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Shimojima Y, Nomura S, Ushiyama S, Ichikawa T, Takamatsu R, Kishida D, Sekijima Y. Early skeletal muscle manifestations in polyarteritis nodosa and ANCA-associated vasculitis. Autoimmun Rev 2024:103602. [PMID: 39153646 DOI: 10.1016/j.autrev.2024.103602] [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: 04/01/2024] [Revised: 08/03/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024]
Abstract
Skeletal muscle involvement is common in patients with small- and medium-sized vasculitis, particularly polyarteritis nodosa (PAN) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Despite being not included in the standard classification criteria for PAN and AAV, skeletal muscle involvement is an important clinical indicator, particularly when vasculitic myopathy is the only pathological evidence in the absence of other organ involvement. Herein, we comprehensively reviewed and compared the clinical features of 71 and 135 patients with PAN and AAV, respectively, with skeletal muscle involvement at the time of disease onset. Most patients with PAN and AAV exhibited skeletal muscle involvement, often characterized by myalgia and occasional muscular weakness, predominantly in the lower extremities. Myalgia and weakness were observed more frequently in the distal lower extremities in patients with PAN than in those with AAV. In contrast, skeletal muscle involvement tended to exhibit a more dispersed distribution across all four extremities in those with AAV. Muscle magnetic resonance imaging T2-weighted and short-tau inversion recovery sequences can effectively identify hyperintense areas attributed to hypervascularity of affected muscle tissues and serve as a sensitive and useful modality for visually determining the suitable biopsy site. >90% of patients with PAN and AAV demonstrated perivascular inflammation in their affected muscle tissues, whereas fibrinoid necrosis of the vessel walls was reported in two-thirds of patients. Serum creatine kinase (CK) levels were within the normal range in approximately 80% of patients presenting with skeletal muscle involvement in PAN and AAV. Furthermore, muscle fiber damage was milder in patients with skeletal muscle involvement in PAN and AAV than those with idiopathic inflammatory myositis. Meanwhile, serum CK levels were elevated in 65-85% of patients with PAN and AAV who had myofiber necrosis and degeneration in the affected muscles. Most patients with PAN and AAV showed improvement in skeletal muscle involvement following glucocorticoids (GCs) administration; however, relapse was observed in some patients during the tapering of GCs. In summary, skeletal muscle involvement is a potential indicator for establishing PAN and AAV diagnoses during the early phases of the disease.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.
| | - Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Ushiyama
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryota Takamatsu
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
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Enabi J, Shah K, Kondakindi H, Mukkera S. A Rare Presentation of Polyarteritis Nodosa (PAN). Cureus 2024; 16:e55143. [PMID: 38558645 PMCID: PMC10979759 DOI: 10.7759/cureus.55143] [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: 02/25/2024] [Indexed: 04/04/2024] Open
Abstract
Polyarteritis nodosa (PAN) is a connective tissue disease that affects arteries, causing necrotizing inflammation that can weaken the arterial walls, dilatation into aneurysms, and rupture in some cases. We present a case of a male with acute abdomen from aneurysmal rupture. The 48-year-old patient with a history of polysubstance use including cocaine and methamphetamines was admitted for acute hypoxic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia and treated with broad-spectrum antibiotics and steroids. He also reported generalized abdominal pain and discomfort, and examination revealed abdominal distension that was diffusely tender on palpation, bowel sounds intact. Laboratory workup showed a progressive drop in hemoglobin requiring blood transfusions, no coagulopathy, anion gap metabolic acidosis, and lactic acidosis. Abdominal CT showed a 2 cm lobulated saccular aneurysm involving either the left gastric artery or splenic artery, associated with an extensive moderate amount of hemoperitoneum with hematomas (largest measuring up to 8.6 cm) abutting the gastric fundus and greater curvature of the stomach, which was likely secondary to aneurysmal rupture. Additionally, several other mesenteric vessels displayed some degree of dilation. Interventional radiology (IR)-guided splenic artery embolization for splenic artery aneurysm was done, after which his hemoglobin remained stable. The patient was given vaccine recommendations since splenic artery embolization would lead to asplenia. The aneurysms were attributed to either cocaine-related aneurysms or polyarteritis nodosa with visceral artery aneurysms. He denied rashes, oral ulcers, joint pain, subcutaneous nodules, blood in the urine, history of hepatitis or syphilis. Tertiary syphilis was ruled out after the Venereal Disease Research Laboratory (VDRL) test and rapid plasma reagin (RPR) test were negative. Complement C3 and C4 levels were normal. He was treated with high-dose IV methylprednisone after infection was ruled out. Due to the severity of PAN, therapy with IV cyclophosphamide therapy 15 mg/kg once every two weeks for three doses was initiated, followed by 15 mg/kg once every three weeks for three to six months (in combination with glucocorticoids prednisone 1 mg/kg body weight with slow taper). Cyclophosphamide was given with IV hydration and mesna. The presentation of PAN can vary widely. Most commonly, individuals experience symptoms such as fatigue, weight loss, fever, and chills. However, in rare cases, patients may present with isolated abdominal pain, similar to our patient. It's crucial to note that the rupture of an aneurysm can manifest as an acute abdominal issue, potentially leading to life-threatening situations. Immediate interventions to control bleeding are imperative in such cases. The treatment of PAN has a high success rate when a combination of cyclophosphamide and steroids is administered.
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Affiliation(s)
- Joud Enabi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Kejal Shah
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Hema Kondakindi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Srikanth Mukkera
- Rheumatology, Texas Tech University Health Science Center at Permian Basin, Odessa, USA
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3
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Elhardello OAA, Athamnah MN, Paramaguru R. Polyarteritis nodosa presenting as cholecystitis-a case report. J Surg Case Rep 2023; 2023:rjad603. [PMID: 38026741 PMCID: PMC10640672 DOI: 10.1093/jscr/rjad603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Medium and small arteries are mainly affected by polyarteritis nodosa. Lungs are spared but any other organ can be involved. Gallbladder can be part of this systemic disease. Isolated gallbladder disease is not common. The presentation of the systemic polyarteritis nodosa as acute cholecystitis is described in this case report. Management of the disease depends on the involved organs and usually consists of systemic steroids. The diagnosis of polyarteritis nodosa should be considered in patients with previous systemic symptoms who develop picture of acute cholecystitis.
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Affiliation(s)
- Osama A A Elhardello
- General Surgery, Al Salam Al Assima Hospital, Bneid AL Gar, Port Said street, 35151, Kuwait
| | - Mohammad N Athamnah
- General Surgery, Al Salam Al Assima Hospital, Bneid AL Gar, Port Said street, 35151, Kuwait
| | - Rajaguru Paramaguru
- Histopathology, Al Salam Al Assima Hospital, Bneid AL Gar, Port Said street, 35151, Kuwait
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4
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Wang HY, Robson DC, Kim SJ. Annular vasculitic lesions. Clin Dermatol 2023; 41:326-339. [PMID: 37423264 DOI: 10.1016/j.clindermatol.2023.07.002] [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: 07/11/2023]
Abstract
Vasculitic skin findings may present with annular morphologies. This group of conditions consists of capillaritis, such as pigmented purpuric dermatoses, and vasculitis, which is often classified by the affected vessel size. Annular vasculitic lesions may be the presenting sign of systemic disease, thus requiring thorough exploration to reach an accurate diagnosis and guide proper disease management. Herein we review the clinical presentation, histopathology, and treatments for cutaneous vasculitic disease that may present with annular lesions.
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Affiliation(s)
| | | | - Soo Jung Kim
- Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA.
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Hankard A, Puéchal X, Martin Silva N, Deshayes S, Lorcy N, Le Gallou T, Carron PL, Daugas E, Kaplanski G, Boutemy J, Maigné G, Galimard C, Terrier B, Aouba A, de Boysson H. Characteristics of ANCA-associated vasculitis with aneurysms: Case series and review of the literature. Autoimmun Rev 2023; 22:103293. [PMID: 36787809 DOI: 10.1016/j.autrev.2023.103293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION ANCA-associated vasculitis (AAV) is an exceptional cause of small and large vascular aneurysms. Here, we present the phenotypic characteristics of patients with AAV associated with the presence of aneurysms. METHODS We conducted a retrospective multicenter study and a systematic review of the literature. Only AAV patients with positive ANCA results and > 1 aneurysm(s) were enrolled. Patients were recruited through a call of observations among the French Vasculitis Study Group (FVSG) and the French Internal Medicine Network. Patients with aneurysm rupture were compared to those without. RESULTS We enrolled 51 patients in the cohort, including 31 (67%) with granulomatosis with polyangiitis. The median Birmingham Vasculitis Activity Score was 18 [6-41]. A total of 92 aneurysms were noted, 74% of which involved medium-sized arteries, particularly the renal artery. During a follow-up of 24 [6-56] months, 22 (43%) patients experienced aneurysmal rupture, 91% of which involved medium-sized vessels. Patients with aneurysmal rupture showed significantly more pulmonary infiltrates and higher creatinine levels at baseline than patients without rupture. Initial treatments did not differ between the two groups. Ten (20%) patients died during the follow-up, including three from an aneurysmal rupture. CONCLUSION Aneurysms were more frequently observed in GPA patients and predominantly affected medium-sized vessels, especially the renal arteries. The risk of rupture was high and occurred in >40% of patients. Because of their increased mortality, further studies are required to better manage this subset of patients.
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Affiliation(s)
- Antoine Hankard
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France.
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Nicolas Martin Silva
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Nolwenn Lorcy
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | - Thomas Le Gallou
- Department of Internal Medicine, Rennes University Hospital, South Hospital, Rennes, France
| | | | - Eric Daugas
- Department of Nephrology, Bichat-Claude-Bernard Hospital, University Hospital Center, APHP, Paris, France
| | - Gilles Kaplanski
- Department of Internal Medicine, La Conception Hospital, University Hospital Center, APHM, Marseille, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Caroline Galimard
- Department of Infectious Disease Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
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Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J. Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review. Angiology 2022:33197221100601. [PMID: 35921630 DOI: 10.1177/00033197221100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.
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Affiliation(s)
- Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Jenna Smith
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Sydney L Olson
- 12244Northwestern University Feiberg School of Medicine, Chicago, IL, USA
| | - Opema L Lohese
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Aleem Mirza
- Department of Cardiovascular and Vascular Surgery, 12340University of Texas Health Science, Houston, TX, USA
| | - Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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7
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What to Know About Biopsy Sampling and Pathology in Vasculitis? Curr Rheumatol Rep 2022; 24:279-291. [PMID: 35895226 DOI: 10.1007/s11926-022-01082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize the histologic findings of vasculitis, and to give some practical considerations on biopsy samples. RECENT FINDINGS The larger use of imaging and the discoveries of serological markers in the diagnosis of vasculitis have increased the clinical recognition of these entities. Nevertheless, biopsy remains the gold standard for diagnosis in most cases. So far, biopsies are also useful to obtain information about prognosis and to guide a more specific treatment. In recent years, less invasive diagnostic approaches have become available, lowering the risks related to the procedure and permitting a definite diagnosis in most cases. Histological examination permits a definite diagnosis of vasculitis. However, the findings may be nonspecific if not evaluated in the proper clinical setting. The interaction between clinicians and pathologists is crucial to obtain a definite diagnosis.
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8
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Waisayarat J, Niyasom C, Vilaiyuk S, Molagool S. Polyarteritis Nodosa with Cytomegalovirus Enteritis and Jejunoileal Perforation: Report of a Case with a Literature Review. Vasc Health Risk Manag 2022; 18:595-601. [PMID: 35924006 PMCID: PMC9342704 DOI: 10.2147/vhrm.s354548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/19/2022] [Indexed: 12/29/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a rare systemic necrotizing vasculitis affecting small- to medium-sized arteries. The most common gastrointestinal manifestation of PAN is postprandial abdominal pain from mesenteric arteritis causing bowel ischemia. When transmural ischemia develops, there may be ischemic necrosis and perforation of the bowel wall, which are life-threatening. Severe, life-threatening gastrointestinal involvement is relatively rare in pediatric PAN and may require different management in adult patients. We report a pediatric PAN case in a patient who presented with acute abdominal pain and superimposed cytomegalovirus enteritis with jejunoileal perforation. The patient improved with emergency small intestinal resection followed by conventional immunosuppressive drugs of a corticosteroid and cyclophosphamide, and anti-viral drugs. Before increasing the immunosuppressive drug dosage, initial screening of infectious cytomegalovirus and comprehensive evaluation for surgical conditions are essential in pediatric PAN with severe gastrointestinal involvement. Early aggressive treatment for acute abdomen is useful in reducing morbidity and mortality in pediatric PAN.
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Affiliation(s)
- Jariya Waisayarat
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Jariya Waisayarat, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rajathevee, Bangkok, 10400, Thailand, Tel +66 2 201 1432, Fax +66 2 354 7266, Email
| | - Chayakamon Niyasom
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sani Molagool
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Massicotte-Azarniouch D, Herrera CA, Jennette JC, Falk RJ, Free ME. Mechanisms of vascular damage in ANCA vasculitis. Semin Immunopathol 2022; 44:325-345. [PMID: 35254509 PMCID: PMC9064952 DOI: 10.1007/s00281-022-00920-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
The discovery of anti-neutrophil cytoplasmic antibodies (ANCA) and their antigenic targets, myeloperoxidase (MPO) and proteinase 3 (PR3), has led to further understanding as to the pathophysiologic processes that underlie vascular and tissue damage in ANCA vasculitis. ANCA trigger neutrophil activation leading to vascular damage in ANCA vasculitis. However, decades of study have determined that neutrophil activation alone is not sufficient to cause disease. Inflammatory stimuli are drivers of ANCA autoantigen expression and ANCA production. Certain infections or bacterial peptides may be crucial players in the initial steps of ANCA immunopathogenesis. Genetic and epigenetic alterations of gene encoding for MPO and PR3 provide additional disturbances to the immune homeostasis which provide a substrate for pathogenic ANCA formation from an adaptive immune system predisposed to autoreactivity. Promoted by inflammatory cytokines, ANCA binding leads to neutrophil activation, a process characterized by conformational changes, production and release of cytotoxic substances, and alternative complement pathway activation, thus creating an intense inflammatory milieu. This cascade of events perpetuates a vicious cycle of further inflammatory cell recruitment and activation, culminating in tissue necrosis. Our understanding of the pathogenic process in ANCA vasculitis paves the way for the development of therapies targeting crucial steps in this process. The greater appreciation of the role for complement, monocytes, and the adaptive immune system has already led to novel complement blockers and is poised to lead to further innovations which will allow for tailored antigen- or cell-specific immunotherapy targeting the autoimmune process without exposure to undue risks or toxicities.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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10
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Yokota K, Kurihara I, Nakamura T, Nakatsuka S, Miyashita K, Kobayashi S, Murai-Takeda A, Sone M, Itoh H. Remission of Angiographically Confirmed Minocycline-induced Renal Polyarteritis Nodosa: A Case Report and Literature Review. Intern Med 2022; 61:103-110. [PMID: 34176836 PMCID: PMC8810245 DOI: 10.2169/internalmedicine.7340-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 23-year-old man presented with severe hypertension. Based on his history of minocycline treatment for over three years and clinical symptoms, such as myalgias and renovascular hypertension with multiple intrarenal aneurysms, he was diagnosed with minocycline-induced renal polyarteritis nodosa (PAN). After minocycline treatment cessation and management of the hypertension, his blood pressure, renin-aldosterone levels, and urinary protein levels gradually improved. Seven and a half years later, repeated angiography found that the aneurysms had resolved. This is the first report in English describing a case of minocycline-induced renal PAN that was reversed functionally and morphologically without steroids or immunosuppressive drugs.
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Affiliation(s)
- Kenichi Yokota
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Isao Kurihara
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Toshifumi Nakamura
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Seishi Nakatsuka
- Department of Radiology, Keio University School of Medicine, Japan
| | | | - Sakiko Kobayashi
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Ayano Murai-Takeda
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hiroshi Itoh
- Department of Internal Medicine, Keio University School of Medicine, Japan
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11
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White M, Reginato AM, Cunha JS. Evolving Chest Pain in a Young Male. Arthritis Care Res (Hoboken) 2021; 74:867-878. [PMID: 34619016 DOI: 10.1002/acr.24802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022]
Abstract
A 33-year-old Hispanic male with a history of recent orchiectomy for suspected testicular cancer presented to the emergency department with worsening exertional chest pain and dyspnea in the setting of a 2-month history of diffuse myalgias and symmetric polyarthralgias.
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Affiliation(s)
- Matthew White
- Division of Rheumatology. Lifespan Physician Group, Pawtucket
| | - Anthony M Reginato
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
| | - Joanne S Cunha
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
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12
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Murakawa M, Arai S, Kawagoe M, Tomomitsu Y, Odajima K, Ueno M, Asakawa S, Hirohama D, Nagura M, Yamazaki O, Tamura Y, Uchida S, Shibata S, Fujigaki Y. A Ruptured Jejunal Arterial Aneurysm in a Young Woman Undergoing Chronic Hemodialysis Due to Myeloperoxidase-antineutrophil Cytoplasmic Antibody-associated Vasculitis. Intern Med 2021; 60:2939-2945. [PMID: 33776003 PMCID: PMC8502660 DOI: 10.2169/internalmedicine.6721-20] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 21-year-old woman was admitted to our hospital because of massive intestinal bleeding. She started hemodialysis due to myeloperoxidase antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at 18 years of age. Her ANCA titers remained stable; however, her C-reactive protein increased on 5 mg/day prednisolone before admission. Computed tomography angiography revealed a ruptured jejunal arterial aneurysm. Transcatheter arterial embolization, blood transfusion and the reinforcement of steroid therapy resolved her symptoms of AAV. Our case of a young patient with AAV and medium-sized arterial vasculitis is rare and emphasizes that the ANCA titer does not always rise, especially in patients with nonrenal vasculitis flare-ups.
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Affiliation(s)
- Masataka Murakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Mika Kawagoe
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihiro Tomomitsu
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Kohei Odajima
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Masaki Ueno
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Daigoro Hirohama
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Kumar KV, Unni VN, Kachare N, Kumar RA, Prasannan B, Urs V. Renal transplantation in a patient with polyarteritis nodosa - A case report. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_106_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Development of Arthritis as the Initial Involvement in Adult-Onset Cutaneous Polyarteritis Nodosa: Two Cases and Literature Review. Case Rep Rheumatol 2020; 2020:8897358. [PMID: 33014504 PMCID: PMC7516710 DOI: 10.1155/2020/8897358] [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: 06/13/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022] Open
Abstract
Articular symptoms are commonly present in polyarteritis nodosa (PAN). Meanwhile, they may occur as the initial and main involvement of PAN, raising a concern of a delay in a definitive diagnosis of disease unless the histological evidence is obtained. Herein, we report two cases of cutaneous PAN (c-PAN) in which arthritis developed as the initial clinical episode of disease and we argued, through a review of the literature, the clinical feature of patients presenting with arthritis as the initial symptom of PAN. To our knowledge, only six cases have been reported in the English literature, and all six patients were categorized as having c-PAN. Of those patients, four had arthritis with indicating destructive changes. A median of 9 years elapsed prior to the induction of immunosuppressive treatment despite the fact that the other reviewed cases as well as our two patients, who received treatment significantly earlier, showed no evidence of joint destruction. Taken together, this report suggests that the early induction of therapy based on the definitive diagnosis of PAN may be required for preventing joint disruption even though it is not easy to make a diagnosis of PAN unless biopsied tissue can provide the evidence of necrotizing vasculitis.
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15
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Ushiyama S, Shimojima Y, Ueno KI, Kishida D, Miyazaki D, Sekijima Y. Clinical characteristics of patients with myalgia as the initial manifestation of small and medium-sized vasculitis: a retrospective study. Rheumatol Int 2020; 40:1667-1674. [PMID: 32710199 DOI: 10.1007/s00296-020-04652-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/11/2020] [Indexed: 11/26/2022]
Abstract
Myalgia is a common symptom in small and medium-sized systemic vasculitis, sometimes occurring as the initial or only clinical manifestation of vasculitis. This study investigated the clinical features and diagnostic process in patients presenting with myalgia as the initial symptom of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) or polyarteritis nodosa (PAN). We included 93 patients diagnosed with AAV or PAN by retrospectively reviewing their clinical records at the initial diagnosis. Clinical findings and diagnostic methods were assessed in patients with myalgia. Of 93 patients, myalgia was observed in 21 (22.6%) patients, with diagnostic classifications of microscopic polyangiitis (MPA) in 12 (52.4%), granulomatosis with polyangiitis in 2 (9.5%), eosinophilic granulomatosis with polyangiitis in 2 (9.5%), and PAN in 5 (23.8%). Myalgia was present in the lower extremities of all patients; more than 80% of patients had pain in the calf muscle. In 10 patients with myalgia, including 7 with MPA and 3 with PAN, muscle biopsy was performed because myalgia was the main symptom and no other impaired organs were suitable for biopsy. Consequently, 8 patients had necrotizing vasculitis, leading to MPA or PAN diagnosis, although muscle pathology was not evaluated in patients without myalgia. Muscle magnetic resonance imaging was useful in determining the biopsy site. Myalgia, especially in the lower limbs, may be an initial clinical sign of vasculitis, particularly in MPA or PAN patients. Moreover, the histological evidence of muscular vasculitis can contribute to a definite diagnosis especially in patients presenting with myalgia as an early symptom of AAV or PAN.
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Affiliation(s)
- Satoru Ushiyama
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Ken-Ichi Ueno
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Daigo Miyazaki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Institute for Biomedical Sciences, Shinshu University, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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16
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Alsohime F, AlHoshan T, Almojel F, Rezeni NA, Temsah MH. Hypertensive Crisis: The Other Side of Polyarteritis Nodosa. Cureus 2020; 12:e6775. [PMID: 32015938 PMCID: PMC6984167 DOI: 10.7759/cureus.6775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hypertensive crisis is a deadly complication that should be avoided at all costs, let alone when it is associated with a rare disease, such as polyarteritis nodosa. We present a case of a child who initially came to our hospital with a prolonged high-grade fever responding to antipyretics. Upon follow up, the patient went into a hypertensive crisis, which led to the admission to the Pediatric Intensive Care Unit (PICU). The hypertension was difficult to control until the culprit was revealed. Polyarteritis nodosa was then diagnosed by angiography, which revealed tight stenosis of the right renal artery. Prompt treatment was initiated, and the patient's blood pressure normalized. Our case highlights the importance of detecting such diseases, since it may be easily missed as it usually presents with nonspecific symptoms. Hypertension in children shouldn't be taken lightly and should be investigated promptly. We hope our case report sheds enough light on this issue for other clinicians and researches to identify and prevent later on.
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Affiliation(s)
- Fahad Alsohime
- Pediatric Intensive Care Unit, King Khalid University Hospital, Riyadh, SAU
| | - Talal AlHoshan
- Pediatric Intensive Care Unit, King Khalid University Hospital, Riyadh, SAU
| | - Faisal Almojel
- Pediatric Intensive Care Unit, King Khalid University Hospital, Riyadh, SAU
| | - Nader A Rezeni
- Pediatric Intensive Care Unit, King Khalid Unversity Hospital, Riyadh, SAU
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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.
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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
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18
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Skeik N, Hyde JR, Olson SL, Thaler CM, Abuatiyeh W, Ahmed AK, Lyon DR, Witt DR, Garberich R, Sullivan T. Nonatherosclerotic Abdominal Vasculopathies. Ann Vasc Surg 2019; 60:128-146. [DOI: 10.1016/j.avsg.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/11/2019] [Accepted: 04/04/2019] [Indexed: 11/28/2022]
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20
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A Child Diagnosed With Treatment-Resistant Polyarteritis Nodosa: Can the Clinical Diagnosis Be Different? Arch Rheumatol 2019; 34:338-342. [PMID: 31598601 DOI: 10.5606/archrheumatol.2019.7075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 12/11/2018] [Indexed: 11/21/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a necrotizing systemic vasculitis involving the wall of small and medium sized arteries. The histological aspect is defined by the presence of fibrinoid necrosis and an infiltrate rich in neutrophil polynuclears in the artery wall and rare granulomas. CECR1 (Cat Eye Syndrome Chromosome Region 1) gene mutation causing adenosine deaminase 2 (ADA2) deficiency is also associated with systemic inflammation, vasculopathy, and frequently PAN. Strokes, neurological involvement, and gastrointestinal involvement have poor prognosis in the cases with ADA2 deficiency particularly in early stage. In this article, we report a 17-year-old male patient diagnosed with PAN who had severe gastrointestinal system involvement that was resistant to intensive and conventional immunosuppressive treatment and showed a fatal course despite the emergency surgical intervention. After the patient was exitus, he was detected to have a heterozygous mutation (V276A) of familial Mediterranean fever (FMF) and also a homozygous ADA2 mutation. The aim of this article is to highlight that ADA2 deficiency may be present in treatment-resistant PAN cases who apply due to severe systemic involvement. In this case, accompanying FMF mutation was also observed.
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Ginsberg S, Rosner I, Slobodin G, Rozenbaum M, Kaly L, Jiries N, Boulman N, Awisat A, Hussein H, Novofastovski I, Silawy A, Rimar D. Infliximab for the treatment of refractory polyarteritis nodosa. Clin Rheumatol 2019; 38:2825-2833. [PMID: 30972576 DOI: 10.1007/s10067-019-04474-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 01/29/2019] [Accepted: 02/07/2019] [Indexed: 01/22/2023]
Abstract
Polyarteritis nodosa (PAN) is a necrotizing vasculitis predominantly affecting medium and small size arteries. Cyclophosphamide, a drug with narrow therapeutic range and poor safety profile, constitutes the treatment of choice for PAN vasculitis with major organ involvement. To describe our clinical experience in treating refractory PAN with infliximab (a TNF inhibitor), a drug with good tolerability and better safety profile than cyclophosphamide. Twenty-six PAN patients were admitted to our rheumatology unit between 2006 and 2017, of whom nine patients, with severe and refractory disease, were treated with infliximab after failure of standard treatment. We describe herein the patients' characteristics, clinical manifestations, severity and response to infliximab treatment and review the current literature. Complete remission was defined as the absence of features of active disease and withdrawal of prednisone therapy. Significant improvement was defined as clinical improvement and prednisone dose reduction of at least 50% or a 50% reduction in immune modulatory medications other than prednisone. After 4 months of treatment, 8/9 (89%) patients achieved significant improvement, with two of them achieving complete remission. We suggest that anti-TNF agents, and in particular infliximab, are relatively safe and efficacious treatment options in refractory PAN. A randomized controlled trial should be done in order to objectively evaluate infliximab in PAN.
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Affiliation(s)
- Shira Ginsberg
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel.
- Internal Medicine B Department, Bnai Zion Medical Center, 47 Eliyahu Golomb Street, 33048, Haifa, Israel.
| | - Itzhak Rosner
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | | | - Lisa Kaly
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Nizar Jiries
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
- Internal Medicine B Department, Bnai Zion Medical Center, 47 Eliyahu Golomb Street, 33048, Haifa, Israel
| | - Nina Boulman
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Abid Awisat
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Haya Hussein
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | | | - Amal Silawy
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Doron Rimar
- Rheumatology Unit, Bnai-Zion Medical Center, Haifa, Israel
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Senarathna HM, Fonseka CL, Perera HAS, De Silva PUT, Weerarathna TP. Severe Disabling Myalgia as an Initial Presentation of Polyarteritis Nodosa. Case Rep Rheumatol 2019; 2019:4364289. [PMID: 31093408 PMCID: PMC6476074 DOI: 10.1155/2019/4364289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/02/2019] [Accepted: 03/06/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Polyarteritis nodosa (PAN) is a form of necrotizing vasculitis affecting medium or small blood vessels with multiorgan involvement. Although myalgia is a clinical feature of PAN, severe disabling myalgia as the initial presentation is rarely noted. CASE PRESENTATION We present a case of 54-year-old male with recently detected chronic kidney disease admitted with progressive severe disabling muscular pains predominantly over calves with constitutional symptoms for seven weeks. He was weak to mobilize out of the bed. Later, he developed a vasculitic rash, unilateral ulnar claw, and bilateral foot drop. His skin and muscle biopsies showed evidence of vasculitis. His renal and mesenteric artery CT angiogram revealed stenosed segment of the celiac artery without evidence of visible aneurysms elsewhere. He completed six cycles of intravenous cyclophosphamide pulse therapy with high-dose oral prednisolone with good response. With continuation of aggressive immunosuppression and rehabilitation for five months, the patient improved and was able to walk without support. CONCLUSION Musculoskeletal predominant PAN, even though rare, needs to be considered in patients presenting with disabling muscle pain and weakness. These features may herald over days to months along with constitutional symptoms before other systems getting affected. Early recognition of such symptoms and initiating specific treatment would be important for better outcomes.
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Affiliation(s)
- H. M. Senarathna
- Registrar in Medicine, University Medical Unit, Teaching Hospital, Karapitiya, Sri Lanka
| | - C. L. Fonseka
- Consultant Physician, Department of Internal Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - H. A. S. Perera
- Consultant Histo-Pathologist, Department of Pathology, Teaching Hospital, Karapitiya, Sri Lanka
| | - P. U. T. De Silva
- Senior Registrar in Medicine, University Medical Unit, Teaching Hospital, Karapitiya, Sri Lanka
| | - T. P. Weerarathna
- Professor in Medicine, Department of Internal Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
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23
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Kobayashi T, Kanno K, Kikuchi Y, Kakimoto M, Kawahara A, Kimura K, Ishida R, Miyamori D, Otani Y, Kishikawa N, Tazuma S. An Atypical Case of Non-asthmatic Eosinophilic Granulomatosis with Polyangiitis Finally Diagnosed by Tissue Biopsy. Intern Med 2019; 58:871-875. [PMID: 30449779 PMCID: PMC6465012 DOI: 10.2169/internalmedicine.1167-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 78-year-old woman with fever of unknown origin that had persisted for 3 months, systemic edema, and cervical lymphadenopathy was admitted to our hospital. Skin purpura and jaw claudication were subsequently observed. Histopathological examinations of the lymph nodes, skin, and temporal artery revealed findings characteristic of eosinophilic granulomatosis with polyangiitis (EGPA). However, she had no past medical history of asthma with modest eosinophilia. Although EGPA is a systemic vasculitis characterized by asthma and eosinophilia, various limited forms have been described. This was therefore considered to be an atypical form of non-asthmatic EGPA complicating with temporal arteritis (TA) diagnosed by tissue biopsy.
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Affiliation(s)
- Tomoki Kobayashi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuka Kikuchi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Masaki Kakimoto
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Akihiro Kawahara
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Kazuki Kimura
- Department of Community Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Ryoko Ishida
- Department of Community Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuichiro Otani
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Nobusuke Kishikawa
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
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24
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Shavit E, Alavi A, Sibbald RG. Vasculitis-What Do We Have to Know? A Review of Literature. INT J LOW EXTR WOUND 2018; 17:218-226. [PMID: 30501545 DOI: 10.1177/1534734618804982] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cutaneous and other vasculitides are specific inflammations of the blood vessel wall that can take place in any organ system of the body including the skin. Vasculitis has been traditionally divided according to the size of the vessel involved (small, medium, and large). Vasculitis is more of a reaction pattern rather than a specific disease entity. Therefore, the clinical presentation of vasculitis (most commonly palpable purpura on the lower extremities) dictates a thorough history, review of systems, and a meticulous physical examination. The diagnosis of vasculitis relies also on the histopathological and immunofluorescence studies. Wound care specialist may face with vasculitis-associated ulcers along with a spectrum of other cutaneous presentations associated with vasculitis. The focus of this article is to update the types, etiology, pathogenesis, and management options for cutaneous vasculitis.
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Affiliation(s)
- Eran Shavit
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Alavi
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - R Gary Sibbald
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
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25
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Adams TN, Zhang D, Batra K, Fitzgerald JE. Pulmonary manifestations of large, medium, and variable vessel vasculitis. Respir Med 2018; 145:182-191. [PMID: 30509707 DOI: 10.1016/j.rmed.2018.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/14/2018] [Accepted: 11/06/2018] [Indexed: 02/01/2023]
Abstract
The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.
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Affiliation(s)
- Traci N Adams
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States.
| | - Da Zhang
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
| | - Kiran Batra
- University of Texas Southwestern Medical Center, Department of Radiology, United States
| | - John E Fitzgerald
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
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26
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Long JD, Rutledge SM, Sise ME. Autoimmune Kidney Diseases Associated with Chronic Viral Infections. Rheum Dis Clin North Am 2018; 44:675-698. [PMID: 30274630 DOI: 10.1016/j.rdc.2018.06.006] [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] [Indexed: 02/08/2023]
Abstract
Autoimmune kidney diseases triggered by viruses are an important cause of kidney disease in patients affected by chronic viral infection. Hepatitis B virus (HBV) infection is associated with membranous nephropathy and polyarteritis nodosa. Hepatitis C virus (HCV) infection is a major cause of cryoglobulinemic glomerulonephritis. Patients with human immunodeficiency virus (HIV) may develop HIV-associated nephropathy, a form of collapsing focal segmental glomerulosclerosis, or various forms of immune-complex-mediated kidney diseases. This article summarizes what is known about the pathogenesis, diagnosis, and management of immune-mediated kidney diseases in adults with chronic HBV, HCV, and HIV infections.
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Affiliation(s)
- Joshua D Long
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA
| | - Stephanie M Rutledge
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA.
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27
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Marzano AV, Raimondo MG, Berti E, Meroni PL, Ingegnoli F. Cutaneous Manifestations of ANCA-Associated Small Vessels Vasculitis. Clin Rev Allergy Immunol 2018; 53:428-438. [PMID: 28578472 DOI: 10.1007/s12016-017-8616-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Skin lesions are frequent manifestations of underlying systemic conditions, including systemic autoimmune vasculitis. In particular, anti-neutrophil cytoplasmic antibodies (ANCA) are associated with distinct forms of vasculitis characterized by inflammatory cell infiltration of the walls of small and medium-sized vessels leading to vascular destruction and tissue necrosis. ANCA-associated vasculitis is rare and systemic diseases, which can be classified based on different distribution of vascular inflammation and presence or absence of granulomatosis and asthma. Despite their diversities, ANCA-associated vasculitis, namely microscopic polyangiitis, granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis, can all display a broad variety of cutaneous manifestations, which can appear during the course of the disease or even as first sign at the time of onset. Different skin manifestations might coexist in the same patient and occur in different occasions during the course of the vasculitis. Thus, a deep knowledge of the spectrum of skin lesions as part of ANCA-associated vasculitis is mandatory for a correct diagnostic process, whenever cutaneous vasculitis is suspected. Due to this broad variety of manifestations, the diagnosis of skin involvement in ANCA-associated vasculitis is very challenging and it must be supported by a detailed medical history, accurate physical examination, specific histopathological analysis of skin biopsy and the presence of ANCA serology. In this review, we focus on the cutaneous manifestations that can develop in the context of ANCA-associated vasculitis, detailing the clinical features, the histopathological aspects as well as the direct immunofluorescence studies for each of the three conditions. Moreover, we acknowledged the differential diagnoses that must be ruled out in the diagnostic process and the main therapeutic approaches available for treatment of ANCA-associated vasculitis.
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Affiliation(s)
- Angelo Valerio Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Unità Operativa di Dermatologia, IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Maria Gabriella Raimondo
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Emilio Berti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Unità Operativa di Dermatologia, IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Pier Luigi Meroni
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy. .,Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy.
| | - Francesca Ingegnoli
- Division of Rheumatology, ASST Pini, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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28
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Batra K, Chamarthy M, Chate RC, Jordan K, Kay FU. Pulmonary vasculitis: diagnosis and endovascular therapy. Cardiovasc Diagn Ther 2018; 8:297-315. [PMID: 30057877 DOI: 10.21037/cdt.2017.12.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.
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Affiliation(s)
- Kiran Batra
- UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Rodrigo Caruso Chate
- Hospital Israelita Albert Einstein and Instituto to Coração HCFMUSP, Sao Paulo, Brazil
| | - Kirk Jordan
- UT Southwestern Medical Center, Dallas, TX, USA
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29
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Eriksson P, Segelmark M, Hallböök O. Frequency, Diagnosis, Treatment, and Outcome of Gastrointestinal Disease in Granulomatosis with Polyangiitis and Microscopic Polyangiitis. J Rheumatol 2018; 45:529-537. [DOI: 10.3899/jrheum.170249] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 12/17/2022]
Abstract
Objective.Involvement of the gastrointestinal (GI) tract is a rare complication of granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). The aim was to describe frequency, diagnosis, treatment, and outcome of GI disease in a large series of patients in a single center.Methods.A database that includes all patients with GPA and MPA diagnosed since 1997 in a defined area of southeastern Sweden as well as prevalent older cases and tertiary referral patients was screened for patients with GI disease. Data were retrieved from the patient’s medical records, and GI manifestations of vasculitis were defined as proposed by Pagnoux,et alin 2005.Results.Fourteen (6.5%) of 216 consecutive patients with GPA/MPA had GI manifestations. Abdominal pain and GI bleeding were the most common symptoms. Radiology was important for detection of GI disease, while endoscopy failed to support the diagnosis in many patients. Because of perforation, 5 patients underwent hemicolectomy or small intestine resection. Primary anastomosis was created in 2/5 and enterostomy in 3/5 patients. One patient had a hemicolectomy because of lower GI bleeding. One sigmoid abscess was treated with drainage, and 1 intraabdominal bleeding condition with arterial coiling. Two patients died from GI disease. GPA and MPA patients with and without GI disease exhibited a similar overall survival.Conclusion.GI disease was found in 6.5% among 216 patients with GPA or MPA. Surgery was judged necessary only in cases with GI perforation or severe bleeding. Multidisciplinary engagement is strongly recommended.
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Iida H, Hanaoka H, Asari Y, Ishimori K, Kiyokawa T, Takakuwa Y, Yamasaki Y, Yamada H, Okazaki T, Doi M, Ozaki S. Rhabdomyolysis in a Patient with Polyarteritis Nodosa. Intern Med 2018; 57:101-106. [PMID: 29021478 PMCID: PMC5799066 DOI: 10.2169/internalmedicine.8913-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a medium vessel vasculitis affecting systemic organs. Muscle involvement of PAN usually lacks elevation of creatinine kinase (CK). We herein report a case of PAN with rhabdomyolysis. A 71-year-old man was hospitalized because of muscle weakness of the lower limbs that persisted for 1 month. On a physical examination, rapidly progressive lower proximal muscle weakness and bilateral drop foot were observed. His blood test showed an elevation in the C-reactive protein (19.5 mg/dL) and CK (13,435 IU/L) levels and negativity for anti-neutrophilic cytoplasmic antibody. Computed tomographic angiography showed stenosis of the left renal artery. Electromyogram indicated mono-neuritis multiplex pattern, and enhanced magnetic resonance imaging demonstrated discretely granular hyperintensities on T2 and slow tau inversion recovery in his femoral muscles. A femoral muscle-biopsy specimen showed fibrinoid necrosis of medium-sized vessels and disruption of the elastic lamina of the vessel wall in fascia. Furthermore, muscle necrosis was localized depending on the arterial distribution, suggesting ischemic changes in the muscles. Given these findings, he was diagnosed with PAN with rhabdomyolysis and treated with methyl-prednisolone pulse therapy followed by oral prednisolone at 50 mg/day. He was additionally treated with monthly intravenous cyclophosphamide at 500 mg. Sustained remission has been obtained for two months since the treatment. Although rhabdomyolysis rarely manifests with PAN, it should be included in a differential diagnosis of febrile patients presenting with acute myalgia and weakness with CK elevation.
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Affiliation(s)
- Harunobu Iida
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hironari Hanaoka
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yusa Asari
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Kana Ishimori
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Tomofumi Kiyokawa
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yukiko Takakuwa
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yoshioki Yamasaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hidehiro Yamada
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Takahiro Okazaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Masatomo Doi
- Division of Pathology, St. Marianna University School of Medicine, Japan
| | - Shoichi Ozaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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Matsuda S, Yoshida S, Fujiki Y, Satomi H, Takeuchi T, Hirose Y, Makino S, Arawaka S. Eosinophilic granulomatosis with polyangiitis complicated by subarachnoid hemorrhage and coronary vasculitis: a case report and review of the literature. Rheumatol Int 2017; 38:689-696. [PMID: 29127573 DOI: 10.1007/s00296-017-3875-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/03/2017] [Indexed: 02/03/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by necrotizing vasculitis of small-sized vessels with extravascular granulomas and eosinophilic infiltration. The case of a 48-year-old Japanese woman with EGPA, who presented concurrently with subarachnoid hemorrhage (SAH) and coronary vasculitis, is reported. She initially presented with bronchial asthma, and then 8 months later she developed various symptoms caused by systemic eosinophilic vasculitis and was admitted to our hospital. Three days after admission, she started oral corticosteroid therapy, and her 2009 Five-Factor Score (FFS) was 0. However, she developed an SAH, followed by coronary vasculitis 1 day later. With extensive treatment with a combination of betamethasone, cyclophosphamide, intravenous immunoglobulin, and rituximab, her systemic vasculitis improved dramatically. This seems to be the first case of EGPA with SAH and coronary vasculitis. In previous reports of EGPA with SAH, 4 of 11 cases developed SAH as an exacerbation of systemic vasculitis during remission induction therapy. The present patient also had SAH during remission induction therapy. However, the period between bronchial asthma and SAH was only 8 months. This is the shortest among case reports of EGPA with SAH. In addition, the present patient rapidly developed coronary vasculitis. These findings suggest that EGPA causes SAH and coronary vasculitis as early complications of systemic vasculitis. In EGPA, it is necessary to pay careful attention to rapid changes of disease activity, even when the FFS indicates a good prognosis.
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Affiliation(s)
- Shogo Matsuda
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Shuzo Yoshida
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Youhei Fujiki
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Hidetoshi Satomi
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Yoshinobu Hirose
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Shigeki Makino
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Shigeki Arawaka
- Department of Internal Medicine (IV), Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Oh YJ, Ahn SS, Park ES, Jung SM, Song JJ, Park YB, Lee SW. Birmingham vasculitis activity score at diagnosis is a significant predictor of relapse of polyarteritis nodosa. Rheumatol Int 2017; 37:685-694. [PMID: 28341881 DOI: 10.1007/s00296-017-3706-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/16/2017] [Indexed: 01/05/2023]
Abstract
The objective of this study was to investigate whether clinical and laboratory data, Birmingham vasculitis activity score (BVAS) and five factor scores (FFS) at diagnosis could predict relapse in 30 patients with polyarteritis nodosa (PAN) having the follow-up duration for over 12 months. We reviewed the medical charts of 30 patients with PAN. We obtained clinical and laboratory data at diagnosis, and we compared them between the two groups based on relapse. The optimal cut-off values of BVAS and FFS (1996) at diagnosis to predict relapse were extrapolated. The mean age of patients (15 men) was 50.8 years, and the mean follow-up duration was 64.1 months. Nine patients (30.0%) had experience relapse after remission. Patients having relapse showed the higher frequency of weight loss and ocular symptoms and the less frequency of diastolic hypertension than those having not (p < 0.005 for all). On multivariate logistic regression analysis, weight loss was the only independent predictor of relapse, but on Cox Hazard model analysis, its statistical significance disappeared. The mean initial BVAS and FFS (1996) of patients in relapse group were higher than those of patients in no relapse group (p < 0.005 for all). Patients having initial BVAS over 13.5 and FFS (1996) over 1 exhibited significantly higher risk of relapse than those having not (RR 40.0 and RR 7.0, respectively). However, initial BVAS over 13.5 only remained significant in Kaplan-Meier survival analysis. In conclusion, BVAS over 13.5 at diagnosis was the only independent predictor of relapse of PAN.
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Affiliation(s)
- Yoon-Jeong Oh
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Eun Seong Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Chetty R, Serra S. A pragmatic approach to vasculitis in the gastrointestinal tract. J Clin Pathol 2017; 70:470-475. [PMID: 28119348 DOI: 10.1136/jclinpath-2016-204308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/02/2017] [Indexed: 11/03/2022]
Abstract
Although vasculitis involving the gastrointestinal tract (GIT) is an uncommon occurrence, occasionally vasculitis can present as haemorrhagic infarction or ischaemia for which a length of bowel is removed. Invariably, the appropriate clinical history is not forthcoming, or vasculitis is not clinically suspected. The purpose of this overview is to provide the practising gastrointestinal (GI) pathologist with a framework to recognise and diagnose vasculitides within the GIT. The classification may be approached by aetiological agent or size of vessel involved; an international consensus group now favours the latter approach. The symptoms that systemic and/or localised vasculitis may cause in the GIT are protean and non-specific. As a result, pathologists examining resection specimens for unexplained haemorrhagic infarction or ischaemia should be aware that vasculitis may be a potential cause. Several well-known systemic vasculitides such as polyarteritis nodosa, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis or Churg-Strauss syndrome and granulomatosis with polyangiitis or Wegener's granulomatosis can occur in the GIT. The latter three constitute the antineutrophil cytoplasmic antibody-positive vasculitides. In addition, the so-called solitary organ vasculitis (SOV) can occur in the GIT as the harbinger of later onset systemic vasculitis, and be the cause of the GIT symptoms. In addition, SOV can occur incidentally and coexist with GIT disease such as gallstones or polyps, and there may be no manifestations of systemic vasculitis for years, or not at all.
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Affiliation(s)
- Runjan Chetty
- Department of Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Stefano Serra
- Department of Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Jagwani AV, Fathi NQ, Jailani RF, Zakaria AD. Rare and unusual case of polyarteritis nodosa involving the gastrointestinal tract leading to bowel gangrene. BMJ Case Rep 2017; 2017:bcr-2016-217865. [PMID: 28062430 DOI: 10.1136/bcr-2016-217865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis preferentially targeting medium-sized arteries and not related with glomerulonephritis or small vessel involvement. Clinical manifestations of PAN are multisystem. The gastrointestinal, renal, cardiac, musculoskeletal, skin and central nervous systems may be involved. The aetiology remains unknown, and the ensuing vasculitis may lead to aneurysm formation and thrombosis in any organs of the body with resultant ischaemia. PAN of the intestines is a relatively common manifestation of this disease but rarely causes bowel ischaemia resulting in necrosis. Here we report a case of a young Chinese patient who presented with an acute abdomen requiring surgery and made good recovery post operatively. He remains free of symptoms while on steroid therapy.
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Affiliation(s)
- Arvind Vashdev Jagwani
- Department of Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Nik Qisti Fathi
- Department of Surgery, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ruhi Fadzlyana Jailani
- Department of Surgery, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan, Malaysia
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Sim HC, Lee JH, Lee JW, Park SH, Lee JW, Jeong HJ, Lee J, Yang SY. Failure of Conservative Treatment in Two Cases of Polyarteritis Nodosa with Superior Mesenteric Artery Involvement Presenting with Abdominal Pain. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2017. [DOI: 10.7704/kjhugr.2017.17.3.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Ho Chan Sim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ju Hyoung Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Woon Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seung Hyun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ju Won Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Heui-Jeong Jeong
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sung Yeun Yang
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Mahmoud S, Ghosh S, Farver C, Lempel J, Azok J, Renapurkar RD. Pulmonary Vasculitis: Spectrum of Imaging Appearances. Radiol Clin North Am 2016; 54:1097-1118. [PMID: 27719978 DOI: 10.1016/j.rcl.2016.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pulmonary vasculitis is a relatively uncommon disorder, usually manifesting as part of systemic vasculitis. Imaging, specifically computed tomography, is often performed in the initial diagnostic workup. Although the findings in vasculitis can be nonspecific, they can provide important clues in the diagnosis, and guide the clinical team toward the right diagnosis. Radiologists must have knowledge of common and uncommon imaging findings in various vasculitides. Also, radiologists should be able to integrate the clinical presentation and laboratory test findings together with imaging features, so as to provide a meaningful differential diagnosis.
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Affiliation(s)
- Shamseldeen Mahmoud
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Subha Ghosh
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Carol Farver
- Department of Pathology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jason Lempel
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Joseph Azok
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rahul D Renapurkar
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Section of Cardiovascular Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Pourafshar N, Sobel E, Segal M. A case of isolated renal involvement of polyarteritis nodosa successfully treated with steroid monotherapy. BMJ Case Rep 2016; 2016:bcr-2016-215702. [PMID: 27440849 DOI: 10.1136/bcr-2016-215702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis that affects medium-sized and small-sized arteries. The spectrum of disease ranges from involving a single organ to polyvisceral failure. We report a case of a 75-year-old male presented with solely hypertension and mild renal function impairment as a consequence of diffuse renal necrotising vasculitis with occlusive but non-stenotic lesions associated with PAN. The overall prognosis of PAN has been improved in recent decades, primarily reflecting early diagnosis and more effective treatments. Therefore, early diagnosis is critical and it warrants full investigations even in those patients without obvious multiorgan manifestations. In those instances, with mild disease, steroid monotherapy has been shown to be effective with excellent response. Our patient responded well to steroid monotherapy and we were able to gauge his response by improvement in his blood pressure.
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Affiliation(s)
- Negiin Pourafshar
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Eric Sobel
- Division of Rheumatology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Mark Segal
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
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De Virgilio A, Greco A, Magliulo G, Gallo A, Ruoppolo G, Conte M, Martellucci S, de Vincentiis M. Polyarteritis nodosa: A contemporary overview. Autoimmun Rev 2016; 15:564-70. [PMID: 26884100 DOI: 10.1016/j.autrev.2016.02.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis predominantly targeting medium-sized arteries. PAN is a rare form of vasculitis, and the precise frequency of this disease is difficult to determine. The major environmental factor associated with PAN is HBV infection. The pathogenesis of "idiopathic PAN" remains enigmatic, although the clinical responses to immunosuppressive therapy support the concept that immunological mechanisms play an active pathogenic role. The spectrum of disease ranges from involving a single organ to polyvisceral failure. Any organ might be affected; however, for reasons that are not understood, PAN does not affect the lungs. In addition to the systemic idiopathic form, called "idiopathic generalized PAN," there are 2 clinical variants of this disease: "cutaneous PAN" and "hepatitis B virus (HBV)-associated PAN". Diagnosis requires the integration of clinical, angiographic, and biopsy findings. The overall prognosis of this disease has been improved in recent decades, primarily reflecting early diagnosis and more effective treatments. Idiopathic generalized PAN should be treated with a combination of glucocorticoids and cyclophosphamide. The treatment of HBV-associated PAN involves a different approach, centered on the use of an antiviral agent to control the infection. The therapy for cutaneous PAN requires a less aggressive approach based on the administration of non-steroidal anti-inflammatory drugs over short periods of time.
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Affiliation(s)
- Armando De Virgilio
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy; Department of Otolaryngology-Head and Neck Surgery, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
| | - Antonio Greco
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy
| | - Giuseppe Magliulo
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy
| | - Andrea Gallo
- Department of Medico-Surgical Sciences and Biotechnologies, Otorhinolaryngology Section "Sapienza" University of Rome, Corso della Repubblica, 79, 04100 Latina, (LT), Italy
| | - Giovanni Ruoppolo
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy
| | - Michela Conte
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy.
| | - Salvatore Martellucci
- Department of Medico-Surgical Sciences and Biotechnologies, Otorhinolaryngology Section "Sapienza" University of Rome, Corso della Repubblica, 79, 04100 Latina, (LT), Italy
| | - Marco de Vincentiis
- Department Organs of Sense, ENT Section, University of Rome "La Sapienza", Viale del Policlinico 155, 00100 Roma, Italy
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Pagnoux C, Khalidi NA. Polyarteritis nodosa – Challenges and options in management. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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da Silva LS, de Campos KVM, de Melo AKG, de Brito DCSE, Braz AS, Freire EAM. Rituximab as an alternative for patients with severe systemic vasculitis refractory to conventional therapy: report of seven cases and literature review. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 55:531-5. [PMID: 26318692 DOI: 10.1016/j.rbr.2015.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 06/13/2015] [Accepted: 07/01/2015] [Indexed: 10/23/2022] Open
Abstract
The greater understanding of pathophysiology and behavior of systemic vasculitis, together with the development of therapeutic regimens with increasingly better safety and efficacy profiles, dramatically changed the prognosis of patients diagnosed with these clinical entities. Recently, the use of rituximab in the treatment of patients with ANCA-associated vasculitis in randomized clinical trials showed an important alternative in selected cases, especially patients refractory or intolerant to standard therapy with cyclophosphamide and corticosteroids. This article presents the report of seven cases of systemic vasculitis successfully treated with rituximab.
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Affiliation(s)
| | - Karla Valéria Miranda de Campos
- Serviço de Reumatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil
| | - Ana Karla Guedes de Melo
- Serviço de Reumatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil
| | - Danielle Christinne Soares Egypto de Brito
- Serviço de Reumatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Curso de Medicina, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Departamento de Medicina Interna, Centro de Ciências Médicas, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil
| | - Alessandra Sousa Braz
- Serviço de Reumatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Curso de Medicina, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Departamento de Medicina Interna, Centro de Ciências Médicas, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil
| | - Eutilia Andrade Medeiros Freire
- Serviço de Reumatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Curso de Medicina, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil; Departamento de Medicina Interna, Centro de Ciências Médicas, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brasil.
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41
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Teng GG, Chatham WW. Vasculitis related to viral and other microbial agents. Best Pract Res Clin Rheumatol 2015; 29:226-43. [PMID: 26362741 DOI: 10.1016/j.berh.2015.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/08/2015] [Indexed: 12/11/2022]
Abstract
Vasculitis due to infection may occur as a consequence of the inflammation of vessel walls due to direct or contiguous infection, type II or immune complex-mediated reaction, cell-mediated hypersensitivity, or inflammation due to immune dysregulation triggered by bacterial toxin and/or superantigen production. As immunosuppressive therapy administered in the absence of antimicrobial therapy may increase morbidity and fail to effect the resolution of infection-associated vascular inflammation, it is important to consider infectious entities as potential inciting factors in vasculitis syndromes. The causality between infection and vasculitis has been established in hepatitis B-associated polyarteritis nodosa (HBV-PAN) and hepatitis C-associated (cryoglobulinemic) vasculitis (HCV-CV). The review summarizes the recent literature on the pathophysiological mechanisms and the approaches to the management of HBV-PAN and HCV-CV. Roles of other viral and microbial infections, which either manifest as vasculitic syndromes or are implicated in the pathogenesis of primary vasculitides, are also discussed.
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Affiliation(s)
- Gim Gee Teng
- Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
| | - W Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Microscopic polyangiitis: Advances in diagnostic and therapeutic approaches. Autoimmun Rev 2015; 14:837-44. [PMID: 25992801 DOI: 10.1016/j.autrev.2015.05.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/12/2015] [Indexed: 11/24/2022]
Abstract
Microscopic polyangiitis (MPA) is an idiopathic autoimmune disease characterized by systemic vasculitis. The disease predominantly affects small-calibre blood vessels and is associated with the presence of antineutrophil cytoplasmic autoantibodies (ANCA). Microscopic polyangiitis was considered to be a disease entity by Savage et al. in 1985. Microscopic polyangiitis has a reported low incidence and a slight male predominance. The aetiology of MPA remains unknown. There is, however, increased evidence that MPA is an autoimmune disease in which ANCAs, particularly those reacting with MPO, are pathogenic. MPA belongs to the systemic vasculitides, indicating that multiple organs can be affected. The major organs involved in MPA are the kidneys and the lungs. As expected for an illness that affects multiple organ systems, patients with MPA can present with a myriad of different symptoms. Ear, nose and throat (ENT) manifestations are not considered to be clinical symptoms of MPA, but in the majority of populations described, ENT involvement was found in surprisingly high percentages. MPA is part of the ANCA-associated vasculitides, which are characterized by necrotizing vasculitis of small vessels. Diagnosis is mainly established by clinical manifestations, computed tomography (TC), ANCA antibody detection and renal and pulmonary biopsy. The introduction of aggressive immunosuppressive treatment has substantially improved the prognosis. The standardized therapeutic regimen is based on cyclophosphamide and corticosteroids. Using this regimen, remission can be achieved in most of the patients. Rituximab may represent an important alternative to cyclophosphamide for patients who may not respond adequately to antimetabolite therapies.
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Kim CZ, Nam KY, Lee SJ, Lee SU. A Case of Polyarteritis Nodosa with Decreased Vision as a First Symptom. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.12.1979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Chang Zoo Kim
- Department of Ophthalmology, Kosin University College of Medicine, Busan, Korea
| | - Ki Yup Nam
- Department of Ophthalmology, Kosin University College of Medicine, Busan, Korea
| | - Sang Joon Lee
- Department of Ophthalmology, Kosin University College of Medicine, Busan, Korea
- Institute of Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seung Uk Lee
- Department of Ophthalmology, Kosin University College of Medicine, Busan, Korea
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Moazzam AA, Savvas SN, Amar AP, Ham SW, Panush RS, Clavijo LC. Diffuse aneurysmal disease – A review. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rvm.2013.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Jog NR, Caricchio R. The role of necrotic cell death in the pathogenesis of immune mediated nephropathies. Clin Immunol 2014; 153:243-53. [PMID: 24845790 DOI: 10.1016/j.clim.2014.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/30/2014] [Accepted: 05/03/2014] [Indexed: 02/08/2023]
Abstract
Necrosis, an inflammatory form of cell death, has been considered to be an accidental death and/or cell death due to injury. However, the literature in the last decade has established that necrosis is a regulated form of cell death, and that inhibition of specific molecular pathways leading to necrosis can block it and reduce inflammation. Since necrotic lesions are observed in several immune mediated human pathologies, in this review we will discuss the impact that this form of programmed cellular demise has in the pathology of immune mediated nephropathies.
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Affiliation(s)
- Neelakshi R Jog
- Rheumatology Section, Department of Medicine, Temple Autoimmunity Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Roberto Caricchio
- Rheumatology Section, Department of Medicine, Temple Autoimmunity Center, Temple University School of Medicine, Philadelphia, PA, USA.
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Hernández-Rodríguez J, Alba MA, Prieto-González S, Cid MC. Diagnosis and classification of polyarteritis nodosa. J Autoimmun 2014; 48-49:84-9. [PMID: 24485157 DOI: 10.1016/j.jaut.2014.01.029] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/13/2013] [Indexed: 12/17/2022]
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis preferentially targeting medium-sized arteries and not associated with glomerulonephritis or small vessel involvement. Anti-neutrophil cytoplasmic antibodies are typically negative. PAN may be triggered by viral infections, particularly hepatitis B virus, but remains idiopathic in most cases. Clinical manifestations of PAN are multisystemic. Peripheral nerve and skin are the most frequently affected tissues. Involvement of the gastrointestinal tract, kidneys, heart, and central nervous system is associated with higher mortality. Laboratory abnormalities reveal a prominent acute phase response but are non-specific. Histologic confirmation of vasculitis in medium sized arteries is desirable and biopsies must be obtained from symptomatic organs if feasible. Skin or muscle and nerve are preferred because of higher diagnostic yield and safety. If biopsies are negative or cannot be obtained, visceral angiography, may reveal multiple micro-aneurysms supporting the diagnosis of PAN. Current treatment policy includes high-dose corticosteroids, which are combined with immunosuppressive agents when critical organ involvement or life-threatening complications occur. IV pulse cyclophosphamide in the remission induction phase, later switched to a safer immunosuppressant for remission maintenance is a frequently used therapeutic approach. A recent consensus algorithm for the classification of PAN has attempted to overcome some of the caveats of the 1990 American College of Rheumatology (ACR) classification criteria which have proven to be unsatisfactory, and has also confirmed the low prevalence of PAN compared to other systemic necrotizing vasculitides. European league against rheumatic diseases (EULAR)/ACR endorsed international cooperation to establish new diagnostic/classification criteria is currently under way.
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Affiliation(s)
- José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marco A Alba
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Maria C Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Pagnoux C, Kluger N, Francès C, Guillevin L. Cutaneous granulomatous vasculitis and extravascular granulomas. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.1.2.315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sharma A, Gopalakrishan D, Nada R, Kumar S, Dogra S, Aggarwal MM, Gupta R, Minz RW, Kakkar N, Vashishtha RK, Singh S. Uncommon presentations of primary systemic necrotizing vasculitides: the Great Masquerades. Int J Rheum Dis 2013; 17:562-72. [PMID: 24237487 DOI: 10.1111/1756-185x.12223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Systemic vasculitides are great masqueraders and at times their presenting manifestations can be very different from the usual recognized patterns. Such uncommon presentations of granulomatosis with polyangiitis (Wegener's granulomatosis), classical polyarteritis nodosa and unclassifiable vasculitides are described here with the relevant review of literature. METHODS All patients diagnosed as having systemic vasculitides and classified as having granulomatosis with polyangiitis (Wegener's granulomatosis), classic polyarteritis nodosa, microscopic polyangiitis and unclassifiable vasculitis according to EMEA consensus methodology and followed up prospectively from June 2007 to December, 2011 were included. Details of uncommon presentations of these disorders were identified. RESULTS Seventy-nine patients with systemic vasculitides were seen under our rheumatology services during this period. These included 45 patients with granulomatosis with polyangiitis (Wegener's granulomatosis), 18 with classic polyarteritis nodosa, five with microscopic polyangiitis, four with Churg-Strauss syndrome and seven with unclassifiable vasculitis. The uncommon presentations of granulomatosis with polyangiitis were a tumefactive subcutaneous mass in the thigh; prostatomegaly with obstructive uropathy and advanced renal failure; and predominant gastrointestinal (GI) vasculitis with thrombocytopenia and coagulopathy at presentation. The uncommon manifestations of classic polyarteritis nodosa were secondary antiphospholipid antibody syndrome and Budd-Chiari syndrome. One patient with massive lower GI bleeding required surgical resection of the large bowel which showed isolated necrotizing granulomatous GI vasculitis. Single organ vasculitis of the GI tract was diagnosed. CONCLUSIONS Systemic necrotizing vasculitides may present with uncommon manifestations and a high index of suspicion is required for early diagnosis and prompt treatment to prevent adverse outcomes.
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Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Uchida T, Nagai K, Sato T, Iizuka N, Arito M, Takakuwa Y, Nakano H, Ooka S, Kurokawa MS, Suematsu N, Okamoto K, Ozaki S, Kato T. Comparative proteomic analysis of neutrophils from patients with microscopic polyangiitis and granulomatosis with polyangiitis. J Proteomics 2013; 91:259-69. [PMID: 23911962 DOI: 10.1016/j.jprot.2013.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 07/15/2013] [Accepted: 07/21/2013] [Indexed: 11/17/2022]
Abstract
UNLABELLED Both microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) belong to ANCA-associated vasculitis (AAV), in which neutrophils play a key role in their pathology. In this study, in order to discriminate between MPA and GPA, protein profiles of peripheral blood polymorphonuclear cells (PMNs) of 11 MPA patients and 9 GPA patients and 10 healthy controls (HC) were analyzed by 2D-DIGE. In all the 864 spots detected, intensity of 55 spots was significantly different (p<0.05) among the three groups by ANOVA. 31 out of the 55 spots were identified by mass spectrometry. Orthogonal partial-least-squares-discriminate analysis revealed that the abundance profile of the protein spots discriminated the AAV group from the HC group, and the MPA group from the GPA group completely. 13 protein spots were considered as biomarker candidates to distinguish between MPA and GPA. In those, spots whose intensity was higher in MPA than in GPA included actin with various pI values, while a considerable part of spots whose intensity was higher in GPA were proteins related with the activity of neutrophils. Among the candidate proteins, ROC analysis showed that a combination of neutrophil gelatinase-associated lipocalin and a-kinase anchor protein 7 isoforms beta had a high diagnostic potential. BIOLOGICAL SIGNIFICANCE In this study, protein profiles of polymorphonuclear cells (PMNs) of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) patients and healthy controls (HC) were investigated by 2D-DIGE, and MS analysis. As a result, we found that the protein profiles of PMNs were useful for distinguishing between patients (MPA and GPA) and HC, and between patients with MPA and patients with GPA. Especially, we found that the 13 protein spots that consisted of 10 proteins considerably contributed to the discrimination between MPA and GPA. This is the first to demonstrate that protein profiles of PMNs are different among MPA, GPA and healthy control. The 10 proteins we identified in this study would be new biomarkers for the diagnosis of the diseases, and may be reflect the pathology difference between MPA and GPA.
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Affiliation(s)
- Teisuke Uchida
- Clinical Proteomics and Molecular Medicine, St. Marianna University Graduate School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa-ken, Japan
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Abstract
Thromboangiitis obliterans, or Buerger disease, is a chronic nonatherosclerotic endarteritis manifesting as inflammation and thrombosis of distal extremity small and medium-sized arteries resulting in relapsing episodes of distal extremity ischemia. Takayasu arteritis is a rare syndrome characterized by inflammation of the aortic arch, pulmonary, coronary, and cerebral vessels, presenting with cerebrovascular symptoms, myocardial ischemia, or upper extremity claudication in young, often female, patients. Kawasaki disease is a small- and medium-vessel acute systemic vasculitis of young children, with morbidity and mortality stemming from coronary artery aneurysms. Microscopic polyangiitis, Churg-Strauss syndrome, and Wegener granulomatosis are systemic small-vessel vasculitides, affecting arterioles, capillary beds and venules, and each presenting with variable effects on the pulmonary, renal and gastrointestinal systems.
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Affiliation(s)
- William Wu
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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