseline (n = 13 [52%]) retained a higher score at the last examination (P < 0.001), predicting a low therapeutic response. Furthermore, ODSS of greater than 3 was found associated with more neurological relapses (53.8% vs. 0%, P = 0.027). CONCLUSION Overall Disability Sum Score could be a rapid, simple, reliable instrument to evaluate the severity of disability and nerve damage due to neurological involvement caused by vasculitis and to predict, at presentation, improvement and risk of neurological worsening.
Collapse
|
19
|
Strunk D, Schmidt-Pogoda A, Beuker C, Milles LS, Korsukewitz C, Meuth SG, Minnerup J. Biomarkers in Vasculitides of the Nervous System. Front Neurol 2019; 10:591. [PMID: 31244756 PMCID: PMC6562258 DOI: 10.3389/fneur.2019.00591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 05/20/2019] [Indexed: 12/13/2022] Open
Abstract
Besides being affected by the rare and severe primary angiitis of the central nervous system (PACNS) the nervous system is also affected by primary systemic vasculitides (PSV). In contrast to PACNS, PSV affect not only the central but also the peripheral nervous system, resulting in a large array of potential symptoms. Given the high burden of disease, difficulties in distinguishing between differential diagnoses, and incomplete pathophysiological insights, there is an urgent need for additional precise diagnostic tools to enable an earlier diagnosis and initiation of effective treatments. Methods available to date, such as inflammatory markers, antibodies, cerebrospinal fluid (CSF) analysis, imaging, and biopsy, turn out to be insufficient to meet all current challenges. We highlight the use of biomarkers as an approach to extend current knowledge and, ultimately, improve patient management. Biomarkers are considered to be useful for disease diagnosis and monitoring, for predicting response to treatment, and for prognosis in clinical practice, as well as for establishing outcome parameters in clinical trials. In this article, we review the recent literature on biomarkers which have been applied in the context of different types of nervous system vasculitides including PACNS, giant-cell arteritis, Takayasu's arteritis, polyarteritis nodosa, ANCA (anti-neutrophil cytoplasm antibody)-associated vasculitides, cryoglobulinemic vasculitis, IgA vasculitis, and Behçet's disease. Overall, the majority of biomarkers is not specific for vasculitides of the nervous system.
Collapse
Affiliation(s)
- Daniel Strunk
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Lennart S Milles
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Catharina Korsukewitz
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| |
Collapse
|
20
|
|
21
|
Zhang S, Yuan D, Tan G. Neurological Involvement in Primary Systemic Vasculitis. Front Neurol 2019; 10:430. [PMID: 31105641 PMCID: PMC6498988 DOI: 10.3389/fneur.2019.00430] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/09/2019] [Indexed: 11/16/2022] Open
Abstract
Primary systemic vasculitis can affect every structure in both the central and peripheral nervous system, causing varied neurological manifestations of neurological dysfunction. Early recognition of the underlying causes of the neurological symptoms can facilitate timely treatment and improve the prognosis. This review highlights the clinical manifestations of primary systemic vasculitis in the nervous system.
Collapse
Affiliation(s)
- Shanshan Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongli Yuan
- The Institute of Medical Information, Chongqing Medical University, Chongqing, China
| | - Ge Tan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
22
|
Occurrence of cerebral small vessel disease at diagnosis of MPO-ANCA-associated vasculitis. J Neurol 2019; 266:1708-1715. [DOI: 10.1007/s00415-019-09318-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/07/2019] [Accepted: 04/09/2019] [Indexed: 01/22/2023]
|
23
|
Lazzari G, Briatico Vangosa A, Assunta De Cillis M, Buccoliero G, Silvano G. Lower cranial nerve palsy during radiotherapy for glottic cancer in a patient with Wegener's granulomatosis: An interesting case report. Mol Clin Oncol 2019; 10:147-152. [PMID: 30680194 PMCID: PMC6315903 DOI: 10.3892/mco.2018.1748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/15/2018] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to report an unusual case of multiple lower cranial nerve palsies in a patient with Wegener's granulomatosis (WG) during radiotherapy for glottic cancer. WG is an autoimmune disease characterized by necrotizing granulomas mainly in the upper and lower respiratory tract or kidneys; however, the involvement of cranial nerves is not uncommon. Prior to the use of cyclophosphamide (CYC) the 1-year mortality rate was ~82%; the introduction of rituximab (RTX) has revolutionized the course of the WG, with remission rates comparable to those of CYC and superior effectiveness in relapsing patients. Hypogammaglobulinemia and B-cell depletion are the best known monitored side effects affecting survival due to secondary infections. Immunodepression and relapse with lower cranial nerve palsy have a negative impact on prognosis. We herein present the case of a heavily pre-treated GPA patient with secondary immunosuppression, who underwent radiotherapy for glottic cancer and developed multiple low cranial nerve palsies during treatment, which was interrupted at 60 Gy. The possible related causes and the association between previous immunosuppressive treatments and radiotherapy were also analyzed to elucidate the cause of this complication.
Collapse
Affiliation(s)
- Grazia Lazzari
- Department of Radiation Oncology, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
| | | | | | - Giovanni Buccoliero
- Department of Infectious Diseases, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
| | - Giovanni Silvano
- Department of Radiation Oncology, S. Giuseppe Moscati Hospital, I-74100 Taranto, Italy
| |
Collapse
|
24
|
|
25
|
Methotrexate versus cyclophosphamide for remission maintenance in ANCA-associated vasculitis: A randomised trial. PLoS One 2017; 12:e0185880. [PMID: 29016646 PMCID: PMC5634660 DOI: 10.1371/journal.pone.0185880] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/05/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is based on remission-induction and remission-maintenance. Methotrexate is a widely used immunosuppressant but only a few studies explored its role for maintenance in AAV. This trial investigated the efficacy and safety of methotrexate as maintenance therapy for AAV. METHODS In this single-centre, open-label, randomised trial we compared methotrexate and cyclophosphamide for maintenance in AAV. We enrolled patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), the latter with poor-prognosis factors and/or peripheral neuropathy. Remission was induced with cyclophosphamide. At remission, the patients were randomised to receive methotrexate or to continue with cyclophosphamide for 12 months; after treatment, they were followed for another 12 months. The primary end-point was relapse; secondary end-points included renal outcomes and treatment-related toxicity. RESULTS Of the 94 enrolled patients, 23 were excluded during remission-induction or did not achieve remission; the remaining 71 were randomised to cyclophosphamide (n = 33) or methotrexate (n = 38). Relapse frequencies at months 12 and 24 after randomisation were not different between the two groups (p = 1.00 and 1.00). Relapse-free survival was also comparable (log-rank test p = 0.99). No differences in relapses were detected between the two treatments when GPA+MPA and EGPA were analysed separately. There were no differences in eGFR at months 12 and 24; proteinuria declined significantly (from diagnosis to month 24) only in the cyclophosphamide group (p = 0.0007). No significant differences in adverse event frequencies were observed. CONCLUSIONS MTX may be effective and safe for remission-maintenance in AAV. TRIAL REGISTRATION clinicaltrials.gov NCT00751517.
Collapse
|
26
|
Badía Flores JJ, Arévalo Martínez FG. Phlebectasia in a finger in a case of microscopic polyangiitis with peripheral polyneuropathy. ACTA ACUST UNITED AC 2017; 15:368-369. [PMID: 28838824 DOI: 10.1016/j.reuma.2017.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 11/28/2022]
Abstract
The patient was a 56-year-old man with microscopic polyangiitis and symmetrical peripheral polyneuropathy of the extremities who was positive for p-ANCA, EMG pattern of mononeuritis multiplex and skin biopsy showing the presence of nonspecific vasculitis. He had phlebectasia with plethora and tortuous vessels on dorsum of the fingers on both hands, paresis and hypoesthesia of fingers and toes with functional limitations. The administration of prednisone, azathioprine and a cyclophosphamide pulse achieved rapid improvement in the general symptoms, but the changes in the neuropathy occurred very slowly. After 47 months of treatment, he had mild phlebectasia in fingers and slight hypoesthesia in hands and feet, with normal laboratory tests. Phlebectasia was probably the result of an autonomic dysfunction due to vasculitis of the vasa nervorum and could be a sign to look for in similar cases.
Collapse
|
27
|
Involvement of the Peripheral Nervous System in Polyarteritis Nodosa and Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis. Rheum Dis Clin North Am 2017; 43:633-639. [PMID: 29061248 DOI: 10.1016/j.rdc.2017.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Peripheral nerve involvement is common in polyarteritis nodosa and the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. The underlying mechanism is arteritis of the vasa nervorum, leading to ischemic neuropathy. The classic presentation is stepwise involvement of peripheral nerves with ongoing antecedent constitutional symptoms. This article reviews the pathologic findings, clinical syndromes, diagnosis, and treatment of ANCA-associated vasculitides.
Collapse
|
28
|
Cruz S, Schaefer AM, Joshi A, Baker MR. Clinical Reasoning: A 71-year-old woman with subacute progressive distal weakness and paresthesia after vaccination. Neurology 2017; 88:e168-e173. [DOI: 10.1212/wnl.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
29
|
Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
|
30
|
Cho HJ, Yune S, Seok JM, Cho EB, Min JH, Seo YL, Lee BJ, Kim BJ, Choi DC. Clinical Characteristics and Treatment Response of Peripheral Neuropathy in the Presence of Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): Experience at a Single Tertiary Center. J Clin Neurol 2017; 13:77-83. [PMID: 28079316 PMCID: PMC5242145 DOI: 10.3988/jcn.2017.13.1.77] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic small-vessel vasculitis accompanied by asthma, eosinophilia, and eosinophilic inflammation of various tissues including the peripheral nerves. This study investigated the clinical course and long-term outcomes of peripheral neuropathy in patients with EGPA. Methods Seventy-one patients with physician-diagnosed EGPA were identified at Samsung Medical Center between January 1995 and April 2014. Sixty-one of these patients were followed-up for more than 1 year and received corticosteroid therapy with or without intravenous cyclophosphamide pulse therapy for 6 to 18 months. Medical records of the 61 patients including demographic data, clinical features, laboratory and pathological findings, treatments, and outcomes were reviewed. Results Peripheral neuropathy as a manifestation of EGPA was present in 46 (75%) of the 61 patients. The mean follow-up duration of the patients with neuropathy was 6.4 years (range 1.2–18.8 years). The scores on the neurological functional disability scale before and after the combination treatment with corticosteroid and cyclophosphamide were 2.43±0.86 and 0.54±0.95 (mean±SD; p<0.001), respectively. The peripheral neuropathy relapsed in one patient. Conclusions The long-term clinical outcome of peripheral neuropathy in patients with EGPA receiving initial corticosteroid and cyclophosphamide combination therapy was favorable with a very low relapse rate.
Collapse
Affiliation(s)
- Hye Jin Cho
- Department of Neurology, The Catholic University of Korea College of Medicine, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sehyo Yune
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Myoung Seok
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Eun Bin Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Ju Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Yeon Lim Seo
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Jae Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea.
| | - Dong Chull Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| |
Collapse
|
31
|
Naseri Alavi SA, Meshkini M, Pourlak T, Khabbazi A. Microscopic polyangiitis complicated with bilateral brachial plexopathy: a case report and review of the literature. Rheumatol Int 2016; 36:997-1001. [PMID: 26782370 DOI: 10.1007/s00296-016-3424-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 01/05/2016] [Indexed: 11/28/2022]
Abstract
Microscopic polyangiitis is a small-vessel necrotizing vasculitis associated with anti-neutrophil cytoplasmic antibodies and presents itself with glomerulonephritis and hemorrhagic pulmonary capillaritis. Peripheral nervous system involvement is common in anti-neutrophil cytoplasmic antibodies-associated vasculitis, but brachial plexopathy is unusual. We present the case of a 22-year-old man with known microscopic polyangiitis who was under maintenance therapy with prednisolone and cyclophosphamide and developed cough, dyspnea, and hemoptysis which increased in 6 days accompanying pain and paresthesia in the upper limbs. His physical examination revealed hypoesthesia, absence of deep tendon reflexes, and decreased muscle strength in the upper limbs. His chest computed tomography scan showed ground glass pattern in the lower and middle lobes. Electromyography and nerve conduction study showed bilateral brachial plexopathy with involvement of all of the cervical roots that were more severe in the lower roots and left side.
Collapse
Affiliation(s)
- Seyed Ahmad Naseri Alavi
- Connective Tissue Diseases Research Center, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Meshkini
- Connective Tissue Diseases Research Center, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tala Pourlak
- Connective Tissue Diseases Research Center, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research Center, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
32
|
Kannan M, Greene JG. Weakness in an Elderly Woman With Asthma and Chronic Sinusitis. Neurohospitalist 2016; 6:36-40. [PMID: 26753055 DOI: 10.1177/1941874415586194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Weakness and sensory changes are common complaints in both the inpatient and the outpatient setting. However, this presentation remains a diagnostic challenge to clinicians due to the many possible underlying etiologies. The initial evaluation of weakness and sensory changes starts a thorough history and physical examination to guide the diagnostic process. In this article, we present the case of an elderly woman with complaints of weakness and sensory changes to highlight a step-wise approach to diagnosis and management.
Collapse
Affiliation(s)
- Meena Kannan
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - James G Greene
- Department of Neurology, Emory University, Atlanta, GA, USA
| |
Collapse
|
33
|
|
34
|
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) presenting with polyneuropathy--a case series. J Clin Neuromuscul Dis 2015; 16:125-30. [PMID: 25695917 DOI: 10.1097/cnd.0000000000000068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We aim to characterize a group of patients with eosinophilic granulomatosis with polyangiitis (EGPA) with an initial presentation of peripheral neuropathy. METHODS A retrospective analysis of 11 patients with EGPA. RESULTS The most common chief complaint was neuropathic limb pain and numbness (100%), followed by extremity weakness (82%). Nine (82%) patients had acute to subacute onset. All patients had a history of asthma and serum eosinophilia of more than 11%. Combining clinical and electrophysiological data, 10 (91%) patients demonstrated notable asymmetric involvement, whereas 1 patient presented with a length-dependent symmetrical axonal polyneuropathy. All patients improved significantly after immunotherapy, with average time to improvement of 9 weeks. Ten (91%) patients improved steadily and experienced no relapse, whereas 1 relapsed within the first year. CONCLUSIONS EGPA should be suspected in patients with asymmetric axonal peripheral neuropathy associated with asthma and eosinophilia. Early diagnosis and aggressive treatment help to achieve favorable outcome.
Collapse
|
35
|
Schirmer JH, Wright MN, Vonthein R, Herrmann K, Nölle B, Both M, Henes FO, Arlt A, Gross WL, Schinke S, Reinhold-Keller E, Moosig F, Holle JU. Clinical presentation and long-term outcome of 144 patients with microscopic polyangiitis in a monocentric German cohort. Rheumatology (Oxford) 2015; 55:71-9. [PMID: 26297628 DOI: 10.1093/rheumatology/kev286] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To evaluate the clinical presentation and long-term outcome of a vasculitis centre cohort of patients with microscopic polyangiitis (MPA) with respect to organ manifestations, treatment, chronic damage and mortality. METHODS We performed a retrospective chart review at our vasculitis referral centre. MPA patients admitted between 1991 and 2013 classified by a modified European Medicines Agency algorithm were diagnosed and treated according to a standardized interdisciplinary approach. RESULTS Comprehensive data from standardized interdisciplinary workups was available for 144 patients (median follow-up 72 months). The overall standardized mortality ratio was 1.40 (95% CI 0.91, 2.07; P = 0.13). We observed a higher mortality [hazard ratio (HR) 4.04 (95% CI 1.21, 13.45), P = 0.02] in 17 patients with MPA-associated fibrosing interstitial lung disease (ILD) and 56 patients with peripheral nervous system involvement [HR 5.26 (95% CI 1.10, 25.14), P = 0.04] at disease onset. One hundred and fifteen patients (79.9%) responded to the initial treatment. Sixty-one (42.3%) achieved complete remission and 54 (37.5%) achieved partial remission. Twenty (13.9%) showed a refractory disease course. CONCLUSION MPA patients at our tertiary rheumatology referral centre seemed to have a less severe phenotype resulting in a less severe disease course and better outcome than reported in other cohorts. Fibrosing ILD was significantly associated with mortality in this cohort.
Collapse
Affiliation(s)
- Jan H Schirmer
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt,
| | - Marvin N Wright
- Department of Medical Biometry and Statistics, University of Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck
| | - Reinhard Vonthein
- Department of Medical Biometry and Statistics, University of Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Center for Clinical Trials Lübeck, University of Lübeck, Lübeck
| | - Kristine Herrmann
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | | | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Frank O Henes
- Clinic and Policlinic for Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andreas Arlt
- Department of Medical and Neurological Rehabilitation, Klinikum Bad Bramstedt, Bad Bramstedt and
| | - Wolfgang L Gross
- University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Susanne Schinke
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Eva Reinhold-Keller
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Frank Moosig
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| | - Julia U Holle
- Department of Rheumatology, University Medical Center Schleswig-Holstein and Klinikum Bad Bramstedt, Bad Bramstedt
| |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW This article discusses the clinical features, pathophysiology, and management of primary and secondary acquired immune axonal neuropathies. RECENT FINDINGS Although there are many collagen vascular disorders associated with vasculitic neuropathy, a quarter of cases have been described to be due to nonsystemic vasculitis of the peripheral nervous system. Enhanced surveillance and aggressive treatment of conditions such as cryoglobulin-related vasculitic neuropathy with cyclophosphamide, rituximab, and alfa interferons has led to improved morbidity and mortality, however, many cases of immune axonal acquired neuropathy are still associated with poor outcomes. Acute motor axonal neuropathy (AMAN) and acute motor sensory axonal neuropathy (AMSAN) are well-characterized variants of Guillain-Barré syndrome. SUMMARY Characterizing the clinical and electrophysiologic phenotype can help diagnose conditions such as nonsystemic vasculitic neuropathy, AMAN, AMSAN, and immune small fiber neuropathy, while careful evaluation of systemic features is key to identifying secondary immune axonal neuropathies such as vasculitic neuropathy related to collagen vascular disease. Additional research is needed to determine the exact immune pathogenesis and optimized treatment regimens for all acquired immune axonal neuropathies.
Collapse
|
37
|
Hilhorst M, van Paassen P, Tervaert JWC. Proteinase 3-ANCA Vasculitis versus Myeloperoxidase-ANCA Vasculitis. J Am Soc Nephrol 2015; 26:2314-27. [PMID: 25956510 DOI: 10.1681/asn.2014090903] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In patients with GN or vasculitis, ANCAs are directed against proteinase 3 (PR3) or myeloperoxidase (MPO). The differences between PR3-ANCA-associated vasculitis (AAV) and MPO-AAV described in the past have been supplemented during the last decade. In this review, we discuss the differences between these two small-vessel vasculitides, focusing especially on possible etiologic and pathophysiologic differences. PR3-AAV is more common in northern parts of the world, whereas MPO-AAV is more common in southern regions of Europe, Asia, and the Pacific, with the exception of New Zealand and Australia. A genetic contribution has been extensively studied, and there is a high prevalence of the HLA-DPB1*04:01 allele in patients with PR3-AAV as opposed to patients with MPO-AAV and/or healthy controls. Histologically, MPO-AAV and PR3-AAV are similar but show qualitative differences when analyzed carefully. Clinically, both serotypes are difficult to distinguish, but quantitative differences are present. More organs are affected in PR3-AAV, whereas renal limited vasculitis occurs more often in patients with MPO-AAV. For future clinical trials, we advocate classifying patients by ANCA serotype as opposed to the traditional disease type classification.
Collapse
Affiliation(s)
- Marc Hilhorst
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Pieter van Paassen
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Jan Willem Cohen Tervaert
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands jw.cohentervaert@maastrichtuniversity
| | | |
Collapse
|
38
|
Huang YH, Ro LS, Lyu RK, Chang HS, Wu YR, Chang KH, Kuo HC. Wegener's granulomatosis with nervous system involvement: a hospital-based study. Eur Neurol 2015; 73:197-204. [PMID: 25791920 DOI: 10.1159/000375492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 01/25/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to ascertain the clinical manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) with the involvement of the peripheral nervous system (PNS) and central nervous system (CNS). SUMMARY All neurologic inpatients in a hospital over a 12-year period were reviewed. Nine patients met both the ACR 1990 traditional format criteria for the classification of GPA and the Chapel Hill nomenclature mandatory criteria for GPA. We focused on the clinical presentation, serological data, biopsy reports, disease activities [as assessed by the Birmingham Vasculitis Activity Score (BVAS)], electrophysiology, and brain images. Nine patients met the diagnostic criteria for GPA. The neurological signs of the initial manifestation of GPA were found in 6/9 (67%) patients. Eight patients had GPA-related CNS involvement, including four patients with chronic hypertrophic pachymeningitis, with either diffuse or focal thickening; three had intracranial hemorrhages and two had orbital mass lesions with optic nerve compression. In addition, six patients showed PNS involvement, including three with asymmetric sensorimotor polyneuropathy, two with symmetric sensorimotor polyneuropathy, and one with bilateral mononeuropathy. Key Messages: Neurological manifestation is not uncommon and can be the first clinical sign of GPA. The involvement of both CNS and PNS raises the possibility of GPA in hospitalized neurologic patients.
Collapse
|
39
|
Zhang YS, Sun AP, Chen L, Dong RF, Zhong YF, Zhang J. Nerve biopsy findings contribute to diagnosis of multiple mononeuropathy: 78% of findings support clinical diagnosis. Neural Regen Res 2015; 10:112-8. [PMID: 25788930 PMCID: PMC4357093 DOI: 10.4103/1673-5374.150716] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 11/25/2022] Open
Abstract
Multiple mononeuropathy is an unusual form of peripheral neuropathy involving two or more nerve trunks. It is a syndrome with many different causes. We reviewed the clinical, electrophysiological and nerve biopsy findings of 14 patients who suffered from multiple mononeuropathy in our clinic between January 2009 and June 2013. Patients were diagnosed with vasculitic neuropathy (n = 6), perineuritis (n = 2), chronic inflammatory demyelinating polyradiculoneuropathy (n = 2) or Lewis-Sumner syndrome (n = 1) on the basis of clinical features, laboratory data, electrophysiological investigations and nerve biopsies. Two patients who were clinically diagnosed with vasculitic neuropathy and one patient who was clinically diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy were not confirmed by nerve biopsy. Nerve biopsies confirmed clinical diagnosis in 78.6% of the patients (11/14). Nerve biopsy pathological diagnosis is crucial to the etiological diagnosis of multiple mononeuropathy.
Collapse
Affiliation(s)
- Ying-shuang Zhang
- Department of Neurology, Peking University Third Hospital, Beijing, China
| | - A-ping Sun
- Department of Neurology, Peking University Third Hospital, Beijing, China
| | - Lu Chen
- Department of Neurology, Peking University Third Hospital, Beijing, China
| | - Rong-fang Dong
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Yan-feng Zhong
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Jun Zhang
- Department of Neurology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
40
|
Gioffredi A, Maritati F, Oliva E, Buzio C. Eosinophilic granulomatosis with polyangiitis: an overview. Front Immunol 2014; 5:549. [PMID: 25404930 PMCID: PMC4217511 DOI: 10.3389/fimmu.2014.00549] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/15/2014] [Indexed: 11/13/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disorder, belonging to the small vessel anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, defined as an eosinophil-rich and necrotizing granulomatous inflammation often involving the respiratory tract, and necrotizing vasculitis predominantly affecting small to medium-sized vessels, associated with asthma and eosinophilia. EGPA pathogenesis is not well known: HLA-DRB1*04 and *07, HLA-DRB4 and IL10.2 haplotype of the IL-10 promoter gene are the most studied genetic determinants. Among the acquired pathogenetic factors, the exposure to different allergens, infections, vaccinations, drugs, and silica exposure have been involved. Eosinophils are the most characteristic cells in EGPA and different studies have demonstrated their role as effector and immunoregulatory cells. EGPA is considered as a disease with a prevalent activation of the Th-2 cellular-mediated inflammatory response and also humoral immunity plays an important role. A link between B and T inflammatory responses may explain different disease features. EGPA typically develops into three sequential phases: the allergic phase, distinguished by the occurrence of asthma, allergic rhinitis, and sinusitis, the eosinophilic phase, in which the main pathological finding is the eosinophilic organ infiltrations (e.g., lungs, heart, and gastrointestinal system), and the vasculitic phase, characterized by purpura, peripheral neuropathy, and constitutional symptoms. ANCA (especially pANCA anti-myeloperoxidase) are present in 40-60% of the patients. An elevation of IgG4 is frequently found. Corticosteroids and cyclophosphamide are classically used for remission induction, while azathioprine and methotrexate are the therapeutic options for remission maintenance. B-cell depletion with rituximab has shown promising results for remission induction.
Collapse
Affiliation(s)
- Andrea Gioffredi
- Unit of Nephrology, University Hospital of Parma , Parma , Italy
| | | | - Elena Oliva
- Unit of Nephrology, University Hospital of Parma , Parma , Italy
| | - Carlo Buzio
- Unit of Nephrology, University Hospital of Parma , Parma , Italy
| |
Collapse
|
41
|
Cojocaru IM, Cojocaru M, Silosi I, Vrabie CD. Peripheral nervous system manifestations in systemic autoimmune diseases. MAEDICA 2014; 9:289-94. [PMID: 25705295 PMCID: PMC4306001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 08/14/2014] [Indexed: 06/04/2023]
Abstract
The peripheral nervous system refers to parts of the nervous system outside the brain and spinal cord. Systemic autoimmune diseases can affect both the central and peripheral nervous systems in a myriad of ways and through a heterogeneous number of mechanisms leading to many different clinical manifestations. As a result, neurological complications of these disorders can result in significant morbidity and mortality. The most common complication of peripheral nervous system (PNS) involvement is peripheral neuropathy, with symptoms of numbness, sensory paresthesias, weakness, or gait imbalance. The neuropathy may be multifocal and asymmetric or, less frequently, distal and symmetric.
Collapse
Affiliation(s)
- Inimioara Mihaela Cojocaru
- Clinic of Neurology, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Manole Cojocaru
- Discipline of Physiology, "Dr. Ion Stoia" Clinical Center for Rheumatic Diseases, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, Romania
| | - Isabela Silosi
- Discipline of Immunology, Faculty of Medicine, University of Medicine and Pharmacy, Craiova, Romania
| | - Camelia Doina Vrabie
- "Sfantul Ioan" Emergency Clinical Hospital, "Victor Babes" National Institute for Pathology and Biomedical Sciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| |
Collapse
|
42
|
Abstract
The vasculitic neuropathies are a diverse group of disorders characterised by the acute-to-subacute onset of painful sensory and motor deficits that result from inflammatory destruction of nerve blood vessels and subsequent ischaemic injury. They are common in patients with primary systemic vasculitis and are seen in vasculitis secondary to disorders such as rheumatoid arthritis, viral infections, and diabetic inflammatory neuropathies. It is imperative that neurologists recognise these disorders to initiate treatment promptly and thereby prevent morbidity and mortality. To simplify the approach to patients with vasculitis of the peripheral nerves, a straightforward, dichotomous classification scheme can be used in which the vasculitic neuropathies are divided into two groups-nerve large arteriole vasculitis and nerve microvasculitis-on the basis of the size of the involved vessels. The size of the affected blood vessels correlates with the clinical course and prognosis in patients with vasculitic neuropathy.
Collapse
|
43
|
Abstract
The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.
Collapse
Affiliation(s)
- Harold P Adams
- Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa Health Care Stroke Center, University of Iowa, Iowa City, IA, USA.
| |
Collapse
|
44
|
Kim SH, Park J, Bae JH, Cho MS, Park KD, Jeong JH. ANCA-negative Wegener's granulomatosis with multiple lower cranial nerve palsies. J Korean Med Sci 2013; 28:1690-6. [PMID: 24265538 PMCID: PMC3835517 DOI: 10.3346/jkms.2013.28.11.1690] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 05/16/2013] [Indexed: 11/20/2022] Open
Abstract
Wegener's granulomatosis (WG) is a systemic vasculitis affecting small and medium-sized vessels with granulomatous formation. Though it is known for respiratory tract and kidney involvement, neurologic manifestation has been also reported. Herein we report a patient who suffered pansinusitis with multiple lower cranial nerve palsies but reached remission by immunosuppressant after the diagnosis of WG. A 54-yr-old female visited with headache, hearing difficulty, and progressive bulbar symptoms. She experienced endoscopic sinus surgeries due to refractory sinusitis. Neurologic examination revealed multiple lower cranial nerve palsies. Vasculitic markers showed no abnormality. Nasal biopsy revealed granulomatous inflammation and vasculitis involving small vessels. Given cyclophosphamide and prednisolone, her symptoms were prominently improved. WG should be considered in the patient with multiple cranial nerve palsies, especially those with paranasal sinus disease. Because WG can be lethal if delayed in treatment, prompt immunosuppressant is warranted after the diagnostic tissue biopsy.
Collapse
Affiliation(s)
- Sung-Hee Kim
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Jin Park
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Jung Ho Bae
- Department of Otolaryngology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Min-Sun Cho
- Department of Pathology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Kee Duk Park
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Jee Hyang Jeong
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| |
Collapse
|
45
|
Szczeklik W, Jakieła B, Adamek D, Musiał J. Cutting edge issues in the Churg-Strauss syndrome. Clin Rev Allergy Immunol 2013; 44:39-50. [PMID: 21380944 DOI: 10.1007/s12016-011-8266-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Churg-Strauss syndrome (CSS) is a rare systemic small-vessel vasculitis that develops in the background of bronchial asthma, which is characterized by eosinophilia and eosinophilic infiltration of various tissues. It belongs to the group of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides. The triggering factors and pathogenesis of CSS are still unknown. The possible role of eotaxin-3 and CCR4-related chemokines in selective recruitment of eosinophils to the target tissues in CSS has been recently suggested, but the role of eosinophilic inflammation in the development of vasculitic lesions is not completely understood. From the clinical view, two distinct phenotypes of the disease are slowly emerging depending on the ANCA-positivity status. Glucocorticoids are still the mainstay of treatment; however, data are accumulating regarding the beneficial role of novel immunosuppressants and biologic compounds, especially in patients with poorer prognosis.
Collapse
Affiliation(s)
- Wojciech Szczeklik
- Department of Medicine, Jagiellonian University Medical College, Skawińska 8, 31 - 066, Kraków, Poland.
| | | | | | | |
Collapse
|
46
|
|
47
|
Vaglio A, Buzio C, Zwerina J. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): state of the art. Allergy 2013; 68:261-73. [PMID: 23330816 DOI: 10.1111/all.12088] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2012] [Indexed: 12/24/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss, EGPA) is a systemic small-vessel vasculitis associated with asthma and eosinophilia. Histology of EGPA shows tissue eosinophilia, necrotizing vasculitis, and eosinophil-rich granulomatous inflammation. EGPA commonly presents with upper airway tract and lung involvement, peripheral neuropathy, cardiac and skin lesions. Antineutrophil cytoplasmic antibodies (ANCA) are positive in ~40% of the cases and more often in patients with clinical manifestations due to small-vessel vasculitis. The pathogenesis of EGPA is multifactorial: the disease can be triggered by exposure to allergens or drugs, but a genetic background has also been recognized, particularly an association with HLA-DRB4. Th2 responses are prominent, with up-regulation of IL-4, IL-13, and IL-5; however, Th1 and Th17 responses are not negligible. Eosinophils are activated, have a prolonged lifespan and probably cause tissue damage by releasing their granule proteins; their tissue recruitment can be regulated by chemokines such as eotaxin-3 and CCL17. Humoral immunity is also dysregulated, as demonstrated by prominent IgG4 and IgE responses. EGPA promptly responds to glucocorticoid therapy, although combinations of glucocorticoids and immunosuppressants (e.g., cyclophosphamide, azathioprine) are eventually required in most cases. Newer therapeutic options include the anti-IL5 antibody mepolizumab, whose efficacy has been described in small clinical trials, and the B-cell-depleting agent rituximab, reported in several case series.
Collapse
Affiliation(s)
- A. Vaglio
- Department of Clinical Medicine, Nephrology and Health Sciences; University Hospital of Parma; Parma; Italy
| | - C. Buzio
- Department of Clinical Medicine, Nephrology and Health Sciences; University Hospital of Parma; Parma; Italy
| | | |
Collapse
|
48
|
[Neurological manifestations of vasculitis and primary central nervous system vasculitis]. Z Rheumatol 2013; 71:551-63. [PMID: 22930106 DOI: 10.1007/s00393-012-0957-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Neurologic complications of vasculitis occur frequently in the form of either peripheral neuropathy or manifestations within the central nervous system (CNS). Primary vasculitis of the CNS is characterized by central nervous system manifestations only with no evidence of systemic disease manifestations. Large vessel vasculitis is particularly associated with central nervous system complications, such as ischemic cerebral infarcts whereas medium size, e.g. polyarteritis nodosa and small vessel vasculitis, e.g. antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis manifest with peripheral neuropathies and central nervous system complications. The same also holds true for Behçet's disease which affects both large, medium and small sized arteries and veins. Due to the severity of nervous system manifestations a highly potent immunosuppressive therapy (e.g. cyclophosphamide and glucocorticoids) is usually required for remission induction. Virus-associated vasculitis (e.g. hepatitis C-associated cryoglobulinemic vasculitis) should receive antiviral therapy as first line treatment. Chronic damage is frequent in spite of swift initiation of immunosuppressive treatment.
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW Vasculitic neuropathy is a heterogeneous disorder that usually occurs in systemic diseases, but less commonly appears as nonsystemic vasculitic neuropathy (NSVN). This review is intended to highlight recent developments in the field of vasculitic neuropathies. RECENT FINDINGS A Peripheral Nerve Society guideline provides data-driven consensus recommendation on classification of vasculitic neuropathies and diagnosis/treatment of NSVN. NSVN is sometimes accompanied by subclinical inflammation of adjacent skin. Amyotrophic lateral sclerosis with sensory involvement can mimic NSVN. Systemic vasculitides with neuropathy include polyarteritis nodosa, microscopic polyangiitis (MPA), rheumatoid vasculitis, Churg-Strauss syndrome (CSS), and hepatitis C-related mixed cryoglobulinemic vasculitis (MCV). At autopsy, MPA affects limb nerves diffusely, with maximal damage in proximal/middle segments. CSS can be accompanied by antineutrophil cytoplasmic antibodies (ANCAs), but most patients with neuropathy lack ANCAs. Cryoglobulinemic neuropathies are usually caused by vasculitis, irrespective of phenotype. Two randomized trials revealed rituximab to be noninferior to cyclophosphamide for inducing remission in ANCA-associated vasculitis. Many reports also document efficacy of rituximab in MCV. SUMMARY Consensus guidelines on NSVN should be evaluated prospectively. MPA-associated vasculitic neuropathy results from vasculitic lesions distributed diffusely throughout peripheral extremity nerves. Rituximab is effective for ANCA-associated and cryoglobulinemic vasculitis with neuropathy.
Collapse
|
50
|
Murakami M, Shimane K, Takahashi H, Tomiyama J, Nagashima M. ANCA-associated vasculitis with dual ANCA positivity in coexistence with mixed connective tissue disease. Mod Rheumatol 2013. [DOI: 10.3109/s10165-012-0619-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masanori Murakami
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Kenichi Shimane
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Hiroshi Takahashi
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Junji Tomiyama
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masakazu Nagashima
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| |
Collapse
|