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Saghari S, Arslan K, Sordo S. Polyarteritis Nodosa With Complications: A Diagnostic Challenge and Management Dilemma. Cureus 2023; 15:e49677. [PMID: 38033446 PMCID: PMC10686717 DOI: 10.7759/cureus.49677] [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: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
Polyarteritis nodosa (PAN) is a rare autoimmune vasculitis characterized by the inflammation of medium-sized arteries throughout the body. This case report presents the clinical course of a 48-year-old female patient who experienced a complex diagnostic journey and complications during the management of PAN. The patient initially presented with dry skin, rash, and pruritus, which led to an extensive evaluation. Despite multiple visits and investigations, the definitive diagnosis of PAN was delayed. Eventually, the patient was diagnosed with PAN based on skin biopsy findings demonstrating vasculitis and inflammation of blood vessel walls. The treatment course was further complicated by the development of steroid-induced diabetes and recurrent vasculitis symptoms. Recurrence of symptoms, including rashes and neuropathy, necessitated adjustments in therapeutic interventions. This case highlights the challenges encountered in managing both PAN and its associated complications and emphasizes the importance of a multidisciplinary approach and improved patient compliance to optimize treatment outcomes.
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Affiliation(s)
- Saviz Saghari
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Kudret Arslan
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Sarah Sordo
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
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2
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Roy D, Sathyanarayana VA, Nagaraju B, Rao VKR. Tofacitinib as monotherapy in cutaneous polyarteritis nodosa: a case series. Rheumatol Adv Pract 2023; 7:rkad049. [PMID: 37325248 PMCID: PMC10267297 DOI: 10.1093/rap/rkad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Cutaneous polyarteritis nodosa (CPAN) is a distinct clinical entity represented by a chronic, relapsing, benign course, with rare systemic involvement. Treatment is with CSs, CYC or other conventional synthetic DMARDs (csDMARDs). In this case series, we aimed to share our varied clinical experience of successfully treating patients with CPAN, with tofacitinib in a refractory/relapsing course or as upfront monotherapy without CSs/csDMARDs. Methods We report this retrospective case series managed at our rheumatology centre in Bangalore from 2019 to 2022. Four patients identified as CPAN on biopsy were able to achieve disease-free remission with tofacitinib as part of their treatment, with no relapse on further follow-up. Our patients presented with subcutaneous nodules and cutaneous ulcers. After systemic evaluation, all the patients underwent skin biopsy, which showed fibrinoid necrosis in the vessel walls of the dermis, with a histopathological impression of CPAN. They were initially treated with a conventional approach of CSs with/without csDMARDs. On experiencing a refractory/relapsing course, tofacitinib was tried in all the patients as either CS sparing or upfront monotherapy without concomitant csDMARDs. Results Use of tofacitinib resulted in improvement of ulcers and paraesthesia and in gradual healing of skin lesions, albeit with scarring, with no further recurrence or relapse over a follow-up period of 6 months for all the patients. The therapeutic effect of tofacitinib was consistent when used either as CS sparing or as upfront monotherapy, thereby proving the drug to be a promising option that warrants larger trials in future to treat the subset of patients with established CPAN. Conclusion Tofacitinib could be used for disease-free remission as monotherapy for CPAN either upfront or as CS sparing, even without concomitant csDMARDs, in those patients who are dependent on CSs or multiple DMARDs.
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Affiliation(s)
- Debaditya Roy
- Correspondence to: Debaditya Roy, Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India. E-mail:
| | | | | | - Vijay K R Rao
- Divisha Arthritis and Medical Center, Bangalore, India
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3
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Micheletti RG. Treatment of cutaneous vasculitis. Front Med (Lausanne) 2022; 9:1059612. [PMID: 36465944 PMCID: PMC9716566 DOI: 10.3389/fmed.2022.1059612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/28/2022] [Indexed: 02/05/2024] Open
Abstract
Cutaneous vasculitis encompasses a spectrum of disease states, with varied morphology, severity, and potential for systemic involvement. Even vasculitis which is skin-limited can have a significant quality-of-life impact, necessitating treatment. This manuscript summarizes the available evidence for management of various types of skin-limited vasculitis and provides a proposed therapeutic ladder based on published studies and expert opinion.
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Affiliation(s)
- Robert G. Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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4
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Martins-Martinho J, Dourado E, Khmelinskii N, Espinosa P, Ponte C. Localized Forms of Vasculitis. Curr Rheumatol Rep 2021; 23:49. [PMID: 34196889 PMCID: PMC8247627 DOI: 10.1007/s11926-021-01012-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/26/2022]
Abstract
Purpose of Review To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis. Recent Findings Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment. Summary Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.
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Affiliation(s)
- Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal. .,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pablo Espinosa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
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5
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Micheletti RG, Pagnoux C. Management of cutaneous vasculitis. Presse Med 2020; 49:104033. [PMID: 32645416 DOI: 10.1016/j.lpm.2020.104033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Cutaneous vasculitis encompasses cutaneous components of systemic vasculitides, skin-limited variants of systemic vasculitides, such as IgA vasculitis or cutaneous polyarteritis nodosa, and single-organ cutaneous vasculitis, as individualized in 2012 in the Chapel Hill Consensus Conference Nomenclature. In this article, we focus on the management of skin-limited and single-organ vasculitides, often referred to, in clinical practice, as isolated "cutaneous leukocyctoclastic vasculitis", terms which may correspond to histological findings or descriptions, but are imprecise and not specific. Since most cases of isolated cutaneous vasculitis are self-limited and resolve spontaneously over 3 to 4 weeks, most patients require no systemic treatment. For those with severe, intractable, or chronic and recurring vasculitis, systemic therapy can be indicated and should be tailored to the severity of the disease. High-quality literature is lacking to guide management. Oral glucocorticoids may be required for a short period of time for painful, ulcerative, or otherwise severe disease in order to speed resolution. Among drugs which are reasonable longer-term options are colchicine, dapsone, azathioprine or hydroxychloroquine. Additional studies, including an ongoing multicenter randomized trial, are needed to determine the most effective therapies for skin-limited vasculitis.
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Affiliation(s)
- Robert G Micheletti
- Departments of Dermatology and Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 7 South, Room 724, Philadelphia, PA 19104, United States
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Ste 2-220, Toronto, Ontario, M5T 3L9, Canada.
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Cutaneous Polyarteritis Nodosa Presenting Atypically with Severe Pharyngeal Ulceration. Case Rep Rheumatol 2019; 2019:2631948. [PMID: 31019829 PMCID: PMC6452561 DOI: 10.1155/2019/2631948] [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: 11/27/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 12/02/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a multisystem, necrotising vasculitis of small- and medium-sized arteries with a predilection for the visceral vessels. Cutaneous PAN is a rare variant with symptomatic vasculitis limited to the skin, typically presenting as nodular lesions on the extremities with a propensity to ulcerate. We describe a rare case of histologically confirmed cutaneous PAN presenting in a 55-year-old Ghanaian woman with severe oropharyngeal ulceration. This was associated with dysphagia and significant weight loss. Oesophagoduodenoscopy showed that the ulceration extended throughout the oropharynx. Systemic polyarteritis nodosa was ruled out with magnetic resonance angiography. Our patient was treated successfully with corticosteroids and methotrexate. This case suggests that cutaneous PAN should be considered in the differential diagnosis of patients with oropharyngeal ulceration and that histological assessment is pivotal in establishing the diagnosis early in order to instigate appropriate therapy.
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Alquorain NAA, Aljabr ASH, Alghamdi NJ. Cutaneous Polyarteritis Nodosa Treated with Pentoxifylline and Clobetasol Propionate: A Case Report. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2019; 6:104-107. [PMID: 30787830 PMCID: PMC6196709 DOI: 10.4103/sjmms.sjmms_148_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cutaneous polyarteritis nodosa is a rare type of cutaneous vasculitis. It affects the small- and medium-sized arteries of the dermis and subcutaneous tissue without extracutaneous involvement. The diagnosis is by skin biopsy, and the characteristic finding is a leukocytoclastic vasculitis. We report a case of a 14-year-old Saudi girl who was referred to the dermatology service because of multiple ulceronecrotic lesions on the frontal aspects of the distal lower limbs. She had past medical consultations and treatment but without improvement. The histopathology confirmed the clinical diagnosis of cPAN, and ultimately, she responded to treatment with pentoxifylline and topical clobetasol propionate. It is important to be aware of this disease and refer the patient to the dermatology service for the appropriate evaluation and treatment.
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Affiliation(s)
- Nada Abdulaziz A Alquorain
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdullah Salih H Aljabr
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nada Juman Alghamdi
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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8
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Mahmood-Rao H, Gandhi N, Ding T. Gangrenous digital infarcts in a severe case of cutaneous polyarteritis nodosa. BMJ Case Rep 2017; 2017:bcr-2017-220300. [PMID: 28663247 DOI: 10.1136/bcr-2017-220300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cutaneous polyarteritis nodosa (CPAN) is a rare diagnosis which is distinct from polyarteritis nodosa (PAN). PAN is a medium-vessel vasculitis which can affect multiple organs and classically produces microaneurysms in the vasculature. CPAN is limited to the skin mainly affecting small vessels. There is an absence of microaneurysms in CPAN and it does not affect internal organs. However, the histopathological findings on the skin are similar to PAN. CPAN rarely progresses to PAN but relapses more often. We will illustrate a challenging case of a patient with CPAN who developed gangrenous infarcts despite initial immunosuppressive treatment with high-dose steroids and azathioprine. His treatment had to be escalated to intravenous cyclophosphamide which induced disease remission.
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9
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Alibaz-Oner F, Koster MJ, Crowson CS, Makol A, Ytterberg SR, Salvarani C, Matteson EL, Warrington KJ. Clinical Spectrum of Medium-Sized Vessel Vasculitis. Arthritis Care Res (Hoboken) 2017; 69:884-891. [PMID: 27564269 DOI: 10.1002/acr.23007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/25/2016] [Accepted: 08/09/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of medium-sized visceral vessels. However, cutaneous arteritis (CA) and gastrointestinal (GI) vasculitis are forms of single-organ vasculitis having indistinguishable histopathologic findings from PAN. The aim of this study was to evaluate and compare the clinical characteristics, treatment, and outcomes of patients with systemic PAN, CA, and GI vasculitis. METHODS Retrospective cohorts were assembled, consisting of patients with PAN, CA, and GI vasculitis between 1980 and 2014. The demographics, clinical characteristics, treatment, and outcomes of patients were abstracted from medical records. RESULTS We included 48 patients with PAN, 41 patients with CA, and 19 patients with GI vasculitis. The disease of 1 patient evolved from CA to systemic PAN during the disease course. At diagnosis, 94% of patients with PAN, 93% of patients with CA, and 67% of patients with GI vasculitis were treated with glucocorticoids. Additional immunosuppressive agents were used in 67% of PAN, 37% of GI vasculitis, and 32% of CA cases. The 5-year cumulative relapse rate was 45.2% in CA, and only 9.6% in PAN during a followup of approximately 6 years. No deaths were observed in the CA group. The survival rate at 10 years was 66% in the PAN group and 61% in the GI vasculitis group. CONCLUSION Systemic PAN, CA, and GI vasculitis take different clinical courses and therefore may be different diseases, rather than existing on a spectrum of the same disease. Progression of CA to systemic PAN is very rare. Relapse risk is low during followup in PAN. Patients with CA have a higher relapse rate than those with systemic PAN, possibly due to less use of immunosuppressive therapy in CA.
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Affiliation(s)
| | | | | | | | | | - Carlo Salvarani
- Azienda Ospedaliera Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
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Alaidarous A, Bouissou X, Mazereeuw-Hautier J, Bulai-Livideanu C, Lamant L, Paul C. Angiolymphoid hyperplasia with eosinophilia treated with low-dose methotrexate. JAAD Case Rep 2016; 1:342-4. [PMID: 27051774 PMCID: PMC4809377 DOI: 10.1016/j.jdcr.2015.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Abdulqader Alaidarous
- Paul Sabatier University, Toulouse, France; Department of Dermatology, University Hospitals of Toulouse, Toulouse, France
| | - Xavier Bouissou
- Department of Dermatology, University Hospitals of Toulouse, Toulouse, France
| | - Juliette Mazereeuw-Hautier
- Paul Sabatier University, Toulouse, France; Department of Dermatology, University Hospitals of Toulouse, Toulouse, France
| | - Cristina Bulai-Livideanu
- Paul Sabatier University, Toulouse, France; Department of Dermatology, University Hospitals of Toulouse, Toulouse, France
| | - Laurence Lamant
- Paul Sabatier University, Toulouse, France; Department of Histopathology, University Hospitals of Toulouse, Toulouse, France
| | - Carle Paul
- Paul Sabatier University, Toulouse, France; Department of Dermatology, University Hospitals of Toulouse, Toulouse, France
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11
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Abstract
Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.
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Affiliation(s)
- Tracy V Ting
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4010, Cincinnati, OH 45229, USA.
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12
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Subbanna PKA, Singh NV, Swaminathan RP. Cutaneous polyarteritis nodosa: A rare isolated cutaneous vasculitis. Indian Dermatol Online J 2012; 3:21-4. [PMID: 23130255 PMCID: PMC3481924 DOI: 10.4103/2229-5178.93488] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cutaneous polyarteritis nodosa (CPAN) is a rare form of cutaneous vasculitis that involves small and medium sized arteries of the dermis and subcutaneous tissue without systemic involvement. It presents with tender subcutaneous nodules, digital gangrene, livedo reticularis and subcutaneous ulcerations. The diagnosis is by skin biopsy and characteristic pathologic feature is a leukocytoclastic vasculitis in the small to medium-sized arterioles of the dermis. We report a rare case of benign cutaneous PAN in a 14-year-old girl who presented with history of fever, subcutaneous nodules with cutaneous ulcer and digital gangrene. The skin biopsy showed leukocytoclastic vasculitis with fibrinoid necrosis in the dermal vessels. She received treatment with steroids and lesions resolved completely over a period of month.
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Affiliation(s)
- Praveen Kumar A Subbanna
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Nakano H, Ooka S, Shibata T, Ogawa H, Ito H, Takakuwa Y, Tonooka K, Maeda A, Yamasaki Y, Kiyokawa T, Nagafuchi H, Yamada H, Ozaki S. Cutaneous polyarteritis nodosa associated with HLA-B39-positive undifferentiated spondyloarthritis in a Japanese patient. Mod Rheumatol 2012; 22:783-6. [PMID: 22270344 DOI: 10.1007/s10165-011-0576-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 11/28/2011] [Indexed: 11/30/2022]
Abstract
We present the case of a 43-year-old man diagnosed with HLA-B39-positive spondyloarthritis who developed cutaneous lesions consistent with cutaneous polyarteritis nodosa (CPN). Previous studies indicated an elevated incidence of HLA-B39 in HLA-B27-negative Japanese patients with spondyloarthritis. This case suggested that CPN may also occur in association with forms of HLA-B39-positive spondyloarthritis. The rarity of this association is emphasized. Therapy with corticosteroid and methotrexate improved both the cutaneous lesions and the clinical symptoms of spondyloarthritis.
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Affiliation(s)
- Hiromasa Nakano
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
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Shen S, O’Brien T, Yap LM, Prince HM, McCormack CJ. The use of methotrexate in dermatology: a review. Australas J Dermatol 2011; 53:1-18. [DOI: 10.1111/j.1440-0960.2011.00839.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Fujita H, Ishimatsu Y, Motomura M, Kakugawa T, Sakamoto N, Hayashi T, Kohno S. A case of acute sarcoid myositis treated with weekly low-dose methotrexate. Muscle Nerve 2011; 44:994-9. [DOI: 10.1002/mus.22222] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Cutaneous polyarteritis nodosa is a rare form of vasculitis relating to small-to-medium-sized arteries. Its etiology is unknown. Clinical manifestations include tender subcutaneous nodules, livedo reticularis, cutaneous ulcers and necrosis. Although it is distinct from systemic polyarteritris nodosa in that it lacks significant internal organ involvement, extra-cutaneous manifestations may be evident. Commonly encountered symptoms include fever, malaise, myalgias, arthralgias, and paresthesias. Exclusion of systemic polyarteritis nodosa is essential in diagnosis. The clinical course is chronic with remissions, relapses, and a favorable prognosis. Mild cases may resolve with nonsteroidal anti-inflammatory drugs. If more severe, treatment with systemic corticosteroids generally achieves adequate response; however, adjunctive therapy is often necessary to allow reduction in steroid dosage.
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Dillon MJ, Eleftheriou D, Brogan PA. Medium-size-vessel vasculitis. Pediatr Nephrol 2010; 25:1641-52. [PMID: 19946711 PMCID: PMC2908435 DOI: 10.1007/s00467-009-1336-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 09/10/2009] [Accepted: 09/11/2009] [Indexed: 01/20/2023]
Abstract
Medium-size-artery vasculitides do occur in childhood and manifest, in the main, as polyarteritis nodosa (PAN), cutaneous PAN and Kawasaki disease. Of these, PAN is the most serious, with high morbidity and not inconsequential mortality rates. New classification criteria for PAN have been validated that will have value in epidemiological studies and clinical trials. Renal involvement is common and recent therapeutic advances may result in improved treatment options. Cutaneous PAN is a milder disease characterised by periodic exacerbations and often associated with streptococcal infection. There is controversy as to whether this is a separate entity or part of the systemic PAN spectrum. Kawasaki disease is an acute self-limiting systemic vasculitis, the second commonest vasculitis in childhood and the commonest cause of childhood-acquired heart disease. Renal manifestations occur and include tubulointerstitial nephritis and renal failure. An infectious trigger and a genetic predisposition seem likely. Intravenous immunoglobulin (IV-Ig) and aspirin are effective therapeutically, but in resistant cases, either steroid or infliximab have a role. Greater understanding of the pathogenetic mechanisms involved in these three types of vasculitis and better long-term follow-up data will lead to improved therapy and prediction of prognosis.
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Affiliation(s)
- Michael J Dillon
- Nephrourology Unit, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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19
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Abstract
Cutaneous vasculitis can present with a variety of lesions and associated symptoms. It is important for the clinician to be able to recognize vasculitis lesions and know when to pursue further laboratory studies that will determine the extent of the disease process in a patient. This review compares and contrasts polyarteritis nodosa with its cutaneous counterpart. The diagnostic workup and management of these two entities as well as the overall approach to a patient with a possible vasculitic condition are emphasized.
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Affiliation(s)
- Courtney R Herbert
- Department of Dermatology, Tulane University Medical Center, New Orleans, LA 70112, USA
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20
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Abstract
The term polyarteritis nodosa (PAN) presently includes classic systemic PAN, cutaneous PAN, and microscopic PAN (microscopic polyangeiitis). Cutaneous PAN involves the deep dermis and the panniculus, with anatomopathological findings diagnostic for arteritis. The most frequent clinical manifestation of cutaneous PAN is the presence of nodules on the lower legs, which frequently are found at different stages of development. At times, they may not leave residual changes, but generally a violaceous livedoid color or pigmentation with retiform appearance persists for months and even years. Ulceration also is a frequent complication of cutaneous PAN. Pain, arthralgias, malaise, and moderate fever are frequently associated symptoms. Histopathologically, cutaneous PAN shows a single artery involved with diagnostic inflammatory changes. The involved artery is always located in the deep dermis or in the panniculus. Inflammatory active skin nodules show a necrotizing arteritis with variable amounts of fibrinoid necrosis and leukocytoclasia, edema and inflammatory cells. The presence of focal panniculitis surrounding the involved artery is characteristic, in contrast with the more diffuse panniculitis usually found in other nodular diseases. Cutaneous PAN has a variable course, with repeated exacerbations. Salicilates relieve the pain in most instances and may be the only treatment required to improve the symptoms in patients with moderate flare-ups. A short course of corticosteroids therapy at a moderate dose is the most effective treatment to relieve the symptoms and to reduce the inflammation. Patients with an increased ASO titer should always be treated with penicillin.
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Affiliation(s)
- José L Díaz-Pérez
- Department of Dermatology, Hospital de Cruces, Baracaldo, Vizcaya, Spain.
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Choi SW, Lew S, Cho SD, Cha HJ, Eum EA, Jung HC, Park JH. Cutaneous polyarteritis nodosa presented with digital gangrene: a case report. J Korean Med Sci 2006; 21:371-3. [PMID: 16614534 PMCID: PMC2734024 DOI: 10.3346/jkms.2006.21.2.371] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cutaneous polyarteritis nodosa (CPAN) is an uncommon form of vasculitis involving small and medium sized arteries of unknown etiology. The disease can be differentiated from polyarteritis nodosa by its limitation to the skin and lack of progression to visceral involvement. The characteristic manifestations are subcutaneous nodule, livedo reticularis, and ulceration, mostly localized on the lower extremity. Arthralgia, myalgia, peripheral neuropathy, and constitutional symptoms such as fever and malaise may also be present. We describe a 34-yr-old woman presented with severe ischemic change of the fingertip and subcutaneous nodules without systemic manifestations as an unusual initial manifestation of CPAN. Therapy with corticosteroid and alprostadil induce a moderate improvement of skin lesions. However, necrosis of the finger got worse and the finger was amputated.
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Affiliation(s)
- Seung Won Choi
- Department of Internal Medicine, Ulsan University Hospital, College of Medicine, University of Ulsan, Dong-gu, Ulsan, Korea.
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Abstract
UNLABELLED Vasculitis can range in severity from a self-limited single-organ disorder to a life-threatening disease with the prospect of multiple-organ failure. This condition presents many challenges to the physician, including classification and diagnosis, appropriate laboratory workup, treatment, and the need for careful follow-up. The physician must not only be able to recognize vasculitis but also be able to provide a specific diagnosis (if possible) as well as recognize and treat any underlying etiologic condition. Most diagnostic criteria are based on the size of vessel involvement, which often correlates with specific dermatologic findings. This may allow the dermatologist to provide an initial diagnosis and direct the medical evaluation. This article reviews the classification and diagnosis of cutaneous vasculitic syndromes and current treatment options; it also presents a comprehensive approach to diagnosing and treating the patient with suspected cutaneous vasculitis. (J Am Acad Dermatol 2003;48:311-40.) LEARNING OBJECTIVE At the completion of this learning activity, participants should be familiar with the classification and clinical features of the various forms of cutaneous vasculitis. They should also have a rational approach to diagnosing and treating a patient with vasculitis.
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MESH Headings
- Drug Therapy, Combination
- Female
- Humans
- Incidence
- Male
- Prognosis
- Risk Factors
- Severity of Illness Index
- Skin Diseases, Vascular/diagnosis
- Skin Diseases, Vascular/drug therapy
- Skin Diseases, Vascular/epidemiology
- Vasculitis/diagnosis
- Vasculitis/drug therapy
- Vasculitis/epidemiology
- Vasculitis, Leukocytoclastic, Cutaneous/diagnosis
- Vasculitis, Leukocytoclastic, Cutaneous/drug therapy
- Vasculitis, Leukocytoclastic, Cutaneous/epidemiology
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Affiliation(s)
- David F Fiorentino
- Department of Dermatology, Stanford University School of Medicine, CA 94305, USA.
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