Treatment strategies for ANCA-associated vasculitides: from standard protocols to future horizons

INTRODUCTION

ANCA-associated vasculitides (AAV), classified into granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis represent a group of disorders characterized by necrotizing vasculitis of small vessels, endothelial injury and tissue damage. The outcomes and prognosis of AAV have undergone significant changes with the introduction of glucocorticoids (GCs) and other immunosuppressants (cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil). The enhanced understanding of pathogenesis has subsequently led to the incorporation into clinical practice of drugs targeting specific therapeutic targets.

AREAS COVERED

After an extensive literature search of Pubmed, Medline, Embase of the most recent evidence, we provide an overview of available treatments, highlighting how newer drugs have integrated into standard protocols. Our review also explores potential new therapeutic targets, including B cell depletion and inhibition, T cell inhibition, complement inhibition, and IL-5 and IgE inhibition.

EXPERT OPINION

There is hope that the new treatment targets currently under study in AAV may enable a faster and more lasting clinical response, ensuring the reduction of possible side effects from therapies. Moreover, numerous aspects necessitate further exploration in the future, such as tailoring of GCs, integration of GCs-sparing agents, efficacy of combination therapy, optimal maintenance therapy, to reduce organ-damage and improve quality of life.

A Case of Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis Presenting With Diffuse Alveolar Hemorrhage and Renal Sparing

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis disease that traditionally includes three variants classified based on their clinical and pathological appearance: microscopic polyangiitis (MPA), granulomatosis with polyangiitis, and eosinophilic granulomatosis with polyangiitis (alternatively, Churg-Strauss syndrome). The mainstay of AAV treatment is immunosuppressive treatments, which improve survival and lower rates of end-stage kidney disease. Here we describe a patient with MPA ANCA who presented with diffuse alveolar hemorrhage and, six months later, recurrent pulmonary hemorrhage with renal sparing while off therapy.

Vasculitis and Kidney Disease

Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.

Granulomatosis with polyangiitis in a patient with polydipsia, facial nerve paralysis, and severe otologic complaints: a case report and review of the literature

BACKGROUND

Granulomatosis with polyangiitis, formerly known as Wegener granulomatosis, is a necrotizing vasculitis with granulomatous inflammation that belongs to the class of antineutrophil cytoplasmic antibodies-positive diseases. It occurs in a localized and a systemic form and may present with a variety of symptoms. Involvement of the upper respiratory tract is very common, while neurologic, endocrinological, and nephrological dysfunction may occur.

CASE PRESENTATION

We describe the case of a 29-year-old Central European male patient presenting with severe bilateral sensorineural hearing loss, otorrhea, and one-sided facial nerve paralysis. The patient was unsuccessfully treated with i.v. antibiotics at another hospital in Berlin, and tympanic tubes were inserted. After presentation to our emergency room, he was hospitalized and further diagnostics started. Increased fluid intake and 12 kg weight gain over the last months were reported. The patient was diagnosed with granulomatosis with polyangiitis and diabetes insipidus. The patient's condition improved after treatment with rituximab.

DISCUSSION

A comprehensive PubMed search of all articles with granulomatosis with polyangiitis and diabetes insipidus was conducted to assess which combination of symptoms occurs simultaneously and whether other parts of the pituitary are commonly involved. The 39 selected articles, describing 61 patients, showed that ear-nose-throat involvement occurred most commonly, in 71% of cases. Of patients, 59% had involvement of the anterior pituitary gland, while true panhypopituitarism occurred in 13% of cases. Only one case report featured the same set of symptoms as described herein.

CONCLUSION

Granulomatosis with polyangiitis is a highly variable disease, commonly involving the upper airways, but that may present with symptoms solely related to the pituitary gland. Clinicians should have a low threshold to investigate for granulomatosis with polyangiitis in patients with therapy-resistant otorrhea. Patients may present with a complex set of symptoms, and integrating different specialists when additional symptoms occur may lead to faster diagnosis.

ANCA Associated Vasculitis (AAV): A Review for Internists

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) compromise a rare group of necrotizing small to medium vessel vasculitides that constitute three distinct disorders: granulomatosis with polyangiitis (GPA) (formerly known as Wegener's granulomatosis), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) (formerly known as Churg-Strauss syndrome).AAV is characterized by the usual presence of circulating autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). These antibodies can activate neutrophils and the complement system resulting in vessel wall inflammation and damage.The clinical presentation of AAV varies from non-severe (non-life threatening) to severe often with potentially life-threatening multi-organ involvement. Early recognition and diagnosis are crucial. In the past two decades, advances in understanding the pathophysiology of AAV have led to development of new treatments and resulted in significant improvement in general outcomes and survival rates.This narrative review will focus on GPA and MPA. We will highlight clinical manifestations, diagnosis, disease monitoring, and treatment strategies in patients with AAV.

A Rare Case of Nephrotic-Range Proteinuria in Antineutrophil Cytoplasmic Antibodies (ANCA)-Associated Vasculitis

Granulomatosis with polyangiitis (GPA), or Wegener’s granulomatosis as it was formerly referred to, is an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). GPA is characterized as a necrotizing vasculitis with few or no immune deposits termed pauci-immune deposits, predominantly affecting small and medium arterial vessels, involving the upper and lower respiratory tract as well as glomeruli. Renal manifestations are of critical importance because of the progression that may ensue following onset. Glomerulonephritis (primarily rapidly progressive crescentic glomerulonephritis) is quite common, which eventually leads to chronic kidney disease or end-stage renal disease. Usually, patients with GPA and rapidly progressive glomerulonephritis have an elevated plasma creatinine level and urinalysis revealing dysmorphic hematuria, red cell casts, and sub-nephrotic levels of proteinuria. We present a case of a 44-year-old male whose biopsy demonstrated crescentic glomerulonephritis, pauci-immune type proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) consistent with GPA, as well as profound proteinuria, an atypical manifestation.

Reasons for hospitalization and in-hospital mortality for anti-neutrophil cytoplasmic antibody vasculitides: analysis of the National Inpatient Sample

OBJECTIVE

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a heterogeneous group of conditions resulting in frequent hospitalizations and high in-hospital mortality (IHM). Our study aimed to use the National Inpatient Sample (NIS) to determine and categorize the main reasons for hospital admission and IHM in patients with AAV.

METHODS

We performed a retrospective study of adult AAV hospitalizations in 2016, 2017, and 2018 in acute care hospitals across the USA conducted using the NIS database. We classified the main reasons for hospital admission and IHM into 19 different categories using the principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis.

RESULTS

A total of 41,155 hospitalizations had either a principal or secondary ICD-10 code for AAV (GPA or MPA). Rheumatologic and respiratory diagnoses were the most common reasons for hospitalization, while infectious and respiratory diagnoses were the most common reasons for IHM. Sepsis, unspecified organism A41.9, was the most common specific principal diagnosis for hospitalized and deceased AAV patients.

CONCLUSIONS

Our results show that the leading reasons for hospitalization and mortality for AAV patients were rheumatologic, respiratory, and infectious diagnoses. This data suggests that careful monitoring and management of infectious and pulmonary complications in AAV may improve hospital outcomes. Key points • AAV is a heterogeneous group of conditions resulting in frequent hospitalizations and high IHM. In our study, AAV hospitalizations ended in IHM 4.5% of the time, substantially greater than non-ANCA patients. • The leading reasons for hospital admission for AAV patients were rheumatologic and respiratory diagnoses, but the main reason for IHM were infectious and respiratory diagnoses. • Sepsis was the most common principal diagnosis for hospitalized and deceased AAV patients. • Our results highlight the importance of close monitoring and timely management of infectious and respiratory complications to improve hospitalization outcomes.

Pulmonary Manifestations of Systemic Vasculitis in Children

Vasculitides are defined according to the vessel size involved, and they tend to affect certain organ systems. Pulmonary involvement is rare in the common childhood vasculitides, such as Kawasaki disease, IgA vasculitis (Henoch Schonlein purpura). On the other hand, lung involvement is common in a rare pediatric vasculitis, granulomatosis with polyangiitis (GPA) (Wegener granulomatosis), where respiratory system findings are common. A criterion in the Ankara 2008 classification criteria for GPA is the presence of nodules, cavities, or fixed infiltrates. The adult data suggest that rituximab may be an alternative to cyclophosphamide in induction treatment.

Granulomatosis with polyangiitis presenting with unilateral facial nerve palsy and nasal septum perforation

Granulomatosis with polyangiitis (GPA) is a necrotising vasculitis of unknown cause that has several systemic manifestations. The disease is characterised by the classical triad involving acute inflammation of the upper and lower respiratory tracts with renal involvement. However, the disease pathology can involve the central nervous system. This case report presents a case of GPA with facial nerve palsy as the first manifestation of the disease, which has been rarely reported in the medical literature.

Should nasal biopsy inevitably be performed for classifying granulomatosis with polyangiitis in patients with rhinosinusitis? A retrospective chart review study

Nasal biopsy is the essential method for differentiating and diagnosing granulomatosis with polyangiitis (GPA) in patients with chronic rhinosinusitis. Nevertheless, in the real clinical settings, there are several cases unable for nasal biopsy. Hence, in this study, we investigated initial clinical manifestations and laboratory factors which could be helpful for diagnosing GPA in cases unable for nasal biopsy performance. We retrospectively reviewed the medical records of 45 patients with GPA. Twenty-five patients exhibited chronic rhinosinusitis, among which 16 patients underwent nasal biopsy. We applied the 2007 European Medicines Agency algorithm for the classification of GPA, the 2012 Chapel Hill Consensus Conferences Nomenclature of Vasculitis and the 2017 American College of Rheumatology/European League Against Rheumatism provisional classification criteria for GPA to them for reclassifying GPA. Among six patients without granuloma on nasal biopsy, three patients with only antineutrophil cytoplasmic antibody (ANCA) and chronic rhinosinusitis could be classified as GPA due to proteinase 3 (PR3)-ANCA (or cytoplasmic (C)-ANCA) positivity. Among nine patients without nasal biopsy, three patients with only chronic rhinosinusitis could be classified as GPA due to GPA-specific lung lesions. When we excluded an item of granuloma in ten GPA patients with granuloma on nasal biopsy, four patients without ANCAs could be classified as GPA due to GPA-specific lung lesions and cartilaginous involvement. In conclusion, PR3-ANCA (or C-ANCA) positivity, GPA-specific lung lesions and cartilaginous involvement could help physicians in charge make a final diagnosis of GPA in cases unable for nasal biopsy.

Serum hepcidin is increased in ANCA-associated vasculitis and correlates with activity markers

Hepcidin is a key regulator of iron metabolism and plays an important role in many pathologies. It is increased by iron administration and by inflammation, while erythropoiesis downregulates its expression. It decreases iron availability and thus contributes to anemia of chronic diseases. The aim of the study was to measure hepcidin as a marker and pathogenetic factor in ANCA-associated vasculitis (AAV). Hepcidin plasma concentration was measured by the immunological method in 59 patients with AAV and compared to patients with non-vasculitic etiology of chronic kidney disease, patients on hemodialysis (HD), with systemic lupus erythematodes (SLE) and to healthy controls and blood donors, and was correlated with the parameters of iron metabolism, inflammation, activity of the process and kidney function. Hepcidin concentration was increased in patients with AAV, SLE and HD and correlated positively with C-reactive protein, serum ferritin and creatinine, and negatively with hemoglobin and serum transferrin. In active form of AAV it correlated with the clinical scoring system (BVAS). Hepcidin can thus be considered as a pathogenetic factor of anemia in AAV and can be used for evaluation of inflammation in AAV and as an additional marker in active forms of the disease.

Nasoseptal Perforation: from Etiology to Treatment

PURPOSE OF REVIEW

Nasal septum perforation (NSP) is a communication between the two nasal cavities. This review contributes to the better knowledge of NSP causes, diagnosis, and treatment.

RECENT FINDINGS

NSP prevalence is about 1%. Clinical presentation may range from absence of symptoms to the presence of bothersome sinonasal symptoms. NSP is more frequently caused by trauma or post-surgery, inflammatory diseases, and abuse substances. Conservative management (nasal irrigation, topical use of antibiotic or lubricant ointments, or placement of prosthesis) is considered the first-line treatment. Symptomatic NSP not improving with local therapies usually requires surgical approach. Selection of the technique for the endoscopic septal repair depends on perforation characteristics and surgeon experience. When NSP is diagnosed, its cause has to be promptly determined. Most of them can be controlled with conservative measures. Surgical/endoscopic approaches are usually needed in refractory cases, and new repair techniques have to be considered.

Characteristics and prognosis of microscopic polyangiitis with bronchiectasis

BACKGROUND

Major pulmonary manifestations associated with microscopic polyangiitis (MPA) include diffuse alveolar hemorrhage (DAH) and interstitial pneumonia (IP).We previously showed bronchiectasis (BE) was one of the pulmonary complications of MPA. However, clinical features of BE patients with MPA are not fully understood. We investigated the characteristics and prognosis of BE patients with MPA.

METHODS

Forty-five MPA patients were retrospectively studied. The patients were divided into two groups: patients with BE and those without BE.

RESULTS

Thirty-one of 45 patients (69%) had pulmonary involvement including IP (23/45, 51%), BE (7/45, 16%), and DAH (5/45, 11%). There were no differences between the patients with BE versus those without with regard to clinical characteristics and initial treatments. However, the prognosis for patients with BE was better than those without BE during the first year after diagnosis, but it was worse between 1 and 5 years, which was statistically significant. Two BE patients died between 1 and 5 years as a result of pneumonia.

CONCLUSIONS

BE as a complication of MPA might be related to lower mortality in the acute phase and higher mortality in the chronic phase compared to other pulmonary manifestations. More attention to pulmonary infection is needed for patients with BE during the chronic phase.

Prevalence and Responsiveness to Treatment of Lung Abnormalities on Chest Computed Tomography in Patients With Microscopic Polyangiitis: A Multicenter, Longitudinal, Retrospective Study of One Hundred Fifty Consecutive Hospital-Based Japanese Patients

OBJECTIVE

To determine the prevalence of lung abnormalities on chest computed tomography (CT) in patients with microscopic polyangiitis (MPA), to assess the responsiveness of such abnormalities to initial treatment, and to assess associations between these abnormalities and patient and disease characteristics and mortality.

METHODS

We retrospectively identified 167 consecutive hospital-based patients with MPA in 3 hospitals in Japan. We longitudinally collected clinical information for 150 of these patients, for whom CT images obtained before treatment were available. We then determined the presence of 22 imaging components of lung abnormalities in these patients.

RESULTS

The vast majority of patients (97%) had at least 1 lung abnormality on chest CT images, including interstitial lung lesions (66%), airway lesions (66%), pleural lesions (53%), and emphysematous lesions (37%). In multivariate analyses, ground-glass opacity was associated with the Birmingham Vasculitis Activity Score, whereas 3 of 4 airway lesions were associated with myeloperoxidase-antineutrophil cytoplasmic antibodies. Latent class analysis identified a distinct group of patients with airway-predominant lung lesions. Airway lesions such as bronchiolitis and bronchovascular bundle thickening were among the components that showed improvement within 3 months of the initial treatment. An idiopathic pulmonary fibrosis pattern was the only chest CT variable that was independently associated with shorter survival.

CONCLUSION

Abnormalities in a wide range of anatomic areas, including the whole airway, can be identified in the lungs of patients with MPA before treatment. The prevalence, clustering patterns, and responsiveness to treatment of individual lung abnormalities provide groundwork for informing future studies to understand the pathophysiology of MPA.

Antineutrophil cytoplasmic antibody-positive conversion and microscopic polyangiitis development in patients with idiopathic pulmonary fibrosis

Background

Increasing evidence indicates that antineutrophil cytoplasmic antibody (ANCA)-positive conversion occurs in patients initially diagnosed with idiopathic pulmonary fibrosis (IPF) and as a result, some of these patients develop microscopic polyangiitis (MPA). However, the incidence density of these patients is not well known.

Objectives

To explore the incidence of ANCA-positive conversion and development of MPA during the disease course in patients with IPF and to evaluate whether corticosteroid therapy reduces MPA development in patients with IPF with myeloperoxidase (MPO)-ANCA positivity at diagnosis or who later acquire MPO-ANCA positivity.

Methods

We retrospectively analysed the medical records of 504 Asian patients with IPF treated at our institution in Saitama, Japan.

Results

Of the 504 patients with IPF, 20 (4.0%) had MPO-ANCA and 16 (3.2%) had PR-3-ANCA when first evaluated. In 264 of 504 patients with IPF, ANCA was measured repeatedly and seroconversion to MPO-ANCA and PR3-ANCA occurred in 15 (5.7%) and 14 (5.3%) patients, respectively, and 9 of 35 patients who were either MPO-ANCA positive at IPF diagnosis or who subsequently seroconverted developed MPA. None of the nine patients who developed MPA had been previously treated with steroids. The incidence of MPA tended to be lower in patients treated than not treated with corticosteroids although this was not statistically significant.

Conclusions

Some patients with IPF with MPO-ANCA positivity at IPF diagnosis or with MPO-ANCA-positive conversion during follow-up developed MPA. Clinical trials to determine whether corticosteroid therapy can reduce MPA development and prolong survival in MPO-ANCA-positive patients with IPF should be considered.

Microscopic polyangiitis: a large single-center series

OBJECTIVE

Microscopic polyangiitis (MPA) is a rare systemic vasculitis, antineutrophil cytoplasmic antibody associated, characterized by necrotizing small vessel involvement with few or no immune complex deposits. Necrotizing glomerulonephritis is common. Pulmonary capillaritis causing alveolar hemorrhage and hemoptysis is well recognized, but most case series are reported in the nephrology literature and emphasize renal considerations. We present a single-center 10-year retrospective review of 40 patients meeting the 2012 Revised Chapel Hill Nomenclature of MPA, with specific p-antineutrophil cytoplasmic antibody and myeloperoxidase positivity, emphasizing initial and subsequent pulmonary manifestations.

METHODS

We searched the electronic database of our large integrated clinic-hospital system and reviewed charts of all patients with related International Classification of Diseases, Ninth Revision codes for vasculitis in the last 10 years. Several variables were reviewed.

RESULTS

Onset of illness was usually abrupt and included respiratory symptoms, and the most common presenting complaint was cough. Hemoptysis occurred during the course of illness in 40%. Pulmonary complaints were found in 80% of patients upon presentation, whereas pulmonary infiltrates were noted in 92%. Managing subspecialty and treatment modalities were quite variable.

CONCLUSIONS

Pulmonary involvement is much more frequent than the currently reported 25% to 50% when features in addition to hemorrhage are recorded. No clear guidelines direct the evaluation and management of MPA patients. Consistent communication between pulmonary, nephrology, and rheumatology services could improve our understanding of the disease process.

Top Differential Diagnosis Should Be Microscopic Polyangiitis in ANCA-Positive Patient with Diffuse Pulmonary Hemorrhage and Hemosiderosis

A rat model of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides reveals crescentic glomerulonephritis as seen in human renal biopsies and diffuse lung hemorrhage that is not well documented in human lung biopsies. A 64-year-old male, with shortness of breath and mild elevation of serum creatinine, was found to have a positive serum test for ANCA, but negative antiglomerular basement membrane antibody. A renal biopsy showed pauci-immune type of crescentic glomerulonephritis and focal arteritis. The prior lung wedge biopsy was retrospectively reviewed to show diffuse hemorrhage and hemosiderosis with focal giant cells. In addition, small arteries revealed subtle neutrophil aggregation, and margination along vascular endothelium, but no definitive vasculitis. The pathology of ANCA associated vasculitides results from activated neutrophils by ANCA and subsequent activation of the alternative complement cascade with endothelial injury, neutrophil aggregation and margination. Our findings, after the correlation between lung biopsy and renal biopsy, imply that the top differential diagnosis in the lung biopsy should be microscopic polyangiitis when diffuse pulmonary hemorrhage and hemosiderosis are present in this ANCA-positive patient.

De novo myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)-associated glomerulonephritis 31 years after living-donor kidney transplantation

A 61-year-old woman was admitted to our hospital because of an unexpected rise in serum creatinine (sCr) level with proteinuria and microhematuria. She had undergone living-donor kidney transplantation 31 years before for end-stage renal disease caused by chronic glomerulonephritis (GN). On admission, her sCr was 1.27 mg/dL which was increased from 0.6 mg/dL, urinary protein/creatinine ratio was 1.39 g/gCr, and urinary red blood cell count was more than 100 per high power field. The allograft biopsy revealed crescentic glomerulonephritis with moderate to severe tubulointerstitial inflammation. Immunofluorescence staining yielded only a minimal staining for immunoglobulin A, and negative C4d in peritubular capillary. Since increased myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titer of 45.5 U/mL was detected, we made the diagnosis of post-transplant MPO-ANCA-associated GN. She was treated with three doses of bolus methylprednisolone (500 mg) followed by oral prednisolone therapy. Her sCr was stable at 1.20 mg/dL thereafter. ANCA-associated GN should be considered in older kidney transplant patients with new-onset urinary abnormalities because typical systemic symptoms and vasculitis in other organs might be masked by maintenance immunosuppression.

Microscopic polyangiitis associated with pulmonary fibrosis

Microscopic polyangiitis (MPA) is a systemic necrotizing vasculitis characterised by inflammation of the small blood vessels, the absence of granulommas on histopathological specimens, with few or no immune deposits and the presence of circulating anti-neutrophil cytoplasmic antibodies (ANCAs). The classic pulmonary manifestation is diffuse alveolar haemorrhage (DAH), but its association with pulmonary fibrosis (PF) has been increasingly reported and may be the first manifestation of MPA. Our aim was to evaluate MPA patients with PF and compare their characteristics and evolution to those of MPA patients without PF. We conducted a retrospective review of MPA patients followed in our hospital over a 15-year period. They were divided into two subgroups, with PF (MPA-PF) and without PF (MPA-non PF), and their clinical and functional features were compared. Nine of the 28 patients were classified as MPA-PF (32%). This subgroup showed significantly more respiratory symptoms and higher mortality than MPA-non PF subgroup. The most frequent chest computed tomographic pattern of PF was usual interstitial pneumonia. PF preceded other manifestations of vasculitis in five patients and occurred simultaneously in the remaining four. During the follow-up period, four deaths were reported in the MPA-PF subgroup. No deaths were registered in the MPA-non PF subgroup. We found a high prevalence of MPA-PF patients (32%), most of whom had a poor outcome and PF was often the first manifestation of the disease.

Pulmonary manifestations of granulomatosis with polyangiitis

OBJECTIVE

To describe the clinical and laboratory data, with special emphasis on thoracic imaging findings, in 14 patients with a definitive diagnosis of granulomatosis with polyangiitis (GPA).

METHODS

The clinical and tomographic data of 14 patients with a definitive diagnosis of GPA are presented. Patients with thoracic manifestations suggestive of GPA were evaluated in 3 hospitals from 2000 to 2012. All patients had a sputum analysis and bronchoalveolar lavage for bacterial, mycobacterial and fungal stains and cultures; antineutrophil cytoplasmic antibodies, antinuclear-antibodies, rheumatoid factor, and a biopsy of involved organs.

RESULTS

A total of 13 patients had at least two organs involved. The most frequent thoracic findings were pulmonary nodules, ground glass opacities and patches of consolidation; other abnormalities were tracheal stenosis, diffuse alveolar hemorrhage, lung masses with organized pneumonia. More than three-quarters (78%) of patients had positive antineutrophil cytoplasmic antibodies (ANCA). Ten patients had respiratory tissue biopsy (8 open lung, one tracheal, and one nasal). In 4 patients the diagnosis was made with the classic organ involvement in GPA, positive ANCA, and renal or skin biopsy, and response to treatment on follow-up. At 6-12 months all patients showed clinical and radiological improvement, with 54% showing a recurrence of disease.

DISCUSSION

The majority of thoracic findings described in GPA are presented in this study. A complete diagnostic approach with invasive diagnostic procedures to rule out other more prevalent respiratory diseases with similar thoracic manifestations must be performed. The positivity of ANCA in this study was high, and the recurrence of the disease was frequent.

Diagnosis and classification of granulomatosis with polyangiitis (aka Wegener's granulomatosis)

Granulomatosis with polyangiitis (GPA, formerly known as Wegener's Granulomatosis) is an autoimmune small vessel vasculitis which is highly associated with anti-neutrophil cytoplasmic antibodies (ANCA). The hallmarks of this condition are systemic necrotising vasculitis, necrotising granulomatous inflammation, and necrotising glomerulonephritis. The aetiology of granulomatosis with polyangiitis is linked to environmental and infectious triggers inciting onset of disease in genetically predisposed individuals. Anti-neutrophil cytoplasmic antibodies are pathogenic and play an important role in the pathogenesis of this disease, although ANCA positivity is not essential for a clinical diagnosis of granulomatosis with polyangiitis. Granulomatosis with polyangiitis is diagnosed based on clinical manifestations of systemic vasculitis and histological evidence of necrotising vasculitis or granulomatous inflammation. This small vessel vasculitis may present as limited disease of the ears, nose and upper airways or mild, moderate or severe systemic disease. Immunosuppression and adjuvant therapies have contributed to the improved prognosis of granulomatosis with polyangiitis over the past decades. Treatment strategies are tailored to the severity of the disease. They are based on published evidence of the efficacy and safety of the immunosuppressive drugs indicated to manage active vasculitis and maintain clinical remission. This review will summarise the history, aetiology, pathogenesis, classification, diagnosis and management of granulomatosis with polyangiitis.

Increased incidence of autoimmune markers in patients with combined pulmonary fibrosis and emphysema

Background

Combined pulmonary fibrosis and emphysema (CPFE) is an umbrella term encompassing upper lobe emphysema and lower lobe pulmonary fibrosis with pathogenesis elusive. The aim of our study was to investigate the incidence of autoimmune markers in patients with CPFE.

Methods

In this multicenter study we retrospectively evaluated records from patients with CPFE (n=40) and IPF (n=60) without emphysema. Baseline demographic characteristics, high-resolution computed tomography (HRCT), spirometry, histopathological, treatment, serum immunologic and survival data were investigated. B cell presence was estimated with CD20 immunostaining in representative lung biopsy samples from CPFE patients and control subjects.

Results

A statistically significant increased number of CPFE patients with elevated serum ANA with or without positive p-ANCA titers compared to patients with IPF without emphysema was observed. Patients with CPFE and positive autoimmune markers exhibited improved survival compared to patients with a negative autoimmune profile. A massive infiltration of clusters of CD20+ B cells forming lymphoid follicles within the fibrotic lung in CPFE patients with positive serum immunologic profile compared to patients with negative profile, was noted and positively correlated with improved survival.

Conclusions

A significant proportion of patients with CPFE may present with underlying auto-immune disorders that may reside insidiously and be associated with favorable prognosis. Early identification of these patients using a panel of auto-antibodies may lead to more targeted and effective therapeutic applications.

Decade long unexplained anemia: alert to ANCA associated vasculitis

A 13-year old girl presented with a decade long anemia, diffuse alveolar hemorrhage and interstistial lung disease; was eventually diagnosed as ANCA associated vasculitis. High index of suspicion is thus warranted for alternative diagnosis in chronic anemia, despite increased prevalence of infectious diseases and nutritional anemia.

AC13, a C-terminal fragment of apolipoprotein A-I, is a candidate biomarker for microscopic polyangiitis

OBJECTIVE

Microscopic polyangiitis (MPA) is necrotizing vasculitis of unknown etiology. We analyzed the serum peptide profile of MPA to find a biomarker for this disease.

METHODS

Serum peptides from 33 patients with MPA, 7 with granulomatosis with polyangiitis (Wegener's), 7 with Churg-Strauss syndrome, 6 with giant cell arteritis, and 25 with systemic lupus erythematosus (SLE) were comprehensively analyzed by mass spectrometry. Peptide function on human microvascular endothelial cells (HMVECs) was examined by enzyme-linked immunosorbent assay and real-time polymerase chain reaction.

RESULTS

A total of 102 serum peptides were detected from the 78 patients. One of the peptides, peptide 1,523, showed significantly higher ion intensity in MPA (mean ± SD 46.8 ± 39.3 arbitrary units [AU]) than in the other systemic vasculitides (14.1 ± 12.2 AU) (P < 0.05) or in SLE (17.0 ± 12.1 AU) (P < 0.05). In MPA, peptide 1,523 showed significantly higher ion intensity before treatment than 1 week (P < 0.05) and 6 weeks (P < 0.05) after the initiation of treatment. Peptide 1,523 was identified as 13 C-terminal amino acid residues of apolipoprotein A-I (Apo A-I) and was designated "AC13." Validation of AC13 ion intensity using another MPA cohort (n = 14) similarly showed significantly higher ion intensity (90.1 ± 167.9 AU) compared to 14 patients with rheumatoid arthritis (8.6 ± 5.4 AU) (P < 0.01) and 14 healthy subjects (11.8 ± 6.1 AU) (P < 0.01). Serum concentrations of Apo A-I and high-density lipoprotein cholesterol were down-regulated in MPA before treatment and returned to their normal ranges 6 weeks after the initiation of treatment (both P < 0.01). Stimulation of HMVECs with AC13 significantly up-regulated secretion of interleukin-6 (IL-6) (P < 0.05) and IL-8 (P < 0.01).

CONCLUSION

AC13, a candidate biomarker for MPA, may be useful for monitoring disease activity and may exacerbate vascular inflammation through up-regulation of proinflammatory cytokines.

Systemic vasculitis associated with anti-neutrophil cytoplasmic antibodies against bactericidal/permeability increasing protein

Myeloperoxidase- and proteinase 3-anti-neutrophil cytoplasmic antibodies (ANCAs) are often negative in cases in which systemic vasculitis is highly suspected. We herein present a case of bactericidal/permeability increasing protein (BPI)-ANCA-positive systemic vasculitis. This case highlights the possible role of BPI-ANCA in the pathogenesis of systemic vasculitis as well as the possible use of BPI as a diagnostic tool. The accumulation of further case-based reports is expected to shed some light on the pathogesis of systemic vasculitis.

Diagnosis and management of pulmonary vasculitis

The pulmonary vasculitides are a heterogeneous group of disorders characterized pathologically by vascular destruction with cellular inflammation and necrosis. These disorders can affect small, medium, and large vessels and may be primary or occur secondary to a variety of conditions. Vasculitis involving the lungs is most commonly due to primary, idiopathic, small-vessel antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, which includes granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), Churg–Strauss syndrome, and microscopic polyangiitis. From a clinical perspective these remain among the most challenging of diseases both in terms of diagnosis and treatment. This review will focus on diagnosis and management of ANCA-associated vasculitides.

Venous thromboembolism with concurrent pulmonary haemorrhage in systemic vasculitis

BACKGROUND

Pulmonary haemorrhage (PH) is a serious manifestation of systemic vasculitis with high mortality rates yet vasculitis is associated with an increased prevalence of venous thromboembolism (VTE). The concurrent presentation of severe PH and VTE poses a challenge in terms of therapeutic management.

METHODS

This is a retrospective case review of the clinical manifestations and response to treatment in vasculitis patients presenting with concurrent pulmonary haemorrhage and VTE (pulmonary embolism and/or deep venous thrombosis).

RESULTS

Of 35 patients with severe PH due to systemic vasculitis, 7 (20%) had concurrent VTE. The most common cause was anti-neutrophil cytoplasm antibody-associated vasculitis, followed by anti-glomerular basement membrane disease. Vasculitis responded to conventional therapies and VTE treatment with anticoagulation was uncomplicated in five of six cases. In one case, anticoagulation precipitated the PH and another was not anticoagulated and developed recurrent VTE. All patients survived without further complications after a mean follow-up of 46 months (3-98).

CONCLUSIONS

Concurrent VTE occurred in one-fifth of cases with severe PH due to vasculitis. Management of VTE with anticoagulation was effective but led to pulmonary haemorrhage in one patient.

[Pneumonitis in elderly patient with ANCA-positive glomerulonephritis during treatment with cyclophosphamide]

A 78 year-old woman with extracapillary glomerulonephritis was treated with cyclophosphamide and corticosteroids. Three months after starting the therapy, the patient had an episode with breathlessness, cough and sputum without fever. X-ray showed bilateral interstitial infiltrates. She was initially treated with empirical antibiotics without achieving clinical or radiological changes. After ruling out an infectious cause, activity of the underlying disease, and other causes of fibrosis, treatment with cyclophosphamide was stopped. Following this, there was an immediate improvement of her clinical and radiological states. The administration of cyclophosphamide was considered directly related to the cause of her symptoms.

Prognosis in adult patients with idiopathic pulmonary hemosiderosis

BACKGROUND

Diffuse alveolar hemorrhage (DAH) of unknown cause has been characterized as idiopathic pulmonary hemosiderosis (IPH). IPH is a rare disease, which has a high prevalence in children and shows a poor prognosis. However, in adults, since there are few reports about collective cases, the details remain to be determined.

METHODS

Between January 2003 and June 2008, consecutive adult patients strictly defined as unknown cause DAH by chest images, fiberoptic bronchoscopy, autoantibody testing, and exclusion of systemic disease were enrolled. We investigated the clinical characterization and course of the enrolled patients.

RESULTS

Nine patients were included. All patients were middle-aged men (56.1 ± 4.2 year-old) with sudden onset. They did not present with anemia (the hemoglobin level was 13.9 ± 0.5 g/dL) despite the quantity of bleeding. In bronchoalveolar-lavage fluid analysis, the cell count was increased (7.6 ± 1.6×10(5) cells/mL) with neutorophilia (33.3 ± 13.3%). The illness resolved within 2 weeks with or without corticosteroid therapy. All of the patients were alive without recurrence during the follow-up period (45.2 ± 6.2 months) after diagnosis.

CONCLUSION

Adult IPH patients showed good prognosis. However, the present patients are clinically slightly different from the previously characterized IPH.

Unusual evolution in Wegener's granulomatosis: recovery of pulmonary involvement while renal disease progressed to end-stage

A 54-year-old male patient was admitted for acute respiratory distress with fever. He was suffering from chronic sinusitis/rhinitis and had persistent otitis for the past 2 months before admission despite several antibiotics courses. He developed a complex pulmonary involvement (embolism and diffuse alveolar hemorrhage) with acute glomerular disease (proteinuria and hematuria but initially no renal failure). Clinical suspicion of Wegener's granulomatosis was confirmed by the positive high titer of antineutrophil cytoplasmic antibodies (c-ANCA with antiproteinase 3 specificity) and despite a negative nasal biopsy. Treatment including cyclophosphamide and methylprednisolone intravenous pulses permitted pulmonary recovery over 4 weeks contrasting with the development of rapidly progressive glomerulonephritis and polyneuropathy of lower limbs. Renal biopsy showed pauci-immune crescentic and necrotizing glomerulonephritis. However, despite additional plasma exchanges, acute kidney injury worsened and the patient ended up in dialysis. Such a dissociated evolution was unexpected in this case since pulmonary and renal involvements reflected the same pathological process (small vessels vasculitis/capillaritis) and the same pathogenic mechanism (antiproteinase 3 autoantibodies).

Diffuse alveolar hemorrhage in lupus nephritis complicated by microscopic polyangiitis

Diffuse alveolar hemorrhage (DAH) is a rare but fatal complication in patients with systemic lupus erythematosus (SLE). We describe a case of a 74-year-old woman who presented with DAH as an initial presentation of SLE. She also had microscopic polyangiitis clinically manifesting as crescentic glomerulonephritis and purpura with positive myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCA). The patient transiently improved when treated with plasma exchange and methylprednisolone pulse therapy; however, she died of recurrent pulmonary hemorrhage and concurrent cryptococcal pneumonia. This case indicates that MPO-ANCA is associated with severe organ involvement such as pulmonary hemorrhage and crescentic glomerulonephritis in SLE.

Diagnostic approach to ANCA-associated vasculitides

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) include Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome. Given their rarity, protean clinical manifestations, imperfect diagnostic tests, and wide differential diagnosis, they pose a diagnostic challenge even to experienced clinicians. This article describes diagnostic approaches for patients suspected of having one of the ANCA-associated vasculitides. The clinical findings at presentation, the role of laboratory and imaging tests, and the importance of tissue diagnosis are presented. In each section, issues relevant to the differential diagnosis of AAV are discussed.