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Box CD, Cronin O, Hauser B. The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides. Front Endocrinol (Lausanne) 2022; 13:806361. [PMID: 35250864 PMCID: PMC8889574 DOI: 10.3389/fendo.2022.806361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/29/2022] Open
Abstract
Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.
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Affiliation(s)
| | - Owen Cronin
- Department of Rheumatology, Bon Secours Hospital Cork, Cork, Ireland
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Barbara Hauser,
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2
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Hong J, Zhu B, Cai X, Liu S, Liu S, Zhu Q, Aierken X, Aihemaiti A, Wu T, Li N. Assessment of the association between red blood cell distribution width and disease activity in patients with systemic vasculitis. Exp Ther Med 2021; 22:691. [PMID: 33986856 PMCID: PMC8112135 DOI: 10.3892/etm.2021.10123] [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: 10/02/2019] [Accepted: 01/28/2021] [Indexed: 11/20/2022] Open
Abstract
The present study aimed to investigate whether red blood cell distribution width (RDW) could serve as a marker for estimating disease activity in patients with systemic vasculitis (SV). A total of 287 patients with SV and 64 age- and sex-matched healthy controls (HCs) were included in the present study. Biochemical indicators and hematologic parameters were evaluated in patients with SV and the HCs. Disease activity was assessed on the basis of the Birmingham Vasculitis Activity Score (BVAS). RDW was significantly elevated in patients with SV compared with HCs (P<0.05). A similar result was obtained for the comparison of patients with various disease states, active vs. inactive (P<0.05). RDW was significantly increased in patients with kidney injury compared with patients without kidney injury (P<0.05). The correlation analysis indicated that there were positive correlations between RDW and BVAS, erythrocyte sedimentation rate, high-sensitivity C-reactive protein, white blood cells and serum creatinine (Scr; all P<0.05). In addition, there was a significant negative correlation between RDW and hemoglobin levels (P<0.05). Multivariate logistic regression analysis indicated that RDW was independently correlated with patients with active SV. The combined diagnosis of RDW and Scr indicated that the sensitivity and specificity were 68.6 and 88.9%, respectively, in terms of assessing disease activity in patients with SV. Therefore, the present study suggested that RDW may serve as a useful index for estimating disease activity and kidney injury in patients with SV. Moreover, the combination of RDW and Scr may be more effective than RDW alone when assessing the risk of disease activity in patients with SV.
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Affiliation(s)
- Jing Hong
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Bin Zhu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Xintian Cai
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Shanshan Liu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Shasha Liu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Qing Zhu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Xiayire Aierken
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Ayiguzaili Aihemaiti
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Ting Wu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
| | - Nanfang Li
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, NHC Key Laboratory of Hypertension Clinical Research, Hypertension Institute of Xinjiang, Tianshan, Urumqi, Xinjiang 830001, P.R. China
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3
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Ferranti M, Cama E, Cacciavillani M, Schiavon F, Felicetti M, Briani C, Alaibac M. Leukocytoclastic vasculitis associated with multifocal sensory neuropathy responsive to intravenous immunoglobulins: a case report. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2021; 38:e2021022. [PMID: 34744418 PMCID: PMC8552574 DOI: 10.36141/svdld.v38i3.10883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 05/14/2021] [Indexed: 11/21/2022]
Abstract
Leukocytoclastic vasculitis (LCV) is a common form of small-vessel vasculitis, which commonly presents as palpable purpura or petechiae, caused by deposition of circulating immune complexes on vessels walls that attracts granulocytes which damage the vascular endothelium and leading to erythrocytes extravasation. The skin is the most commonly involved organ, but also renal, gastrointestinal, pulmonary, cardiovascular and neurological systems may be affected. Skin lesions may be the initial signs of systemic vasculitis. Systemic symptoms may be present, such us fever, myalgia, abdominal pain and arthralgia. The presence of neuropathy/mononeuritis multiplex is expression of severe vasculitic involvement. Herein, we describe the case of a patient with leucocytoclastic vasculitis associated to sensitive neuropathy, responsive to intravenous immunoglobulins (IVIg) therapy, after the failure of classic systemic treatments.
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Affiliation(s)
- Martina Ferranti
- Unit of Dermatology, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Elena Cama
- Unit of Dermatology, Department of Medicine DIMED, University of Padua, Padua, Italy
| | | | - Franco Schiavon
- Unit of Rheumatology, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Mara Felicetti
- Unit of Rheumatology, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Chiara Briani
- Unit of Neurology, Department of Neurosciences, University of Padua, Padua, Italy
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4
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Jung JH, Jeong HS, Choi SJ, Song GG, Kim JH, Lee TH, Han Y. Associations between interleukin 18 gene polymorphisms and susceptibility to vasculitis: A meta-analysis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2020; 37:203-211. [PMID: 33093784 PMCID: PMC7569561 DOI: 10.36141/svdld.v37i2.9399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/15/2020] [Indexed: 11/24/2022]
Abstract
Interleukin 18 (IL18), a pro-inflammatory cytokine, affects the development and progress of vasculitis. The production, expression, and function of this cytokine are affected by polymorphisms of promoter region of the IL18 gene. In this study, a meta-analysis of the associations between several IL18 polymorphisms and susceptibility to vasculitis was performed. Published literature from PubMed and Embase were retrieved. In total, nine studies comprising 1006 patients with vasculitis and 1499 controls combined, and the investigating the rs187238, rs194618, and rs360719 polymorphisms of the promoter region of the IL18 gene, were included in the meta-analysis. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated with fixed-effects model or random-effects model. The recessive model of the rs194618 polymorphism was found to be significantly associated with a high susceptibility to vasculitis (OR = 1.54, 95% CI = 1.02–2.33, P = 0.04), especially in the Mongoloid race, where the A allele of rs194618 was associated with a low risk of the disease (OR = 0.77, 95% CI = 0.62–0.95, P = 0.01). By contrast, the rs187238 and rs360719 polymorphisms were not associated with this inflammatory condition. This meta-analysis showed that some IL18 polymorphisms are associated with susceptibility to vasculitis. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 203-211)
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Affiliation(s)
- Jae Hyun Jung
- Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Han Saem Jeong
- Heart Disease Research Institute, Dr. Jeong's Heart Clinic, 224 Baekje-daero, Wansan-gu, Jeonju-si, Jeollabuk-do, 54985, Korea
| | - Sung Jae Choi
- Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Korea
| | - Gwan Gyu Song
- Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, Korea
| | - Jong-Ho Kim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Tae Hyub Lee
- College of Medicine, Chung-Ang University, 84 Heukseouk-ro, Donjak-gu, Seoul 06974, Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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5
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de Graeff N, Groot N, Brogan P, Ozen S, Avcin T, Bader-Meunier B, Dolezalova P, Feldman BM, Kone-Paut I, Lahdenne P, Marks SD, McCann L, Pilkington C, Ravelli A, van Royen A, Uziel Y, Vastert B, Wulffraat N, Kamphuis S, Beresford MW. European consensus-based recommendations for the diagnosis and treatment of rare paediatric vasculitides - the SHARE initiative. Rheumatology (Oxford) 2020; 58:656-671. [PMID: 30535249 DOI: 10.1093/rheumatology/key322] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/04/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The European initiative Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) aimed to optimize care for children with rheumatic diseases. Systemic vasculitides are very rare in children. Consequently, despite recent advances, paediatric-specific information is sparse. The lack of evidence-based recommendations is an important, unmet need. This study aimed to provide recommendations for diagnosing and treating children with rare forms of childhood systemic vasculitis. METHODS Recommendations were developed by a consensus process in accordance with the European League Against Rheumatism standard operating procedures. A systematic literature review informed the recommendations, which were devised and evaluated by a panel of experts via an online survey, and two consensus meetings using nominal group technique. Recommendations were accepted when ⩾ 80% of experts agreed. RESULTS Ninety-three relevant articles were found, and 78 recommendations were accepted in the two consensus meetings. General, cross-cutting recommendations and disease-specific statements regarding the diagnosis and treatment of childhood-onset PAN, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and Takayasu arteritis are provided. CONCLUSION These Single Hub and Access point for paediatric Rheumatology in Europe recommendations were formulated through an evidence-based consensus process to support uniform, high-quality standard of care for children with rare forms of paediatric systemic vasculitis.
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Affiliation(s)
- Nienke de Graeff
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Noortje Groot
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht.,Department of Paediatric Rheumatology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool
| | - Paul Brogan
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Seza Ozen
- Department of Paediatric Rheumatology, Hacettepe University, Ankara, Turkey
| | - Tadej Avcin
- Department of Paediatric Rheumatology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Brigitte Bader-Meunier
- Department of Paediatric Rheumatology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pavla Dolezalova
- 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Brian M Feldman
- Department of Paediatric Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Isabelle Kone-Paut
- Department of Paediatric Rheumatology, Bicêtre University Hospital, APHP, University of Paris Sud, Paris, France
| | - Pekka Lahdenne
- Department of Paediatric Rheumatology, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Stephen D Marks
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, University College London Great Ormond Street Institute of Child Health and Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
| | - Angelo Ravelli
- Department of Paediatric Rheumatology, Gaslini Children's Hospital, Genoa, Italy
| | - Annet van Royen
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Yosef Uziel
- Meir Medical Center, Kfar Saba, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Bas Vastert
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Nico Wulffraat
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's Hospital, Liverpool.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Biologics for childhood systemic vasculitis. Pediatr Nephrol 2019; 34:2295-2309. [PMID: 30203375 DOI: 10.1007/s00467-018-4076-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022]
Abstract
Recent advances have allowed better understanding of vasculitis pathogenesis and led to more targeted therapies. Two pivotal randomized controlled trials, RITUXVAS and rituximab in ANCA-associated vasculitis (RAVE), provide high-quality evidence demonstrating rituximab (RTX) is efficacious in inducing remission in adult ANCA-associated vasculitis (AAV) patients compared with cyclophosphamide (CYC). RAVE also demonstrated superiority of RTX to oral CYC for induction of remission in relapsing disease. Disappointingly, the RTX regimen was not associated with reduction in early serious adverse events. At least nine randomized trials are in progress, aiming to further delineate optimal dosing and duration of RTX therapy in AAV. In particular, the 6-month interim results of the PEPRS trial provide encouraging data specific to children. Due to special concerns related to growth, preservation of fertility, and potential for high cumulative medication doses, children with AAV should be considered as candidates for RTX even as a first-line remission induction therapy. Two randomized clinical trials have defined the role of infliximab in Kawasaki disease (KD), which appears to be as an alternative to a second infusion of intravenous immunoglobulin (IVIG) for treatment-resistant disease. Support for other biologics in the treatment of AAV or for biologics in the treatment of other vasculidities is largely lacking due to either unimpressive trial results or lack of trials. Except for the KD trials and the PEPRS, trials enrolling children remain scant. This review touches on the key trials and case series with biologics in the treatment of vasculitis that have influenced practice and shaped current thinking.
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8
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Higaki R, Miyazaki A, Tajiri Y, Shoji M, Saito S, Yoshimura SI, Miki N, Hatta K, Doi H. Continuous infusion of lipo-prostaglandin E1 for Takayasu’s arteritis with heart failure in an 11-month-old baby: a case report. J Med Case Rep 2018; 12:266. [PMID: 30172258 PMCID: PMC6119586 DOI: 10.1186/s13256-018-1769-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/13/2018] [Indexed: 11/28/2022] Open
Abstract
Background Takayasu’s arteritis is extremely rare in children aged below 6 years. At the onset of Takayasu’s arteritis in children, symptoms are varied but differ from those in adults. Corticosteroids are the mainstay of treatment for preventing irreversible vascular damage but there is no standard treatment for progressive vascular stenosis. Case presentation A Japanese 11-month-old baby boy presented with Takayasu’s arteritis and heart failure, possibly due to afterload mismatch caused by high blood pressure. Computed tomography was performed and revealed thoracic and abdominal aortic aneurysms. It also revealed severe celiac artery stenosis and bilateral renal artery stenosis. Prednisolone was initiated as first-line therapy. The fever resolved, and C-reactive protein levels returned to normal. Although his general condition improved, deterioration of vascular lesions was evident. Celiac artery occlusion, severe right renal artery stenosis, and new superior mesenteric artery stenosis were observed. We decided to use a continuous infusion of lipo-prostaglandin E1 for prevention of branch stenosis of his abdominal aorta. The progression of vascular stenosis was stopped and our patient’s cardiac function gradually improved. Conclusions A differential diagnosis of heart failure with high blood pressure should be considered in babies. The progression of vascular stenosis may be suppressed by lipo-prostaglandin E1.
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Abstract
Kawasaki disease (KD) is an acute-onset systemic vasculitis of medium-sized vessels that mostly affects infants and toddlers. Globally, it is the most common form of childhood primary vasculitis. Delayed diagnosis and treatment results in coronary artery aneurysms in up to 25% of all affected individuals. Thus, KD is the most common acquired heart disease in developed countries. Here, the current understanding of clinical presentations, pathophysiological concepts, disease-associated complications, and available pharmaceutical treatment is provided and discussed in the context of available literature.
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Affiliation(s)
- Christian M. Hedrich
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
- Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Anja Schnabel
- Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Toni Hospach
- Zentrum für Pädiatrische Rheumatologie am Klinikum Stuttgart, Stuttgart, Germany
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Brogan P, Eleftheriou D. Vasculitis update: pathogenesis and biomarkers. Pediatr Nephrol 2018; 33:187-198. [PMID: 28785984 PMCID: PMC5769819 DOI: 10.1007/s00467-017-3597-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/12/2017] [Accepted: 01/13/2017] [Indexed: 01/29/2023]
Abstract
Better understanding of the pathogenesis and treatment of primary systemic vasculitides (PSV) has led to the development of many potentially clinically relevant biomarkers. Genome-wide association studies have highlighted that MHC class II polymorphisms may influence the development of particular anti-neutrophil cytoplasmic antibody (ANCA) serotypes, but not the clinical phenotype of ANCA-associated vasculitis (AAV). Although ANCAs are overall poor biomarkers of disease activity, they may be useful for the prediction of flares of renal and/or pulmonary vasculitis. Moreover, patients with proteinase 3 (PR3)-AAV may respond better to rituximab than cyclophosphamide. Newer biomarkers of renal vasculitis in AAV include urinary soluble CD163, and may in the future reduce the requirement for renal biopsy. Better understanding of dysregulated neutrophil activation in AAV has led to the identification of novel biomarkers including circulating microparticles, and neutrophil extracellular traps (NETs), although their clinical utility has not yet been realised. Studies examining endothelial injury and repair responses have additionally revealed indices that may have utility as disease activity and/or prognostic biomarkers. Last, next-generation sequencing technologies are revealing monogenic forms of vasculitis, such as deficiency of adenosine deaminase type 2 (DADA2), and are profoundly influencing the approach to the diagnosis and treatment of vasculitis in the young.
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Affiliation(s)
- Paul Brogan
- Infection, Inflammation, and Immunology Section, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N1EH, UK.
| | - Despina Eleftheriou
- Infection, Inflammation, and Immunology Section, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N1EH, UK
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N1EH, UK
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11
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Identification of co-occurrence in a patient with Dent's disease and ADA2-deficiency by exome sequencing. Gene 2018; 649:23-26. [PMID: 29391272 DOI: 10.1016/j.gene.2018.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 12/23/2017] [Accepted: 01/17/2018] [Indexed: 11/24/2022]
Abstract
Patients with co-occurrence of two independent pathologies pose a challenge for clinicians as the phenotype often presents as an unclear syndrome. In these cases, exome sequencing serves as a powerful instrument to determine the underlying genetic causes. Here, we present the case of a 4-year old boy with proteinuria, microhematuria, hypercalciuria, nephrocalcinosis, livedo-like rash, recurrent abdominal pain, anemia and continuously elevated CRP. Single exome sequencing revealed the pathogenic nonsense mutation p.(Arg98*) in the CLCN5 gene causing the X-linked inherited, renal tubular disorder Dent's disease. Furthermore, the two pathogenic and compound heterozygous missense variants p.(Gly47Ala) and p.(Pro251Leu) in the CECR1 gene could be identified. Mutations in the CECR1 gene are associated with a hereditary form of polyarteritis nodosa, called ADA2-deficiency. Both parents were carriers of a single heterozygous variant in CECR1 and the mother was carrier of the CLCN5 variant. This case evidently demonstrates the advantage of whole exome sequencing compared to single gene testing as the pathology in the CECR1 gene might have only been diagnosed after the occurrence of signs of systemic vasculitis like strokes or hemorrhages. Therefore, treatment and prevention can now start early to improve the outcome of these patients.
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12
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Vazquez-Romo KA, Rodriguez-Hernandez A, Paczka JA, Nuño-Suarez MA, Rocha-Muñoz AD, Zavala-Cerna MG. Optic Neuropathy Secondary to Polyarteritis Nodosa, Case Report, and Diagnostic Challenges. Front Neurol 2017; 8:490. [PMID: 28979236 PMCID: PMC5611380 DOI: 10.3389/fneur.2017.00490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/01/2017] [Indexed: 11/22/2022] Open
Abstract
Purpose To describe a case of optic neuropathy as a primary manifestation of polyarteritis nodosa (PAN) and discuss diagnostic challenges. Methods Case report. Results A 41-year-old Hispanic man presented with a 2-day history of reduced visual acuity in his left eye. Physical examination revealed a complete visual field loss in the affected eye. Best-corrected visual acuity (BCVA) in the left eye was hand motion, and fundus examination revealed a hyperemic optic disk with blurred margins, swelling, retinal folds, dilated veins, and normal size arteries. BCVA in the right eye was 20/20; no anomalies were seen during examination of the fundus. The patient was started on oral corticosteroids and once the diagnosis of PAN was made, cyclophosphamide was added to the treatment regimen. Six months later, the patient recovered his BCVA to 20/20 in his left eye. Conclusion Rarely does optic neuropathy present as a primary manifestation of PAN; nevertheless, it represents an ophthalmologic emergency that requires expeditious anti-inflammatory and immunosuppressive treatment to decrease the probability of permanent visual damage. Unfortunately, diagnosing PAN is challenging as it necessitates a high index of suspicion. In young male patients who present for the first time with diminished visual acuity, ophthalmologists become cornerstones in the suspicion of this diagnosis and should be responsible for continuing the study until a diagnosis is reached to ensure rapid commencement of immunosuppressive treatment.
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Affiliation(s)
- Kristian A Vazquez-Romo
- Ophthalmology Department, Hospital Regional "Dr. Valentín Gómez Farías", Zapopan, Jalisco, México
| | - Adrian Rodriguez-Hernandez
- UIEC, Hospital de Especialidades, Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Jalisco, México
| | - Jose A Paczka
- Unidad de Diagnóstico Temprano del Glaucoma, Guadalajara, Jalisco, México
| | - Moises A Nuño-Suarez
- Ophthalmology Department, Hospital Regional "Dr. Valentín Gómez Farías", Zapopan, Jalisco, México
| | - Alberto D Rocha-Muñoz
- Centro Universitario de Tonala (CUTONALA), Universidad de Guadalajara, Tonala, Jalisco, Mexico
| | - Maria G Zavala-Cerna
- Immunology Research Laboratory, Programa Internacional de Medicina, Universidad Autonoma de Guadalajara, Guadalajara, Jalisco, Mexico
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Abstract
Cutaneous vasculitis, inflammatory destruction of blood vessels, can present with a wide range of clinical and pathologic findings across a number of heterogeneous conditions. Although some vasculitides are present in both children and adults, some important differences exist in clinical presentation, etiology, management, and prognosis in childhood vasculitis versus adult vasculitis. Cutaneous vasculitis is rare in children, and most childhood vasculitides, of which Henoch-Schönlein purpura is the most common, histologically are small vessel leukocytoclastic vasculitis. In children, infectious etiologies are more common than in adults. Childhood cutaneous vasculitis is most often self-limited with a good prognosis, and treatment is mainly supportive. © 2017 Elsevier Inc. All rights reserved.
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Affiliation(s)
- Nikita Lakdawala
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI.
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14
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Tian MQ, Liu SY, Li J, Shu XM. [Hypertension and intermittent convulsions for one month in a school-age child]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:816-819. [PMID: 28697838 PMCID: PMC7389928 DOI: 10.7499/j.issn.1008-8830.2017.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 03/06/2017] [Indexed: 06/07/2023]
Abstract
Childhood polyarteritis nodosa (PAN) is a rare systemic vasculitis and the delayed diagnosis and treatment will cause high incidence of sequelae and high mortality. This article reports a girl with childhood PAN due to posterior reversible encephalopathy syndrome (PRES). The girl aged ten years was admitted to the hospital due to hypertension and convulsions for one month. She had complaints of headache, vomiting, and blurred vision before convulsions. At six months before admission, a mass was observed in the neck. The physical examination showed that she had hypertension and no abnormal findings in the central nervous system. The brain magnetic resonance imaging manifested long T1 and T2 signals, high signal intensities on fluid-attenuated inversion recovery (FLAIR) images, and iso-signal intensity on diffusion-weighted imaging in the white matter of the left occipital lobe. Therefore, the cause of convulsions was considered as PRES. Mass biopsy suggested PAN and no findings supported tuberculosis. The right kidney atrophy was observed by ultrasound examination. Emission computed tomography of the kidney showed multiple vascular stenosis and no blood perfusion in the right kidney, so PAN was confirmed. These findings suggest that PAN should be considered in patients with vasculitis who had involvements of multiple systems after excluding common vasculitis, such as Kawasaki disease and Henoch-Schönlein purpura. Biopsy and angiography should be performed as early as possible for timely diagnosis and treatment.
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Affiliation(s)
- Mao-Qiang Tian
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, China.
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15
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Erden A, Batu ED, Sönmez HE, Sarı A, Armagan B, Arıcı ZS, Bilgin E, Kalyoncu U, Karadağ Ö, Bilginer Y, Ertenli AI, Özen S. Comparing polyarteritis nodosa in children and adults: a single center study. Int J Rheum Dis 2017. [PMID: 28626961 DOI: 10.1111/1756-185x.13120] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Polyarteritis nodosa (PAN) is a necrotizing vasculitis of medium/small arteries. We aimed to examine the characteristics of adult- and childhood-onset PAN. METHODS Fifteen pediatric (˂ 18 years) and 22 adult PAN patients who fulfilled the Ankara 2008 and American College of Rheumatology 1990 criteria, respectively, were included in the study. RESULTS Five children had cutaneous and all the rest of the patients had systemic PAN. Weight loss was more common (59.1% vs. 20%, P = 0.041) and presence of an angiography at diagnosis was more frequent (81.8% vs. 33.3%, P = 0.003) in adults than children. Arthralgia/arthritis and skin involvement were more common in children (86.7% vs. 59.1%; 93.3% vs. 72.7%, respectively) while renal and neurologic involvement were more frequently observed in adult patients (50% vs. 20%; 59.1% vs. 40%, respectively) (P > 0.05 for all). Cutaneous PAN patients were treated with corticosteroids only. All but one adult patient received cyclophosphamide while mycophenolate mofetil was used in five and cyclophosphamide was used in four children as induction treatment. The median duration of induction treatment was longer in adults than children (12 vs. 3 months, respectively; P = 0.004). The most common maintenance drug was mycophenolate mofetil in children and azathioprine in adults. The mortality rate was 13.6% (n = 3) and 0% in adults and children, respectively. CONCLUSION To our knowledge, this is the first study comparing characteristics of adult and childhood onset PAN. Our results have suggested that juvenile PAN had a more benign course (with less renal and neurologic involvement, shorter duration of induction treatment) than adult onset PAN.
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Affiliation(s)
- Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi D Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hafize E Sönmez
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alper Sarı
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berkan Armagan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zehra S Arıcı
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emre Bilgin
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ali Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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16
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Efficacy of mizoribine and prednisolone combination therapy in adult patients with IgA vasculitis. Rheumatol Int 2017; 37:1387-1393. [DOI: 10.1007/s00296-017-3685-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/22/2017] [Indexed: 12/01/2022]
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