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Kesarwani V, Phachu D, Trivedi R. Hypocomplementemic Urticarial Vasculitis Syndrome or Systemic Lupus Erythematosus in Evolution? Cureus 2022; 14:e23429. [PMID: 35481300 PMCID: PMC9033644 DOI: 10.7759/cureus.23429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/05/2022] Open
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Berry EC, Wells J, Morey A, Anantharajah A. Hypocomplementemic urticarial vasculitis syndrome presenting with bilateral scleritis. BMJ Case Rep 2021; 14:14/5/e240041. [PMID: 33972296 PMCID: PMC8112411 DOI: 10.1136/bcr-2020-240041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare autoimmune disorder characterised by recurrent urticarial lesions and acquired hypocomplementemia with systemic manifestations. The authors present the case of a 70-year-old man who presented to the ophthalmology clinic with bilateral scleritis and ocular hypertension. He was diagnosed with HUVS after a 6-month period of bilateral scleritis, vestibulitis, significant weight loss, mononeuritis multiplex and recurrent urticarial vasculitis with pronounced persistent hypocomplementemia and the presence of anti-C1q antibodies. Disease control was eventually obtained with mycophenolate and prednisolone.
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Affiliation(s)
- Ella Claire Berry
- Canberra Health Services Library, ACT Government, Garren, Australian Capital Territory, Australia .,Ophthalmology Unit, Canberra Health Services, Garran, Australian Capital Territory, Australia
| | - Jane Wells
- Ophthalmology Unit, Canberra Health Services, Garran, Australian Capital Territory, Australia.,Department of Ophthalmology, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Adrienne Morey
- ACT Pathology, Canberra Health Services, Garran, Australian Capital Territory, Australia.,Australian National University Medical School, Garran, Australian Capital Territory, Australia
| | - Anthea Anantharajah
- Department of Immunology, Canberra Health Services, Garran, Australian Capital Territory, Australia.,John Curtin School of Medical Research, Canberra, Australian Capital Territory, Australia
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Stainer A, Rice A, Devaraj A, Barnett JL, Donovan J, Kokosi M, Nicholson AG, Cairns T, Wells AU, Renzoni EA. Diffuse alveolar haemorrhage associated with subsequent development of ANCA positivity and emphysema in three young adults. BMC Pulm Med 2019; 19:185. [PMID: 31651292 PMCID: PMC6813980 DOI: 10.1186/s12890-019-0947-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diffuse alveolar haemorrhage (DAH) is characterized by the diffuse accumulation of red blood cells within the alveoli, presence of ground glass opacities and/or consolidation on computed tomography (CT). Aside from identifiable non-immune causes, DAH is classically subdivided into idiopathic (idiopathic pulmonary haemosiderosis, IPH) and autoimmune DAH. Here we describe three cases presenting with recurrent pulmonary haemorrhage, initially classified as IPH, who, several years after first presentation, develop anti myeloperoxidase antibodies (MPO) positivity, emphysema on CT and, in one case, renal involvement. CASE PRESENTATION Patient 1 was diagnosed with IPH aged 14. Her disease remained poorly controlled despite immunosuppression, although ANCA remained negative over the years. Nineteen years from initial presentation, she developed MPO-ANCA positive antibodies and mild renal impairment. She was treated with Rituximab with good response. From first presentation, the chest CT was consistently characterized by diffuse ground-glass opacities and interlobular septal thickening. Ten years later, cystic opacities consistent with emphysema, with a striking peribronchovascular distribution, developed. Patient 2 was diagnosed with IPH aged 32. He was treated with corticosteroids and methotrexate, with fluctuating response. At 11 years from initial presentation, MPO-ANCA positivity was identified, and emphysema with a peribronchovascular distribution was observed on CT, with subsequent significant increase in extent. Patient 3 was diagnosed with IPH at the age of seven, and had recurrent episodes of haemoptysis of varying degree of severity, treated with intermittent courses of corticosteroids until age 11, when he was intubated due to severe DAH. Eight years after the diagnosis emphysematous changes were noted on CT and MPO-ANCA positivity developed for the first time 11 years after initial diagnosis. CONCLUSIONS We believe these three cases highlight: 1) the possibility of development of ANCA positivity several years down the line from first DAH presentation 2) the possibility that DAH may lead to cystic/emphysematous changes with peribronchovascular distribution on CT. Moreover, the need for ongoing immunosuppressive treatment and the development of emphysema, emphasize a possible role played by autoimmune phenomena, even when DAH is initially diagnosed as "idiopathic". Further studies are required to better understand the relationship between DAH, ANCA positivity and development of emphysema.
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Affiliation(s)
- Anna Stainer
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Alex Rice
- Department of Histopathology, Royal Brompton Hospital, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton Hospital, London, UK
| | | | - Jacqueline Donovan
- Department of Clinical Biochemistry, Royal Brompton Hospital, London, UK
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Andrew Gordon Nicholson
- Department of Histopathology, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Tom Cairns
- Imperial College Healthcare NHS Trust, London, UK
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Alomari M, Al Momani L, Khazaaleh S, Almomani S, Yaseen K, Alhaddad B. Exceptional association of hypocomplementemic urticarial vasculitis syndrome (HUVS) and symptomatic pulmonary histoplasmosis: a case-based literature review. Clin Rheumatol 2019; 38:1691-1697. [PMID: 30980192 DOI: 10.1007/s10067-019-04548-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 12/01/2022]
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare type III hypersensitivity disorder characterized by urticarial vasculitis and prolonged hypocomplementemia. Individuals with HUVS may also have joint involvement, pulmonary manifestations, ocular disease, kidney inflammation, or any other form of organ involvement. Hypocomplementemia, the presence of C1q antibody in the serum, and urticarial vasculitis are the keys to the diagnosis of HUVS. It has been reported to accompany certain infections such as hepatitis B, hepatitis C, infectious mononucleosis, and coxsackie group A. However, it has never been reported to be linked to histoplasmosis in the literature. To the best of our knowledge, we report the first case of HUVS presenting concurrently with pulmonary histoplasmosis.
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Affiliation(s)
- Mohammad Alomari
- Department of Internal Medicine, Cleveland Clinic Foundation, 18101 Lorain Ave, Cleveland, OH, 44111, USA.
| | - Laith Al Momani
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Shrouq Khazaaleh
- Department of Internal Medicine, Cleveland Clinic Foundation, 18101 Lorain Ave, Cleveland, OH, 44111, USA
| | - Shaden Almomani
- Department of Internal Medicine, Jordanian Royal Medical Services, Irbid, Jordan
| | - Kinanah Yaseen
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bassam Alhaddad
- Departments of Medicine and Rheumatology, MetroHealth Medical Center, Cleveland, OH, USA
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Jachiet M, Flageul B, Bouaziz JD, Bagot M, Terrier B. Les vascularites urticariennes hypocomplémentémiques. Rev Med Interne 2018; 39:90-98. [DOI: 10.1016/j.revmed.2017.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/29/2017] [Accepted: 03/04/2017] [Indexed: 01/21/2023]
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Sjöwall C, Hallbeck M, Sandström P. Clinically suspected recurrence of gastric carcinoid proved to be hypocomplementaemic urticarial vasculitis syndrome with pulmonary involvement. Scand J Rheumatol 2015; 44:337-9. [DOI: 10.3109/03009742.2015.1020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Jachiet M, Flageul B, Deroux A, Le Quellec A, Maurier F, Cordoliani F, Godmer P, Abasq C, Astudillo L, Belenotti P, Bessis D, Bigot A, Doutre MS, Ebbo M, Guichard I, Hachulla E, Héron E, Jeudy G, Jourde-Chiche N, Jullien D, Lavigne C, Machet L, Macher MA, Martel C, Melboucy-Belkhir S, Morice C, Petit A, Simorre B, Zenone T, Bouillet L, Bagot M, Frémeaux-Bacchi V, Guillevin L, Mouthon L, Dupin N, Aractingi S, Terrier B. The clinical spectrum and therapeutic management of hypocomplementemic urticarial vasculitis: data from a French nationwide study of fifty-seven patients. Arthritis Rheumatol 2015; 67:527-34. [PMID: 25385679 DOI: 10.1002/art.38956] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 11/06/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Hypocomplementemic urticarial vasculitis (HUV) is an uncommon vasculitis of unknown etiology that is rarely described in the literature. We undertook this study to analyze the clinical spectrum and the therapeutic management of patients with HUV. METHODS We conducted a French nationwide retrospective study that included 57 patients with chronic urticaria, histologic leukocytoclastic vasculitis, and hypocomplementemia. We assessed clinical and laboratory data and evaluated the patients' cutaneous and immunologic responses to therapy. We evaluated treatment efficacy by measuring the time to treatment failure. RESULTS Urticarial lesions were typically more pruritic than painful and were associated with angioedema in 51% of patients, purpura in 35%, and livedo reticularis in 14%. Extracutaneous manifestations included constitutional symptoms (in 56% of patients) as well as musculoskeletal involvement (in 82%), ocular involvement (in 56%), pulmonary involvement (in 19%), gastrointestinal involvement (in 18%), and kidney involvement (in 14%). Patients with HUV typically presented with low C1q levels and normal C1 inhibitor levels, in association with anti-C1q antibodies in 55% of patients. Hydroxychloroquine or colchicine seemed to be as effective as corticosteroids as first-line therapy. In patients with relapsing and/or refractory disease, rates of cutaneous and immunologic response to therapy seemed to be higher with conventional immunosuppressive agents, in particular, azathioprine, mycophenolate mofetil, or cyclophosphamide, while a rituximab-based regimen tended to have higher efficacy. Finally, a cutaneous response to therapy was strongly associated with an immunologic response to therapy. CONCLUSION HUV represents an uncommon systemic and relapsing vasculitis with various manifestations, mainly, musculoskeletal and ocular involvement associated with anti-C1q antibodies, which were found in approximately half of the patients. The best strategy for treating HUV has yet to be defined.
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Affiliation(s)
- Marie Jachiet
- Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris 5, Paris, France
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Hypocomplementemic urticarial vasculitis (HUVS) with precocious emphysema responsive to azathioprine. J Clin Immunol 2013; 33:891-5. [PMID: 23615811 DOI: 10.1007/s10875-013-9886-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 03/18/2013] [Indexed: 10/26/2022]
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Abstract
Chronic obstructive pulmonary disease (COPD) has traditionally been considered a disease of the lungs secondary to cigarette smoking and characterized by airflow obstruction due to abnormalities of both airway (bronchitis) and lung parenchyma (emphysema). It is now well known that COPD is associated with significant systemic abnormalities, such as renal and hormonal abnormalities, malnutrition, muscle wasting, osteoporosis, and anemia. However, it is still unclear whether they represent consequences of the pulmonary disorder, or whether COPD should be considered as a systemic disease. These systemic abnormalities have been attributed to an increased level of systemic inflammation. Chronic inflammation, however, may not be the only cause of the systemic effects of COPD. Recent data from humans and animal models support the view that emphysema may be a vascular disease. Other studies have highlighted the role of repair failure, bone marrow abnormality, genetic and epigenetic factors, immunological disorders and infections as potential causes of COPD systemic manifestations. Based on this new evidence, it is reasonable to consider COPD, and emphysema in particular, as 'a disease with a significant systemic component' if not a 'systemic disease' per se. The aim of this review is to give an overview of the most relevant and innovative hypothesis about the extrapulmonary manifestations of COPD.
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Affiliation(s)
- Alice Huertas
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Peroni A, Colato C, Zanoni G, Girolomoni G. Urticarial lesions: if not urticaria, what else? The differential diagnosis of urticaria: part II. Systemic diseases. J Am Acad Dermatol 2010; 62:557-70; quiz 571-2. [PMID: 20227577 DOI: 10.1016/j.jaad.2009.11.687] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 11/02/2009] [Accepted: 11/10/2009] [Indexed: 12/15/2022]
Abstract
UNLABELLED There are a number of systemic disorders that can manifest with urticarial skin lesions, including urticarial vasculitis, connective tissue diseases, hematologic diseases, and autoinflammatory syndromes. All of these conditions may enter into the differential diagnosis of ordinary urticaria. In contrast to urticaria, urticarial syndromes may manifest with skin lesions other than wheals, such as papules, necrosis, vesicles, and hemorrhages. Lesions may have a bilateral and symmetrical distribution; individual lesions have a long duration, and their resolution frequently leaves marks, such as hyperpigmentation or bruising. Moreover, systemic symptoms, such as fever, asthenia, and arthralgia, may be present. The most important differential diagnosis in this group is urticarial vasculitis, which is a small-vessel vasculitis with predominant cutaneous involvement. Systemic involvement in urticarial vasculitis affects multiple organs (mainly joints, the lungs, and the kidneys) and is more frequent and more severe in patients with hypocomplementemia. Clinicopathologic correlation is essential to establishing a correct diagnosis. LEARNING OBJECTIVES After completing the learning activity, participants should be able to distinguish urticarial lesions suggesting diagnoses other than common urticaria; assess patients with urticarial lesions, and suspect systemic diseases presenting with urticarial skin lesions.
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Affiliation(s)
- Anna Peroni
- Department of Biomedical and Surgical Sciences, Section of Dermatology and Venereology, University of Verona, Verona, Italy
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Jara LJ, Navarro C, Medina G, Vera-Lastra O, Saavedra MA. Hypocomplementemic urticarial vasculitis syndrome. Curr Rheumatol Rep 2010; 11:410-5. [PMID: 19922730 DOI: 10.1007/s11926-009-0060-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hypocomplementemic urticarial vasculitis syndrome (HUVS) is an uncommon immune complex-mediated entity characterized by urticaria with persistent acquired hypocomplementemia. First described in 1973, HUVS is associated with several systemic findings including leukocytoclastic vasculitis, severe angioedema, laryngeal edema, pulmonary involvement, arthritis, arthralgia, glomerulonephritis, and uveitis. These manifestations should be present for at least 6 months. Laboratory findings include low complement levels of classical pathway, namely C1q, C2, C3, and C4. The disease marker is the serum presence of anti-C1q antibodies. Treatment, based on disease severity, involves corticosteroids and other immunosuppressive agents that have demonstrated some success. Patients may have significant morbidity and mortality, most commonly caused by chronic obstructive pulmonary disease and acute laryngeal edema.
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Affiliation(s)
- Luis J Jara
- Director of Education and Research, Hospital de Especialidades Centro Medico La Raza, Seris/Zaachila S/N Colonia La Raza, ZP 02990, Mexico City, Mexico.
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