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Sasaki O, Nishioka T. Synchronized motion of intracardiac thrombus with preserved left ventricular contraction in a patient with eosinophilic granulomatosis with polyangiitis. J Echocardiogr 2024:10.1007/s12574-023-00634-8. [PMID: 38227119 DOI: 10.1007/s12574-023-00634-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 12/02/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Osamu Sasaki
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Toshihiko Nishioka
- Division of Cardiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
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2
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Tanaka M, Oshikata C, Yamashita Y, Isono R, Nakadegawa R, Masumitsu H, Motobayashi Y, Osada R, Takayasu H, Masumoto N, Manabe S, Kaneko T, Ueno A, Tsurikisawa N. Eosinophilic granulomatosis with polyangiitis and severe cardiac involvement in a patient surviving for 34 years. J Asthma 2023; 60:2233-2242. [PMID: 37310798 DOI: 10.1080/02770903.2023.2225618] [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: 04/24/2023] [Revised: 06/02/2023] [Accepted: 06/11/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Many studies have reported a poor prognosis for eosinophilic granulomatosis with polyangiitis (EGPA) patients with cardiac involvement. CASE STUDY A woman developed EGPA at 37 years of age, with weight loss, numbness in the right upper and lower extremities, muscle weakness, skin rash, abdominal pain, chest pain, an increased peripheral blood eosinophil count (4165/µL), and necrotizing vasculitis on peroneal nerve biopsy. The patient was treated with prednisolone, immunosuppressants, intravenous immune globulin, and mepolizumab, but she experienced many relapses, with chest pain, abdominal pain, numbness, and paralysis, over a long period. The patient died from aspiration pneumonia at 71 years of age after undergoing left total hip arthroplasty for left hip neck fracture. RESULTS Autopsy showed bronchopneumonia in the lower lung lobes on both sides, as well as infiltration of inflammatory cells, including neutrophils and lymphocytes. There was no evidence of active vasculitis in either the lung or colon. At autopsy the heart showed predominantly subendocardial fibrosis and fatty infiltration, but no active vasculitis or eosinophilic infiltration. CONCLUSION To our knowledge, there have been no autopsy reports of EGPA patients who have survived for 34 years with recurrent cardiac lesions. In this case, the cardiac involvement (active vasculitis and eosinophilic infiltration) had improved by the time of death.
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Affiliation(s)
- Minaho Tanaka
- Department of Allergy and Respirology, Hiratsuka City Hospital, Kanagawa, Japan
| | - Chiyako Oshikata
- Department of Allergy and Respirology, Hiratsuka City Hospital, Kanagawa, Japan
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Yuga Yamashita
- Department of Allergy and Respirology, Hiratsuka City Hospital, Kanagawa, Japan
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Riko Isono
- Department of Allergy and Respirology, Hiratsuka City Hospital, Kanagawa, Japan
| | - Ryo Nakadegawa
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Hinako Masumitsu
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Yuto Motobayashi
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Reeko Osada
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Hirokazu Takayasu
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Nami Masumoto
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Saki Manabe
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Akihisa Ueno
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Naomi Tsurikisawa
- Department of Allergy and Respirology, Hiratsuka City Hospital, Kanagawa, Japan
- Department of Respirology, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
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3
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Ali AM, Yakupoglu HY, Fuchs TA, Larsen TH, Aukrust P, Gunnarsson R, Saeed S. Cardiac involvement in systemic and local vasculitides: The value of non-invasive multimodality imaging. Curr Probl Cardiol 2023; 48:101718. [PMID: 37003450 DOI: 10.1016/j.cpcardiol.2023.101718] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
Despite significant advances in managing systemic vasculitides, cardiovascular morbidity and mortality are still of primary concern. Advances in non-invasive imaging have broadened our understanding of the clinical heterogeneity of cardiac involvement in vasculitides. Common cardiovascular complications in primary or secondary vasculitides are; coronary artery aneurysms, acute coronary syndromes, myocarditis, pericarditis, endocarditis, and valvular dysfunction. Echocardiography, cardiac magnetic resonance (CMR), positron emission tomography (PET), and CT angiography are essential in identifying cardiac involvement and guiding treatment. Here, we present our experiences of cardiac involvement in systemic vasculitides, covering most aspects of common cardiac complications based on a multi-modality approach to challenging (real-world) cases. As many cardiac manifestations are clinically silent, heart function should be systemically assessed by a multi-modality imaging-based approach, including ECG, serial echocardiograms with strain imaging and 3D, and CMR to detect early signs of cardiac manifestations. This enables timely intervention and optimal medical treatment, which is essential for a better prognosis. There is a need for better and closer collaboration in clinical practice and research fields between Cardiologists and Rheumatologists.
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Affiliation(s)
- Abukar Mohamed Ali
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - H Yakup Yakupoglu
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Tobias A Fuchs
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Terje H Larsen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.; Department of Biomedicine, University of Bergen, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital - Rikshospitalet, Oslo; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo.; Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital - Rikshospitalet, Oslo
| | | | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway..
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4
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White J, Dubey S. Eosinophilic granulomatosis with polyangiitis: A review. Clin Exp Rheumatol 2023; 22:103219. [PMID: 36283646 DOI: 10.1016/j.autrev.2022.103219] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/19/2022] [Indexed: 12/27/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, multi-system, inflammatory disease, belonging to the group of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Previously known as Churg-Strauss syndrome, EGPA is characterised by late-onset asthma, eosinophilia and vasculitis affecting small-to-medium vessels. This disease behaves differently in many aspects to the other AAV and is often excluded from AAV studies. The disease is poorly understood and, due to it rarity and unique manifestations, there has been limited research progress to optimise our understanding of its complex pathogenesis and ability to develop management options - although the success of interleukin-5 inhibitors such as Mepolizumab has been a welcome development. The pathophysiology also appears to be different to other forms of AAV and hence management strategies that work for AAV may not fully apply to this condition. There is no current standard therapy for EGPA although corticosteroids are almost universally used for treatment alongside other agents and encouraging modes of treatment continue to evolve beyond glucocorticoid immunosuppression (including interleukin-5 inhibition). There is therefore a significant ongoing unmet need for efficacious steroid-sparing immunosuppressing agents. The prognosis also diverges from other forms of AAV, and we discuss the pathophysiology, clinical features and diagnosis, management and prognosis in this article.
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Affiliation(s)
- Jpe White
- St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, United Kingdom
| | - S Dubey
- Dept of Rheumatology, Oxford University Hospitals NHS FT, Windmill Road, Oxford OX3 7LD, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7HE, United Kingdom.
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5
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Abstract
This review aims to describe the epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of eosinophilic granulomatosis with polyangiitis (EGPA). Eosinophilic granulomatosis with polyangiitis is a small to medium vessel necrotizing vasculitis, typically classified with granulomatosis with polyangiitis (GPA) and microscopic polyangitis (MPA) as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, less than 50% of patients with EGPA have a positive ANCA test. Among all the vasculitides, asthma and eosinophilia are unique features of EGPA. Eosinophilic granulomatosis with polyangiitis is very rare and the diagnosis may be missed as the disease evolves over time. Polyneuropathies are common and may be severe, requiring aggressive immunosuppressive therapy. Heart involvement is the most common cause of death in EGPA. Biopsy of involved tissue supports a clinically suspected diagnosis but is not always feasible. Treatment of EGPA is primarily dictated by the severity of disease and prognostic factors. More severe disease frequently requires the use of aggressive therapy such as cyclophosphamide. Once treatment is initiated, patients can achieve good control of symptoms; unfortunately, disease relapses are common and prolonged treatment with corticosteroids is often necessary for asthma management. A better understanding of the disease heterogeneity is needed for the development of better therapies.
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Affiliation(s)
- Alexandra Villa-Forte
- Cleveland Clinic - Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases 9500 Euclid Ave/A50 Cleveland Ohio 44195-5243, USA
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6
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Affiliation(s)
- Ryan A Denu
- From the Departments of Medicine and Pathology, Brigham and Women's Hospital, Boston
| | - Daniel H Solomon
- From the Departments of Medicine and Pathology, Brigham and Women's Hospital, Boston
| | - Richard N Mitchell
- From the Departments of Medicine and Pathology, Brigham and Women's Hospital, Boston
| | - Yee-Ping Sun
- From the Departments of Medicine and Pathology, Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine and Pathology, Brigham and Women's Hospital, Boston
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7
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Asatani S, Kobayashi H, Nagasawa Y, Nishihara M, Tanikawa Y, Hamaguchi M, Yoshizawa S, Tsuzuki H, Sugiyama K, Tsukamoto M, Kitamura N, Nakamura H. Successful Treatment for Eosinophilic Granulomatosis with Polyangiitis Causing Severe Myocarditis Followed by Cardiac Magnetic Resonance. Mod Rheumatol Case Rep 2022; 6:248-253. [PMID: 35403190 DOI: 10.1093/mrcr/rxac027] [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: 01/17/2022] [Revised: 02/28/2022] [Accepted: 03/16/2022] [Indexed: 11/14/2022]
Abstract
A 38-year-old woman had a history of asthma for 20 years. Bullous lesions had appeared in her left side of the back. Two months before admission, and biopsy revealed eosinophilic cellulitis. She experienced numbness in both legs one month later. She was admitted to our hospital for emergency treatment due to chest pain and loss of consciousness. Emergency coronary angiography revealed triple-vessel vasospasm. She had cardiac arrest for four minutes during the examination. We suspected eosinophilic granulomatosis with polyangiitis due to pulmonary infiltrate, eosinophilia, and a history of illness. We therefore started methylprednisolone pulse therapy. Although her condition and laboratory findings improved, cardiac magnetic resonance (CMR) imaging performed on day 16 showed myocardial edema and myocardial fibrosis on late gadolinium enhancement (LGE). Coronary angiography on day 35 revealed no spasm, and myocardial biopsy showed absence of vasculitis. There was no improvement in myocardial edema. CMR showed enlargement of LGE and formation of ventricular aneurysm. As myocarditis did not improve sufficiently, five courses of intravenous cyclophosphamide pulse therapy were administered. CMR on day 152 showed disappearance of the myocardial edema. We report a unique case of successful treatment of severe myocarditis and the usefulness of follow-up CMR.
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Affiliation(s)
- Shinya Asatani
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Tanikawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Marina Hamaguchi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shoei Yoshizawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuzuki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kaita Sugiyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Tsukamoto
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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8
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Ismail TF, Hua A, Plein S, D'Cruz DP, Fernando MMA, Friedrich MG, Zellweger MJ, Giorgetti A, Caobelli F, Haaf P. The role of cardiovascular magnetic resonance in the evaluation of acute myocarditis and inflammatory cardiomyopathies in clinical practice - a comprehensive review. Eur Heart J Cardiovasc Imaging 2022; 23:450-464. [PMID: 35167664 DOI: 10.1093/ehjci/jeac021] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/24/2022] [Indexed: 01/05/2023] Open
Abstract
Inflammatory cardiomyopathy (I-CMP) is defined as myocarditis in association with cardiac dysfunction and/or ventricular remodelling. It is characterized by inflammatory cell infiltration into the myocardium and has heterogeneous infectious and non-infectious aetiologies. A complex interplay of genetic, autoimmune, and environmental factors contributes to the substantial risk of deteriorating cardiac function, acute heart failure, and arrhythmia as well as chronic dilated cardiomyopathy and its sequelae. Multi-parametric cardiovascular magnetic resonance (CMR) imaging is sensitive to many tissue changes that occur during myocardial inflammation, regardless of its aetiology. In this review, we summarize the various aetiologies of I-CMP and illustrate how CMR contributes to non-invasive diagnosis.
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Affiliation(s)
- Tevfik F Ismail
- CMR Unit, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alina Hua
- CMR Unit, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sven Plein
- CMR Unit, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds & Leeds Teaching Hospitals NHS Trust, Clarendon, Way, Leeds LS2 9JT, UK
| | - David P D'Cruz
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Rheumatology Department, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Michelle M A Fernando
- Rheumatology Department, Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Rheumatology Department, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Matthias G Friedrich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Cardiology, McGill University Health Centre, Montreal, Canada.,Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - Michael J Zellweger
- Department of Cardiology, Clinic of Cardiology, University Hospital Basel and University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | | | - Federico Caobelli
- Department of Nuclear Medicine, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology, Clinic of Cardiology, University Hospital Basel and University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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9
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Uzzo M, Regola F, Trezzi B, Toniati P, Franceschini F, Sinico RA. Novel Targets for Drug Use in Eosinophilic Granulomatosis With Polyangiitis. Front Med (Lausanne) 2021; 8:754434. [PMID: 34796188 PMCID: PMC8593004 DOI: 10.3389/fmed.2021.754434] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare autoimmune disease characterized by medium and small vessels inflammation. Cardiac vasculitic involvement is one of the most severe manifestations with a significant impact on patients' long-term prognosis: anyway, a specific therapeutic approach for heart involvement in EGPA has not been explored yet. Current regimen consists of a long-term therapy with high dose of glucocorticoids, causing the well-known related-adverse events; immunosuppressive drugs are used in patients with severe manifestations, with some limitations. New therapeutic approaches are needed for patients with refractory disease or contraindications to conventional therapies. The quest for the ideal therapy is going toward a more and more personalized approach: on the one hand, efforts are made to use already existing therapies in the most appropriate way; on the other hand, new insights into EGPA pathogenesis allow the discovery of new targets, as demonstrated by mepolizumab and rituximab, targeting eosinophils, and B-cell compartments. This review summarizes the emerging therapies used in EGPA, focusing on the most recent studies on biologics and analyzing their efficacy and safety.
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Affiliation(s)
- Martina Uzzo
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
| | - Francesca Regola
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Barbara Trezzi
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
| | - Paola Toniati
- Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Franco Franceschini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Renato Alberto Sinico
- Department of Clinical and Experimental Sciences, University of Milano-Bicocca, Monza, Italy.,Nephrology and Dialysis Unit, Ospedale San Gerardo di Monza, Monza, Italy
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10
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Trivioli G, Terrier B, Vaglio A. Eosinophilic granulomatosis with polyangiitis: understanding the disease and its management. Rheumatology (Oxford) 2021; 59:iii84-iii94. [PMID: 32348510 DOI: 10.1093/rheumatology/kez570] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/15/2019] [Indexed: 12/14/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis is characterized by asthma, blood and tissue eosinophilia and small-vessel vasculitis. The clinical presentation is variable, but two main clinic-pathologic subsets can be distinguished: one hallmarked by positive ANCA and predominant 'vasculitic' manifestations (e.g. glomerulonephritis, purpura and mononeuritis multiplex) and the other by negative ANCA and prominent 'eosinophilic' manifestations (e.g. lung infiltrates and cardiomyopathy). The pathogenesis is not fully understood but probably results from the interplay between T and B cells and eosinophils. Eosinophilic granulomatosis with polyangiitis must be differentiated from several conditions, including hypereosinophilic syndromes and other small-vessel vasculitides. The overall survival is good; however, patients frequently relapse and have persistent symptoms. The recently developed monoclonal antibodies targeting B cells and eosinophilopoietic cytokines such as IL-5 are emerging as valid alternatives to conventional immunosuppressive therapies. In this review, we discuss the essential features of eosinophilic granulomatosis with polyangiitis, with particular respect to the most relevant issues concerning clinical presentation and management.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Descartes, Paris 5, Paris, France
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
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11
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Springer JM, Kalot MA, Husainat NM, Byram KW, Dua AB, James KE, Chang Lin Y, Turgunbaev M, Villa-Forte A, Abril A, Langford CA, Maz M, Chung SA, Mustafa RA. Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis of Test Accuracy and Benefits and Harms of Common Treatments. ACR Open Rheumatol 2021; 3:101-110. [PMID: 33512787 PMCID: PMC7882521 DOI: 10.1002/acr2.11194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Eosinophilic granulomatosis with polyangiitis (EGPA) is part of a group of vasculitides commonly referred to as antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV), in addition to granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and renal‐limited vasculitis. Patients with EGPA characteristically have asthma and marked peripheral eosinophilia with only approximately 30% to 35% of patients being myeloperoxidase (MPO)‐ANCA positive, distinguishing it from other forms of AAV (1,2). The aim of this systematic review is to support the development of the American College of Rheumatology/Vasculitis Foundation guideline for the management of EGPA. Methods A systematic review was conducted of the literature for seven forms of primary systemic vasculitis (GPA, MPA, EGPA, polyarteritis nodosa, Kawasaki disease, giant cell arteritis, and Takayasu arteritis). The search was done for articles in English using Ovid Medline, PubMed, Embase, and the Cochrane Library. Articles were screened for suitability in addressing population/patients, intervention, comparator, and outcomes (PICO) questions, with studies presenting the highest level of evidence given preference. Two independent reviewers conducted a title/abstract screen and full‐text review for each eligible study. Results The initial search, conducted in August 2019, included 13 800 articles, of which 2596 full‐text articles were reviewed. There were 190 articles (addressing 34 PICO questions) reporting on the diagnosis and management of EGPA. Conclusion This comprehensive systematic review synthesizes and evaluates the accuracy of commonly used tests for EGPA as well as benefits and toxicities of different treatment options.
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Affiliation(s)
| | | | | | | | - Anisha B Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
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12
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Garcia-Vives E, Rodriguez-Palomares JF, Harty L, Solans-Laque R, Jayne D. Heart Disease in Eosinophilic Granulomatosis with Polyangiitis (EGPA) Patients: a screening approach proposal. Rheumatology (Oxford) 2021; 60:4538-4547. [PMID: 33493294 DOI: 10.1093/rheumatology/keab027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To define the pattern of cardiac involvement in eosinophilic granulomatosis and polyangiitis (EGPA) and propose an algorithm for heart disease screening. METHODS Retrospective study of EGPA patients attending a specialized vasculitis clinic (1989-2016). Clinical characteristics and cardiovascular evaluation (CE) results (serum troponin, ECG, echocardiography and cardiac magnetic resonance) were collected and compared according to symptoms and inflammatory cardiac disease (ICD). RESULTS 131 EGPA patients were included, of whom 96 (73%) had undergone CE. The median age was 50 [IQR 38-58] years and 36% showed ANCA+. Asthma preceded diagnosis by a median of 97 [36-240] months. Among the 96 patients who underwent CE, 43% were symptomatic, being dyspnea (47%) and chest pain (29%) the predominant symptoms. In asymptomatic patients, CE reported abnormalities in 45% of cases with a subsequent earlier diagnosis (4 vs 11 months). Overall, 27 patients had EGPA-related ICD (rICD) that was already present at diagnosis in 20 cases, preceded it in 2 cases and developed later in 5. EGPA-rICD patients were younger (46 vs 50 years; p= 0.04), had more frequently abnormal ECG (30.8% vs 2.1%; p< 0.001), negative ANCA (85% vs 69%; NS), higher BVAS score (3 vs 1; p= 0.005), higher eosinophil count (5.60 vs 1.60x109/l; p= 0.029) and higher C reactive protein (52 vs 15 mg/l; p= 0.017). Overall, 11% of cases with EGPA-rICD were asymptomatic. CONCLUSION In our study, 45% of asymptomatic patients had an abnormal baseline cardiac evaluation, which allowed an earlier diagnosis of cardiac disease. We recommend prompt cardiac screening in all EGPA patients, instead of a symptoms-guided algorithm.
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Affiliation(s)
- Eloi Garcia-Vives
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - J F Rodriguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, CIBER-CV, Vall d'Hebrón Institut de recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Len Harty
- Rheumatology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Roser Solans-Laque
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - David Jayne
- Nephrology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
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13
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Liu S, Guo L, Zhang Z, Li M, Zeng X, Wang L, Liu Y, Zhang F. Cardiac manifestations of eosinophilic granulomatosis with polyangiitis from a single-center cohort in China: clinical features and associated factors. Ther Adv Chronic Dis 2021; 12:2040622320987051. [PMID: 33613936 PMCID: PMC7841702 DOI: 10.1177/2040622320987051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/18/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Cardiac manifestations are common and life-threatening in eosinophilic granulomatosis with polyangiitis (EGPA), which remains poorly studied in China. We aim to investigate its clinical features, associated factors, treatment, and outcomes. Methods: We reviewed the clinical records of 110 EGPA patients and examined the independent factors associated with cardiac manifestations using multivariate logistic regression. Receiver operating characteristic curves determined the cut-off values, and survival was calculated via Kaplan–Meier curves. Results: Cardiac involvement was present in 36.4% (40/110) of EGPA patients, which mainly manifested as pericardial effusion (16.4%, 18/110), myocardial involvement (13.6%, 15/110), and heart failure (8.2%, 9/110). The mean age was 42.1 ± 14.23 years with no female/male predominance. Compared with the cardiac-unaffected group, the cardiac-affected group showed a lower rate of biopsy-proved vasculitis (0% versus 20%, p = 0.002). The eosinophil count [odds ratio (OR) = 1.142, 95% confidence interval (CI) 1.029–1.267] was independently associated with cardiac manifestations in EGPA, with a cut-off value of 3.66 × 109/L [area under the curve (AUC) = 0.692, p = 0.001]. Regarding treatment, the cardiac-affected group displayed a higher ratio of glucocorticoid pulse combined with intravenous cyclophosphamide (CYC-IV) (40% versus 21.4%, p = 0.037), and intravenous immunoglobulin combined with glucocorticoid plus CYC-IV (17.5% versus 4.3%, p = 0.035) than the control group. Outcomes (p = 0.131) and survival (p = 0.1972) were not significantly different between the groups. Conclusion: In this single-center Chinese EGPA cohort, cardiac manifestations are observed in 36.4% of patients, which primarily presents as myocardial involvement, pericardial effusion, and heart failure, independently associated with eosinophil count. Glucocorticoid combined with cyclophosphamide is the treatment cornerstone for EGPA patients with cardiac manifestations.
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Affiliation(s)
- Suying Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Ling Guo
- Department of Rheumatology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Zhaocui Zhang
- Department of Rheumatology and Clinical Immunology, Gansu Province People's Hospital, Lanzhou, Gansu Province, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
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14
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Block HS. Neurologic complications of myocarditis. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:111-123. [PMID: 33632429 DOI: 10.1016/b978-0-12-819814-8.00030-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Myocarditis, a nonischemic acquired cardiomyopathy, is an uncommon condition with multiple presentation patterns which may be initially difficult to recognize and may simulate other conditions such as acute myocardial infarction, pericarditis, septicemia, etc. There are four distinct clinical presentation patterns that include: (1) low-grade nonspecific symptoms such as fatigue; (2) symptoms that resemble an acute myocardial infarction, especially in younger individuals; (3) a heart failure presentation which may be acute, subacute, or chronic and may be associated with cardiac conduction system defects and arrhythmias; and (4) an arrhythmia presentation that may produce sudden cardiac death, especially in young athletes with minimal or no prodromal symptoms. This chapter will provide a brief overview of various myocarditis etiologies and diagnostic modalities. The ultimate focus will be directed toward neurologic manifestations of myocarditis and its subtypes, complications of specific therapies including extracorporeal membrane oxygenation (ECMO) for refractory heart failure, and review the current literature regarding the appropriate use of therapeutic anticoagulation in myocarditis and heart failure for stroke prevention. Covid-19 infection has been discovered to cause myocarditis. The emerging science will be discussed. Nuances of brain death (BD) determination in patients receiving venoarterial ECMO for heart failure refractory to standard medical therapies will be discussed.
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Affiliation(s)
- H Steven Block
- SSM Health Dean Medical Group, Department of Neurology, St. Mary's Hospital, Madison, WI, United States.
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15
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Myocardial involvement in eosinophilic granulomatosis with polyangiitis evaluated with cardiopulmonary magnetic resonance. Int J Cardiovasc Imaging 2020; 37:1371-1381. [PMID: 33211241 PMCID: PMC8026437 DOI: 10.1007/s10554-020-02091-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/27/2020] [Indexed: 01/09/2023]
Abstract
Patients with eosinophilic granulomatosis with polyangiitis (EGPA) most commonly die from cardiac causes, however, cardiac involvement remains poorly characterised and the relationship between cardiac and pulmonary disease is not known. This study aimed to characterise myocardial and pulmonary manifestations of EGPA, and their relationship. Prospective comprehensive cardiopulmonary investigation, including a novel combined cardiopulmonary magnetic resonance imaging (MRI) technology, was performed in 13 patients with stable EGPA. Comparison was made with 11 prospectively recruited matched healthy volunteers. Stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis (myocardial extracellular volume 26.9% vs. 24.7%; p = 0.034), which drove a borderline increase in left ventricular mass (56 ± 9 g/m2 vs. 49 ± 8 g/m2; p = 0.065). Corrected QT interval was significantly prolonged and was associated with the severity of myocardial fibrosis (r = 0.582, p = 0.037). Stable EGPA was not associated with increased myocardial capillary permeability or myocardial oedema. Pulmonary tissue perfusion and capillary permeability were normal and there was no evidence of pulmonary tissue oedema or fibrosis. Forced expiratory volume in one second showed a strong inverse relationship with myocardial fibrosis (r = -0.783, p = 0.038). In this exploratory study, stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis, but no evidence of myocardial or pulmonary inflammation or pulmonary fibrosis. Myocardial fibrosis was strongly associated with airway obstruction and abnormal cardiac repolarisation. Further investigation is required to determine the mechanisms underlying the association between heart and lung disease in EGPA and whether an immediate immunosuppressive strategy could prevent myocardial fibrosis formation.
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16
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Sridharan S, Nanthakumaran S, Somagutta MR, Pagad S, Arnold AA, May V, Malik BH. The Critical Role of Cardiac Magnetic Resonance Imaging in Evaluating Patients With Eosinophilic Granulomatosis With Polyangiitis. Cureus 2020; 12:e10279. [PMID: 33042714 PMCID: PMC7538204 DOI: 10.7759/cureus.10279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare autoimmune systemic necrotizing vasculitis of blood vessels that often presents with hypereosinophilia. Cardiac involvement in EGPA directly correlates with the mortality of patients with the disease and is a central part of the disease process. The evaluation and treatment of cardiac anomalies are vital in patients with EGPA. The frequency with which cardiac involvement is seen in the disease process makes early diagnosis crucial in all patients with EGPA. Early treatment has been proven to reverse or cause the disease to go into remission. Several studies have shown that cardiac magnetic resonance (CMR) imaging is the most sensitive and best early indicator of cardiovascular involvement in EGPA. CMR routinely outperforms other diagnostic techniques such as ECG (echocardiography) and CTA (computed tomography angiography) in the detection of cardiac anomalies and should be a part of the standardized assessment of all patients with EGPA. CMR is also a non-invasive diagnostic tool that can also outperform biopsy in the detection of EGPA cardiac involvement. CMR is also a valuable technique that can be used to monitor disease progression while treatment is being performed. Although long-term research studies have yet to show these benefits, the studies that are available today provide ample evidence that shows CMR imaging could ultimately help bring down mortality rates currently seen in EGPA patients if it is used as an evaluation tool from initial diagnosis and throughout the entire course of disease management.
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Affiliation(s)
- Saijanakan Sridharan
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Saruja Nanthakumaran
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Manoj R Somagutta
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sukrut Pagad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ashley A Arnold
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vanessa May
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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17
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Ikonomidis I, Makavos G, Katsimbri P, Boumpas DT, Parissis J, Iliodromitis E. Imaging Risk in Multisystem Inflammatory Diseases. JACC Cardiovasc Imaging 2019; 12:2517-2537. [DOI: 10.1016/j.jcmg.2018.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 05/29/2018] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
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18
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Karthikeyan K, Balla S, Alpert MA. Non-infectious aortic and mitral valve vegetations in a patient with eosinophilic granulomatosis with polyangiitis. BMJ Case Rep 2019; 12:12/5/e225947. [PMID: 31092487 PMCID: PMC6536155 DOI: 10.1136/bcr-2018-225947] [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] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of vasculitis characterised by atopic manifestations, inflammation of small-sized to medium-sized arteries and veins, hypereosinophilia and tissue infiltration with eosinophils. Cardiac complications occur most commonly in the absence of antineutrophil cytoplasmic antibodies. Cardiac complications include coronary arteritis (rare), pericarditis, myocarditis, endocardial fibrosis (Loeffler's endocarditis) and intracavitary thrombosis of the left or right ventricle. This is the first reported case of large non-infectious valvular vegetations associated with EGPA.
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Affiliation(s)
| | - Sudarshan Balla
- Cardiology, University of Missouri Health Care, Columbia, Missouri, USA
| | - Martin A Alpert
- Cardiology, University of Missouri-Columbia, Columbia, Missouri, USA
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19
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Singhal M, Gupta P, Sharma A. Imaging in small and medium vessel vasculitis. Int J Rheum Dis 2019; 22 Suppl 1:78-85. [DOI: 10.1111/1756-185x.13390] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/22/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Manphool Singhal
- Department of Radiodiagnosis and Imaging; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Aman Sharma
- Department of Internal Medicine; Postgraduate Institute of Medical Education and Research; Chandigarh India
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20
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Kurokawa K, Sai E, Hayashi E, Minowa K, Sugano K, Yoshihara T, Miyazaki T, Hiki M, Yokoyama T, Suzuki M, Miyauchi K. Usefulness of Cardiac Magnetic Resonance in the Diagnosis of Löffler Endocarditis Secondary to Eosinophilic Granulomatosis with Polyangiitis. Intern Med 2019; 58:239-242. [PMID: 30146590 PMCID: PMC6378165 DOI: 10.2169/internalmedicine.1303-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 40-year-old man who was diagnosed with bronchial asthma and eosinophilia was transferred to our hospital due to a worsening respiratory status. He was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA), and eosinophilic pneumoniae. Cardiac magnetic resonance (CMR) imaging indicated Löffler endocarditis. Treatment was initiated using intravenous methylprednisolone, cyclophosphamide, and heparin as anticoagulation therapy. Three months later, CMR showed the improvement of the LV myocardium. In this case, the early diagnosis of Löffler endocarditis by CMR could prevent systemic embolism and CMR was useful for assessing the curative effects of steroid and immunosuppressant therapy.
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Affiliation(s)
- Kana Kurokawa
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Eiryu Sai
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Japan
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Eri Hayashi
- Department of Internal Medicine and Rheumatology, Juntendo Tokyo Koto Geriatric Medical Center, Japan
| | - Kentaro Minowa
- Department of Internal Medicine and Rheumatology, Juntendo Tokyo Koto Geriatric Medical Center, Japan
| | - Koji Sugano
- Department of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Japan
| | - Takuma Yoshihara
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Japan
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Tadashi Miyazaki
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Japan
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Makoto Hiki
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Takayuki Yokoyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Masaru Suzuki
- Department of Radiology, Juntendo Tokyo Koto Geriatric Medical Center, Japan
| | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Japan
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Japan
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21
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Dalia T, Parashar S, Patel NV, Gautam A, Dai H, Bormann S. Eosinophilic Myocarditis Demonstrated Using Cardiac Magnetic Resonance Imaging in a Patient with Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Disease). Cureus 2018; 10:e2792. [PMID: 30112268 PMCID: PMC6089482 DOI: 10.7759/cureus.2792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), historically known as the Churg-Strauss disease, is a small- to medium-sized vessel multi-organ vasculitis with a propensity to involve the heart. EGPA is a rare condition with an estimated annual incidence of one to 4.2 people per million. The cardiac involvement causes significant morbidity and mortality in EGPA patients. Approximately 50% of the deaths in EGPA are related to cardiac disease and occur within the first few months since diagnosis. The current recommendations support evaluation of cardiac involvement by using history, physical exam and multimodality imaging including echocardiogram and cardiac magnetic resonance imaging (CMR). Here, we report a rare case of eosinophilic myocarditis in a 19-year-old patient with EGPA seen on CMR. Pertinent literature is also reviewed. We highlighted the importance of CMR in diagnosing and follow up of EGPA patients.
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Affiliation(s)
- Tarun Dalia
- Internal Medicine, University of Kansas, Kansas City, USA
| | - Sonya Parashar
- Internal Medicine, University of Kansas, Kansas City, USA
| | - Nilay V Patel
- Department of Cardiology, University of Kansas, Kansas City, USA
| | - Archana Gautam
- Internal Medicine, UAB School of Medicine,montgomery, Montgomery, USA
| | - Hongyan Dai
- Pathology, University of Kansas, Kansas city, USA
| | - Steven Bormann
- Department of Cardiology, University of Kansa, Kansas City, USA
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22
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Abstract
PURPOSE OF REVIEW In this paper we will review the modern diagnostic approach to patients with clinically suspected myocarditis as well as the treatment modalities and strategy in light of up-to-date clinical experience and scientific evidence. RECENT FINDINGS Rapidly expanding evidence suggests that myocardial inflammation is frequently underdiagnosed or overlooked in clinical practice, although new therapeutic options have been validated. Moreover, the available evidence suggests that subclinical cardiac involvement has negative prognostic impact on morbidity and mortality and should be actively investigated and adequately treated. Myocarditis represents a growing challenge for physicians, due to increased referral of patients for endomyocardial biopsy (EMB) or cardiac magnetic resonance (CMR), and requires a highly integrated management by a team of caring physicians.
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23
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Cereda AF, Pedrotti P, De Capitani L, Giannattasio C, Roghi A. Comprehensive evaluation of cardiac involvement in eosinophilic granulomatosis with polyangiitis (EGPA) with cardiac magnetic resonance. Eur J Intern Med 2017; 39:51-56. [PMID: 27727077 DOI: 10.1016/j.ejim.2016.09.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/08/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis characterized by hypereosinophilia. EGPA typically develops in three clinical phases, beginning with asthma, followed by tissue eosinophilia and finally systemic vasculitis. Cardiac involvement is the most important predictor of mortality; it occurs in approximately 15-60% of EGPA patients, a significant proportion of whom are asymptomatic and have normal electrocardiogram (ECG) and echocardiogram. Early detection and management of cardiac disease could positevely affect prognosis. Cardiovascular magnetic resonance (CMR) has emerged as the gold standard cardiac imaging technique in the evaluation of cardiomyopathies, due to its ability to reliably assess anatomy, function, and tissue characterization. AIM Purpose of this study was to assess the role of CMR in detecting cardiac disease in patients with EGPA in clinical remission. METHODS A dedicated CMR protocol including functional analysis, and pre and post-contrast tissue characterization was performed in 11 patients with EGPA and the results were compared with 11 healthy subjects. RESULTS EGPA patients had lower left ventricular ejection fraction compared to controls (56±19 vs 68.7±5.2, p value 0.02). Late gadolinium enhancement (LGE), representing replacement fibrosis, was positive in 9/11 (82%) patients, mainly with a non-ischemic pattern. In 3/11 (27%) patients a left ventricular thrombus was detected; in 3/11 (27%) patients myocardial edema was detected. CMR parameters of interstitial fibrosis were significantly more elevated in EGPA patients compared to controls. CONCLUSIONS Patients with EGPA in clinical remission showed a high cardiovascular burden as demonstrated by lower EF, signs of active inflammation, presence of interstitial and replacement fibrosis and intraventricular thrombosis. Further studies on wider populations are warranted to better understand how these findings could impact on prognosis and eventually guide therapy.
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Affiliation(s)
- Alberto Francesco Cereda
- Bicocca University, Science of Health Department, Milano, Italy; Department of Cardiology A De Gasperis, Cardiology 4, Cardiovascular Magnetic Resonance Unit, Niguarda Cà Granda Hospital, Milano, Italy.
| | - Patrizia Pedrotti
- Department of Cardiology A De Gasperis, Cardiology 4, Cardiovascular Magnetic Resonance Unit, Niguarda Cà Granda Hospital, Milano, Italy
| | - Lucio De Capitani
- Department of Statistics and Quantitative Methods, Bicocca University, Milano, Italy
| | - Cristina Giannattasio
- Bicocca University, Science of Health Department, Milano, Italy; Department of Cardiology A De Gasperis, Cardiology 4, Niguarda Cà Granda Hospital, Milano, Italy
| | - Alberto Roghi
- Department of Cardiology A De Gasperis, Cardiology 4, Cardiovascular Magnetic Resonance Unit, Niguarda Cà Granda Hospital, Milano, Italy
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Multiple Thromboembolic Cerebral Infarctions from the Aorta in a Patient with Churg-Strauss Syndrome. J Stroke Cerebrovasc Dis 2016; 26:e32-e33. [PMID: 27993446 DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Ischemic stroke is a rare complication of Churg-Strauss syndrome (CSS) and its pathogenesis has not been well clarified yet. We report a case of cerebral infarction in a patient with CSS due to embolism from a thrombus on the wall of the aorta. CASE A 39-year-old man had multiple cerebral infarctions with symptoms of mild left hemiparesis and reduced vision. He was clinically diagnosed to have CSS based on remarkable eosinophilia, history of asthma, sinusitis, pulmonary infiltrates, and histologically proven extravascular eosinophilic infiltrates in the specimen of gastric mucosa. Cerebral angiography did not show any stenotic lesions in cerebral arteries. A thrombus was detected on the wall of the aorta by transesophageal echocardiography, which was considered as the source of embolism. The thrombus resolved on follow-up examination 3 months after the onset of the stroke. CONCLUSIONS This is the first case report on cerebral infarction caused by aortogenic thromboembolism in a CSS patient. Other than cerebral vasculitis, embolism from cardiovascular system, including the wall of the aorta, is a possible cause of cerebral infarctions in a CSS patient.
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25
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Misra DP, Shenoy SN. Cardiac involvement in primary systemic vasculitis and potential drug therapies to reduce cardiovascular risk. Rheumatol Int 2016; 37:151-167. [DOI: 10.1007/s00296-016-3435-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 01/26/2016] [Indexed: 12/13/2022]
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26
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Yune S, Choi DC, Lee BJ, Lee JY, Jeon ES, Kim SM, Choe YH. Detecting cardiac involvement with magnetic resonance in patients with active eosinophilic granulomatosis with polyangiitis. Int J Cardiovasc Imaging 2016; 32 Suppl 1:155-62. [PMID: 26831057 DOI: 10.1007/s10554-016-0843-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/19/2016] [Indexed: 01/31/2023]
Abstract
Cardiac involvement is the most important prognostic factor in eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome). The aims of this study were to describe findings of cardiac magnetic resonance (CMR) in patients with active EGPA and to find factors associated with cardiac involvement detected by CMR that could help identify patients who would benefit from the examination. Medical records and CMR images in 16 consecutive EGPA patients (8 women and 8 men, median age of 47 years ranging from 34 to 68 years) were reviewed. Clinical features and results of laboratory tests were compared according to the presence of myocardial late gadolinium enhancement (LGE) on CMR images. The patients were followed for the development of cardiac symptoms and signs (mean follow up duration, 40.5 ± 12.8 months). Among the total of 16 patients, 8 (50 %) had myocardial LGE according to CMR, located in the subendocardial layer in 7 of them (87.5 %). The extent of LGE had a significant negative correlation with left ventricular ejection fraction (LVEF, ρ = -0.723, p = 0.043). The presence of LGE was associated with larger end-systolic left ventricle internal dimension (34 vs. 28 mm, p = 0.027) and presence of diastolic dysfunction (75 vs. 0 %, p = 0.008) on echocardiography, elevated NT-proBNP (75 vs. 12.5 %, p = 0.012), and elevated CK-MB (62.5 vs. 0 %, p = 0.010) compared to the group without LGE. Only one patient (6.3 %) had cardiac symptoms before CMR and another patient (6.3 %) developed heart failure 4 years later during remission. The other 14 patients remained free from cardiac signs and symptoms during the follow-up period. In patients with active EGPA, CMR enables detection of cardiac involvement when cardiac symptoms are not present. Echocardiographic diastolic dysfunction and elevated NT-proBNP or CK-MB may help identify active EGPA patients who can benefit from CMR to detect cardiac involvement without cardiac symptoms.
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Affiliation(s)
- Sehyo Yune
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Dong-Chull Choi
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jin-Young Lee
- Center for Health Promotion, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Sung Mok Kim
- Department of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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27
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. How to approach the great mimic? Improving techniques for the diagnosis of myocarditis. Expert Rev Cardiovasc Ther 2015; 14:105-15. [PMID: 26559548 DOI: 10.1586/14779072.2016.1110486] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Myocarditis is characterized by inflammation of the myocardium, assessed by histological, immunological and immunohistochemical criteria, due to exogenous or endogenous causes. Abnormal QRS, increased troponin T and left ventricular regional or global dysfunction may be detected. Strain Doppler echocardiography can detect longitudinal segmental dysfunction of the myocardium, due to edema, which is in agreement with cardiac magnetic resonance imaging. Nuclear imaging shows a good sensitivity, but carries serious limitations. Somatostatin receptor positron emission tomography/computed tomography seems promising. Cardiac magnetic resonance imaging, using T2-weighted, early T1-weighted, delayed enhanced images and recently T2 and T1 mapping, has the best diagnostic capability. Endomyocardial biopsy has further contributed to the etiologic diagnosis of myocarditis. To conclude, cardiac magnetic resonance and endomyocardial biopsy have both significantly increased our diagnostic performance. However, further assessment by multicenter studies is needed to establish a clinically useful algorithm.
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Affiliation(s)
- Sophie Mavrogeni
- a Department of Cardiology , Onassis Cardiac Surgery Center , Athens , Greece
| | | | - Genovefa Kolovou
- a Department of Cardiology , Onassis Cardiac Surgery Center , Athens , Greece
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Toussaint M, Gilles RJ, Azzabou N, Marty B, Vignaud A, Greiser A, Carlier PG. Characterization of Benign Myocarditis Using Quantitative Delayed-Enhancement Imaging Based on Molli T1 Mapping. Medicine (Baltimore) 2015; 94:e1868. [PMID: 26512599 PMCID: PMC4985413 DOI: 10.1097/md.0000000000001868] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Delayed contrast enhancement after injection of a gadolinium-chelate (Gd-chelate) is a reference imaging method to detect myocardial tissue changes. Its localization within the thickness of the myocardial wall allows differentiating various pathological processes such as myocardial infarction (MI), inflammatory myocarditis, and cardiomyopathies. The aim of the study was first to characterize benign myocarditis using quantitative delayed-enhancement imaging and then to investigate whether the measure of the extracellular volume fraction (ECV) can be used to discriminate between MI and myocarditis.In 6 patients with acute benign myocarditis (32.2 ± 13.8 year-old, subepicardial late gadolinium enhancement [LGE]) and 18 patients with MI (52.3 ± 10.9 year-old, subendocardial/transmural LGE), myocardial T1 was determined using the Modified Look-Locker Imaging (MOLLI) sequence at 3 Tesla before and after Gd-chelate injection. T1 values were compared in LGE and normal regions of the myocardium. The myocardial T1 values were normalized to the T1 of blood, and the ECV was calculated from T1 values of myocardium and blood pre- and post-Gd injection.In both myocarditis and MI, the T1 was lower in LGE regions than in normal regions of the left ventricle. T1 of LGE areas was significantly higher in myocarditis than in MI (446.8 ± 45.8 vs 360.5 ± 66.9 ms, P = 0.003) and ECV was lower in myocarditis than in MI (34.5 ± 3.3 vs 53.8 ± 13.0 %, P = 0.004).Both inflammatory process and chronic fibrosis induce LGE (subepicardial in myocarditis and subendocardial in MI). The present study demonstrates that the determination of T1 and ECV is able to differentiate the 2 histological patterns.Further investigation will indicate whether the severity of ECV changes might help refine the predictive risk of LGE in myocarditis.
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Affiliation(s)
- Marcel Toussaint
- From the Hôpital Pitié-Salpêtrière, Institut de Myologie and CEA, NMR Laboratory, Paris (MT, RJG, NA, BM, PGC); Hôpital Sud-Francilien, Corbeil-Essonnes (MT); MIRCen, I2BM, CEA, Paris, France (NA, BM, PGC); CHWAPI, Tournai, Belgium (RJG); Siemens Healthcare, Saint-Denis, France (AV); and Siemens AG Healthcare Sector, Erlangen, Germany (AG)
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Jeong HC, Kim KH, Cho JY, Song JE, Yoon HJ, Seon HJ, Ahn Y, Jeong MH, Cho JG, Park JC. Cardiac involvement of churg-strauss syndrome as a reversible cause of dilated cardiomyopathy. J Cardiovasc Ultrasound 2015; 23:40-3. [PMID: 25883756 PMCID: PMC4398784 DOI: 10.4250/jcu.2015.23.1.40] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/08/2014] [Accepted: 02/27/2015] [Indexed: 11/22/2022] Open
Abstract
A 31-year-old male who had been treated for Churg-Strauss syndrome (CSS) presented with sudden onset of dysarthria. Brain magnetic resonance imaging (MRI) showed acute multifocal bilateral cerebral infarctions suggesting embolic causes. Cardiac MRI showed dilated cardiomyopathy with severe biventricular dysfunction with intracardiac thrombi, and multiple high signal intensity spots in myocardium of the left ventricle with multifocal delayed enhancement suggesting multifocal myocarditis due to small vessel vasculitis associated with CSS. After anticoagulation therapy, treatments for heart failure, and immunosuppressive therapy including parenteral steroids and cyclophosphamide to control CSS, the symptoms and signs of heart failure and cardiac function of the patient were improved. Considering the pathophysiologic mechanism of cardiac involvement in CSS, immunosuppressive therapy to control the disease activity of CSS should be taken into account, besides usual management for heart failure.
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Affiliation(s)
- Hae Chang Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Ji Eun Song
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Yoon
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Seon
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
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A Churg-Strauss syndrome patient with myopericardial involvement. J Cardiol Cases 2014; 11:52-55. [PMID: 30534258 DOI: 10.1016/j.jccase.2014.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/06/2014] [Accepted: 10/10/2014] [Indexed: 01/18/2023] Open
Abstract
Churg-Strauss syndrome is a necrotizing vasculitis of small vessels characterized by upper and lower airway disease followed by peripheral eosinophilia and multiple organ involvement. Herein we present the case of a 45-year-old female patient with Churg-Strauss syndrome and myopericardial disease who improved upon cyclophosphamide treatment. Apart from discussing the characteristics of myopericardial disease in eosinophilic syndromes, we highlight the crucial role of cardiac imaging in the prompt recognition and management of such patients. <Learning objective: Churg-Strauss syndrome is a vasculitic disorder characterized by massive hypereosinophilia and multi-organ disease. Myocardial involvement may manifest as myopericarditis, valvular dysfunction, myocardial infarction, or left ventricular thrombi or alternatively may only cause subclinical changes difficult to diagnose with conventional echocardiography. Cardiac magnetic resonance imaging is the gold-standard for the detection of active inflammation and fibrosis that may characterize myocardial disease. This is of major importance since timely diagnosis may enable the establishment of appropriate treatments and arrhythmia screening.>.
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Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): evolutions in classification, etiopathogenesis, assessment and management. Curr Opin Rheumatol 2014; 26:16-23. [PMID: 24257370 DOI: 10.1097/bor.0000000000000015] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome) is a peculiar hybrid condition of a systemic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and a hypereosinophilic disorder with frequent lung involvement that occurs in people with asthma. This review focuses on areas of evidence or persistent uncertainty in the classification, epidemiology, clinical presentation, diagnosis, prognosis and management of EGPA and attempts to identify clues to the mechanisms in the development or course of the disease. RECENT FINDINGS The 2013 revision of the EGPA definition formally placed the disease in the subset of ANCA-associated vasculitides. Recently published large case series underlined that the presence of ANCAs, found in 30-40% of EGPA, determines distinct but partly overlapping disease expression and the major detrimental effect of heart involvement on survival. There is some evidence that asthma in EGPA resembles a nonallergic eosinophilic asthma phenotype. Encouraging results have been reported for the treatment of EGPA with rituximab or with the eosinophil-targeted antiinterleukin-5 agent mepolizumab. SUMMARY The understanding of EGPA continues to advance, but many gaps in knowledge remain. The nomenclature remains a source of conceptual variance in terms of demonstrated presence or not of vessel inflammation or ANCAs in the diagnosis of EGPA. Distinguishing EGPA from hypereosinophilic syndromes can be problematic, and an understanding of the mechanistic relation between the vasculitis and the eosinophilic proliferation is profoundly lacking. Some evidence suggests distinct disease phenotypes, but this concept has not yet been translated to phenotype-adapted therapy.
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Edema and fibrosis imaging by cardiovascular magnetic resonance: how can the experience of Cardiology be best utilized in rheumatological practice? Semin Arthritis Rheum 2014; 44:76-85. [PMID: 24582213 DOI: 10.1016/j.semarthrit.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/19/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis. METHOD CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies. RESULTS Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs. CONCLUSION The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.
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Schneeweis C, Berger A, Kelle S, Fleck E, Gebker R. Endomyocardial fibrosis in patients with confirmed Churg-Strauss syndrome. Rheumatology (Oxford) 2013; 53:84. [DOI: 10.1093/rheumatology/ket328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Churg–Strauss syndrome presenting with eosinophilic myocarditis: A diagnostic challenge. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2012.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Chin JY, Yi JE, Youn HJ. Churg-Strauss Syndrome Associated with Rapid Deterioration of Left Ventricular Diastolic Dysfunction and Conduction Disturbance. Echocardiography 2013; 30:E269-73. [DOI: 10.1111/echo.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jung Yeon Chin
- Division of Cardiology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul; Republic of Korea
| | - Jeong Eun Yi
- Division of Cardiology; St. Mary's Hospital; The Catholic University of Korea; Seoul; Republic of Korea
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Correia AS, Gonçalves A, Araújo V, Almeida e Silva J, Pereira JM, Rodrigues Pereira P, Pizarro M, Silva JC, Maciel MJ. Churg-Strauss syndrome presenting with eosinophilic myocarditis: a diagnostic challenge. Rev Port Cardiol 2013; 32:707-11. [PMID: 23890465 DOI: 10.1016/j.repc.2012.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/22/2012] [Accepted: 10/12/2012] [Indexed: 10/26/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is an unusual disease that presents as systemic vasculitis and peripheral eosinophilia in patients with an atopic constitution. Cardiac involvement is unusual and often not prominent on initial presentation, but is an important cause of morbidity and mortality in patients with CSS. We report the case of a young woman with severe acute myocarditis. Coronary arteriography demonstrated extensive focal vasculopathy, consistent with coronary vasculitis, and myocardial biopsy showed eosinophilic myocarditis. This presentation led to an initial diagnosis of CSS in this patient and appropriate therapy resulted in a spectacular remission of disease activity.
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Affiliation(s)
- Ana Sofia Correia
- Cardiology Department, Centro Hospitalar de São João, Porto, Portugal.
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Szczeklik W, Jakieła B, Adamek D, Musiał J. Cutting edge issues in the Churg-Strauss syndrome. Clin Rev Allergy Immunol 2013; 44:39-50. [PMID: 21380944 DOI: 10.1007/s12016-011-8266-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Churg-Strauss syndrome (CSS) is a rare systemic small-vessel vasculitis that develops in the background of bronchial asthma, which is characterized by eosinophilia and eosinophilic infiltration of various tissues. It belongs to the group of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides. The triggering factors and pathogenesis of CSS are still unknown. The possible role of eotaxin-3 and CCR4-related chemokines in selective recruitment of eosinophils to the target tissues in CSS has been recently suggested, but the role of eosinophilic inflammation in the development of vasculitic lesions is not completely understood. From the clinical view, two distinct phenotypes of the disease are slowly emerging depending on the ANCA-positivity status. Glucocorticoids are still the mainstay of treatment; however, data are accumulating regarding the beneficial role of novel immunosuppressants and biologic compounds, especially in patients with poorer prognosis.
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Affiliation(s)
- Wojciech Szczeklik
- Department of Medicine, Jagiellonian University Medical College, Skawińska 8, 31 - 066, Kraków, Poland.
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Abstract
The Churg-Strauss syndrome (CSS) is the rarest subtype of the so-called anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) and has the lowest frequency of ANCA-positivity (around 30%). In addition to asthma and blood eosinophilia, CSS is characterized by end-organ damage, which can be caused by either vasculitis and/or tissue infiltration of eosinophilic granulocytes. The CSS shares many etiological and clinical features of other hypereosinophilic syndromes. Recently, a distinct genetic background could be demonstrated for both the ANCA-positive and ANCA-negative subtypes of CSS as compared to the other two forms of AAV. Among other cytokines, interleukin-5 (IL-5) could be identified as a key mediator of eosinophilia. Therefore, recent clinical trials in CSS aimed to target IL-5. Outside of clinical trials, treatment of CSS is adapted to disease stage and activity, as recommended for other types of AAV.
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Affiliation(s)
- F Moosig
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt GmbH, Universitätsklinikum Schleswig Holstein, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland.
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The impact of current health-related quality of life on future health outlook in patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Clin Rheumatol 2013; 32:779-85. [PMID: 23329351 PMCID: PMC3682098 DOI: 10.1007/s10067-013-2169-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/17/2012] [Accepted: 01/03/2013] [Indexed: 12/03/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, autoimmune small and medium vessel vasculitis. EGPA is accompanied by asthma and involves mainly the blood vessels of the lungs, gastrointestinal system, and peripheral nerves; however, the skin, kidneys, and heart may be also affected. To investigate if patients with EGPA experience reduced health-related quality of life (HRQOL), and the effect of this parameter on their own perception of future health outlook. Twenty-six EGPA patients are in disease remission and completed a custom-designed questionnaire and the Medical Outcomes Study Short Form 36 (SF-36). Using the RAND method, eight HRQOL dimensions were calculated: general health, physical functioning, emotional role limitations, physical role limitations, social functioning, mental health, bodily pain, and vitality. Using norm-based scores, the HRQOL of patients was compared with that of the general population. EGPA patients had decreased HRQOL across all eight dimensions of the SF-36. Patients with higher mental component score felt more positive about their future health, while patients with low physical component score were likely not to feel negatively about their future health. Also, 36 % of older patients (>50 years) had a positive outlook compared to 47 % of younger patients (<50 years) and patients with a longer disease course were much less likely to have a positive outlook (30 % positive) than those with a shorter course (50 % positive). Although not statistically significant, these correlations warrant further investigation with a larger patient population. Despite being in disease remission, EGPA patients had decreased quality of life, which in turn influenced their perception of their future health outlook.
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Bhatti S, Al-Khalidi H, Hor K, Hakeem A, Taylor M, Quyyumi AA, Oshinski J, Pecora AL, Kereiakes D, Chung E, Pedrizzetti G, Miszalski-Jamka T, Mazur W. Assessment of Myocardial Contractile Function Using Global and Segmental Circumferential Strain following Intracoronary Stem Cell Infusion after Myocardial Infarction: MRI Feature Tracking Feasibility Study. ISRN RADIOLOGY 2013; 2013:371028. [PMID: 24959555 PMCID: PMC4045523 DOI: 10.5402/2013/371028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 09/03/2012] [Indexed: 11/23/2022]
Abstract
Background. Magnetic resonance imaging (MRI) strain analysis is a sensitive method to assess myocardial function. Our objective was to define the feasibility of MRI circumferential strain (εcc) analysis in assessing subtle changes in myocardial function following stem cell therapy. Methods and Results. Patients in the Amorcyte Phase I trial were randomly assigned to treatment with either autologous bone-marrow-derived stem cells infused into the infarct-related artery 5 to 11 days following primary PCI or control. MRI studies were obtained at baseline, 3, and 6 months. εcc was measured in the short axis views at the base, mid and apical slices of the left ventricle (LV) for each patient (13 treatments and 10 controls). Mid-anterior LV εcc improved between baseline −18.5 ± 8.6 and 3 months −22.6 ± 7.0, P = 0.03. There were no significant changes in εcc at 3 months and 6 months compared to baseline for other segments. There was excellent intraobserver and interobserver agreement for basal and mid circumferential strain. Conclusion. MRI segmental strain analysis is feasible in assessment of regional myocardial function following cell therapy with excellent intra- and inter-observer variability's. Using this method, a modest interval change in segmental εcc was detected in treatment group.
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Affiliation(s)
- Sabha Bhatti
- University of Cincinnati Hospital, Cincinnati, OH, USA
| | | | - Kan Hor
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Abdul Hakeem
- University of Cincinnati Hospital, Cincinnati, OH, USA
| | - Michael Taylor
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - Dean Kereiakes
- The Christ Hospital Heart and Vascular Center, Suite 138, 2123 Auburn Avenue, Cincinnati, OH 45219, USA
| | - Eugene Chung
- The Christ Hospital Heart and Vascular Center, Suite 138, 2123 Auburn Avenue, Cincinnati, OH 45219, USA
| | | | | | - Wojciech Mazur
- The Christ Hospital Heart and Vascular Center, Suite 138, 2123 Auburn Avenue, Cincinnati, OH 45219, USA
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Standard and feature tracking magnetic resonance evidence of myocardial involvement in Churg-Strauss syndrome and granulomatosis with polyangiitis (Wegener's) in patients with normal electrocardiograms and transthoracic echocardiography. Int J Cardiovasc Imaging 2012; 29:843-53. [PMID: 23212274 PMCID: PMC3644401 DOI: 10.1007/s10554-012-0158-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 11/14/2012] [Indexed: 01/08/2023]
Abstract
The aim of the study was to evaluate the presence and spectrum of cardiac abnormalities identified by cardiac magnetic resonance (CMR) in subjects in clinical remission of Churg-Strauss syndrome (CSS) and granulomatosis with polyangiitis (Wegener's) (WG) with normal ECG and transthoracic echocardiography (TTE). Eleven (7 females, 4 males, mean age 42.4 ± 9.6 years) CSS and 10 (4 females, 6 males, mean age 45.3 ± 10.9 years) WG patients in clinical remission with normal ECG and TTE underwent CMR. Segmental peak-systolic myocardial strain (εps) was measured using feature tracking cine-sequence based technique. Left ventricular (LV) ejection fraction, end-diastolic volume and myocardial mass indexes were 66.2 ± 5.8 %, 66.1 ± 6.6 ml/m(2), and 61.0 ± 8.9 g/m(2), respectively. No patient showed regional wall motion abnormalities and signs of myocarditis. Nine CSS and 8 WG patients demonstrated decreased segmental longitudinal, circumferential or radial εps and myocardial late gadolinium enhancement (LGE) (6 subendocardial, 10 midwall, 8 subepicardial) areas. In CSS and WG subjects with LVLGE lesions the mean LVLGE extent was 2.0 ± 1.6 % and 2.3 ± 1.5 % (p = 0.65), respectively. Segmental εps was decreased longitudinally (-11.8 ± 5.6 %) for subendocardial LGE, radially (13.7 ± 8.7 %) for subepicardial LGE, and circumferentially (-16.6 ± 4.2 %), longitudinally (-13.2 ± 5.5 %) and radially (18.8 ± 8.1 %) for midwall LGE, if compared to longitudinal (-22.7 ± 5.1 %), circumferential (-23.6 ± 5.6 %) and radial (34.2 ± 15.7 %) εps in controls (11 females, 10 males, mean age 43.9 ± 10.5 years) (all p < 0.01). Despite clinical remission, normal ECG and TTE, most CSS and WG patients demonstrate decreased segmental εps and non-ischemic LGE lesions without signs of myocarditis.
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Multimodality imaging and the emerging role of cardiac magnetic resonance in autoimmune myocarditis. Autoimmun Rev 2012; 12:305-12. [DOI: 10.1016/j.autrev.2012.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 05/16/2012] [Indexed: 02/05/2023]
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Raman SV, Aneja A, Jarjour WN. CMR in inflammatory vasculitis. J Cardiovasc Magn Reson 2012; 14:82. [PMID: 23199343 PMCID: PMC3533951 DOI: 10.1186/1532-429x-14-82] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 11/16/2012] [Indexed: 12/18/2022] Open
Abstract
Vasculitis, the inflammation of blood vessels, can produce devastating complications such as blindness, renal failure, aortic rupture and heart failure through a variety of end-organ effects. Noninvasive imaging with cardiovascular magnetic resonance (CMR) has contributed to improved and earlier diagnosis. CMR may also be used in serial evaluation of such patients as a marker of treatment response and as an indicator of subsequent complications. Unique strengths of CMR favoring its use in such conditions are its abilities to noninvasively visualize both lumen and vessel wall with high resolution. This case-based review focuses on the large- and medium-vessel vasculitides where MR angiography has the greatest utility. Because of increasing recognition of cardiac involvement in small-vessel vasculitides, this review also presents evidence supporting greater consideration of CMR to detect and quantify myocardial microvascular disease. CMR's complementary role amidst traditional clinical, serological and other diagnostic techniques in personalized care for patients with vasculitis is emphasized. Specifically, the CMR laboratory can address questions related to extent and severity of vascular involvement. As ongoing basic and translational studies better elucidate poorly-defined underlying molecular mechanisms, this review concludes with a discussion of potential directions for the development of more targeted imaging approaches.
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Affiliation(s)
- Subha V Raman
- The Ohio State University, 473 W. 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Ashish Aneja
- Division of Cardiovascular Medicine, The Ohio State University, 473 W. 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Wael N Jarjour
- Division of Rheumatology, The Ohio State University, 480 Medical Center Drive, S2056 DMRC, Columbus, Oh, 43210, USA
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Effect of delayed diagnosis on disease course and management of Churg–Strauss syndrome: a retrospective study. Clin Rheumatol 2012. [DOI: 10.1007/s10067-012-2127-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Owlia MB, Mostafavi Pour Manshadi SMY, Naderi N. Cardiac manifestations of rheumatological conditions: a narrative review. ISRN RHEUMATOLOGY 2012; 2012:463620. [PMID: 23119182 PMCID: PMC3483730 DOI: 10.5402/2012/463620] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/21/2012] [Indexed: 01/08/2023]
Abstract
Cardiovascular diseases are common in systemic rheumatologic diseases. They can be presented at the time of diagnosis or after diagnosis. The cardiac involvements can be the first presentation of rheumatologic conditions. It means that a patient with rheumatologic disease may go to a cardiologist when attacked by this disease at first. These manifestations are very different and involve different structures of the heart, and they can cause mortality and morbidity of patients with rheumatologic diseases. Cardiac involvements in these patients vary from subclinical to severe manifestations. They may need aggressive immunosuppressive therapy. The diagnosis of these conditions is very important for choosing the best treatment. Premature atherosclerosis and ischemic heart disease are increased in rheumatoid arthritis and systemic lupus erythematosus, and may be causes of mortality among them. The aggressive control of systemic inflammation in these diseases can reduce the risk of cardiovascular disease especially ischemic heart disease. Although aggressive treatment of primary rheumatologic diseases can decrease mortality rate and improve them, at this time, there are no specific guidelines and recommendations, to include aggressive control and prevention of traditional risk factors, for them.
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Affiliation(s)
- Mohammad Bagher Owlia
- Department of Medicine, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Miszalski-Jamka T, Szczeklik W, Nycz K, Sokołowska B, Bury K, Zawadowski G, Noelting J, Mazur W, Musiał J. The Mechanics of Left Ventricular Dysfunction in Patients with Churg-Strauss Syndrome. Echocardiography 2012; 29:568-78. [DOI: 10.1111/j.1540-8175.2011.01654.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Current World Literature. Curr Opin Rheumatol 2012; 24:119-22. [DOI: 10.1097/bor.0b013e32834f0d5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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