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Terrier B, Darbon R, Durel CA, Hachulla E, Karras A, Maillard H, Papo T, Puechal X, Pugnet G, Quemeneur T, Samson M, Taille C, Guillevin L. French recommendations for the management of systemic necrotizing vasculitides (polyarteritis nodosa and ANCA-associated vasculitides). Orphanet J Rare Dis 2020; 15:351. [PMID: 33372616 PMCID: PMC7771069 DOI: 10.1186/s13023-020-01621-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Systemic necrotizing vasculitis comprises a group of diseases resembling polyarteritis nodosa and anti-neutrophil cytoplasmic antibody-associated vasculitis (ANCA): granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. The definitive diagnosis is made in cooperation with a reference center for autoimmune diseases and rare systemic diseases or a competency center. The management goals are: to obtain remission and, in the long term, healing; to reduce the risk of relapses; to limit and reduce the sequelae linked to the disease; to limit the side effects and the sequelae linked to the treatments; to improve or at least maintain the best possible quality of life; and to maintain socio-professional integration and/or allow a rapid return to school and/or professional activity. Information and therapeutic education of the patients and those around them are an integral part of the care. All health professionals and patients should be informed of the existence of patient associations. The treatment of vasculitis is based on variable combinations of glucocorticoids and immunosuppressants, chosen and adapted according to the disease concerned, the severity and/or extent of the disease, and the underlying factors (age, kidney function, etc.). Follow-up clinical and paraclinical examinations must be carried out regularly to clarify the progression of the disease, detect and manage treatment failures and possible relapses early on, and limit sequelae and complications (early then late) related to the disease or treatment. A distinction is made between the induction therapy, lasting approximately 3–6 months and aimed at putting the disease into remission, and the maintenance treatment, lasting 12–48 months, or even longer. The role of the increase or testing positive again for ANCA as a predictor of a relapse, which has long been controversial, now seems to have greater consensus: Anti-myeloperoxidase ANCAs are less often associated with a relapse of vasculitis than anti-PR3 ANCA.
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Affiliation(s)
| | | | | | | | | | | | - Thomas Papo
- Internal Medicine, CHU Bichat, AP-HP, Paris, France
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Helgeson SA, Heckman AJ, McCain JD, Cowart JB, Maniaci MJ, Garland JL. A 32-year-old man with hypoxemia and bilateral upper-lobe predominant ground-glass infiltrates on chest imaging. Oxf Med Case Reports 2018; 2018:omy072. [PMID: 30302263 PMCID: PMC6169198 DOI: 10.1093/omcr/omy072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 11/27/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare, but potentially fatal, complication of antiphospholipid syndrome, and may present with acute and fulminant symptoms. We report a case of DAH presenting as sudden onset dyspnea in a gentleman with known antiphospholipid syndrome. Chest computed tomography angiography with pulmonary embolism protocol showed right lower lobe segmental filling defects, upper-lobe predominant diffuse ground-glass opacities, and centrilobular nodules bilaterally. The presence of DAH can be confirmed by bronchoalveolar lavage with serial aliquots, but this procedure typically does not elucidate the specific etiology for the hemorrhage. The treatment for patients with severe disease typically consists of a combination of immunosuppressive medications in the form of high-dose intravenous glucocorticoids plus rituximab, cyclophosphamide or mycophenolate; and/or plasma exchange. This case both provides an example of high-quality diagnostic imaging of diffuse alveolar hemorrhage as well as demonstrates the clinical and image-based improvement after treatment.
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Vanoli J, Riva M, Vergnano B, D’Andrea G, L’Imperio V, Pozzi MR, Grassi G. Granulomatosis with polyangiitis presenting with diffuse alveolar hemorrhage requiring extracorporeal membrane oxygenation with rapid multiorgan relapse: A case report. Medicine (Baltimore) 2017; 96:e6024. [PMID: 28353556 PMCID: PMC5380240 DOI: 10.1097/md.0000000000006024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmatic antibodies (ANCA)-associated vasculitis affecting small- and medium-sized blood vessels, mostly involving lung and kidney. PATIENT CONCERNS We report the case of a 33-year-old man that presented with acute respiratory distress syndrome caused by alveolar hemorrhage. DIAGNOSES Aggressive GPA presenting with diffuse alveolar hemorrhage and multiorgan involvement. INTEVENTIONS Immunosuppressive therapy, plasma exchange, extracorporeal membrane oxygenation (ECMO). OUTCOMES Relapse occurred very early, despite immunosuppressive treatment, with a rare involvement of genital system (epididymitis) and rapidly progressive glomerulonephritis difficult to treat. LESSONS GPA is a challenging, multifaceted disease that can require aggressive supportive therapy and is associated with a high rate of relapse that may present with uncommon site of involvement.
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Affiliation(s)
| | | | | | | | | | | | - Guido Grassi
- Divisione di Clinica Medica
- University of Milano-Bicocca and Istituto di Ricerca a Carattere Scientifico IRCCS Multimedica, Sesto San Giovanni, Milano, Italy
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Successful Management of Refractory Dialysis Independent Wegener’s Granulomatosis with Combination of Therapeutic Plasma Exchange and Rituximab. Indian J Hematol Blood Transfus 2016; 32:332-4. [DOI: 10.1007/s12288-015-0507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 01/17/2015] [Indexed: 10/24/2022] Open
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Lichtenberger JP, Digumarthy SR, Abbott GF, Shepard JAO, Sharma A. Diffuse pulmonary hemorrhage: clues to the diagnosis. Curr Probl Diagn Radiol 2015; 43:128-39. [PMID: 24791616 DOI: 10.1067/j.cpradiol.2014.01.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Diffuse pulmonary hemorrhage (DPH) refers to an uncommon but significant condition of bleeding into the alveolar space. Anemia and hemoptysis are important clinical features, but they may be absent. Although the radiographic and computed tomography findings are often varied and nonspecific, the imaging manifestations of pulmonary hemorrhage and the associated findings in the thorax often provide important diagnostic information that may lead to a specific diagnosis. DPH significantly influences patient management and has important prognostic implications. This review article explores the imaging findings in DPH and its differential diagnosis, highlighting important clues to this diagnosis and to its underlying etiology. DPH is an uncommon condition characterized by bleeding into the alveolar space that, when recognized on imaging, provides important diagnostic and prognostic information.
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Affiliation(s)
- John P Lichtenberger
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA.
| | - Subba R Digumarthy
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Gerald F Abbott
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Jo-Anne O Shepard
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Amita Sharma
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA
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Nishio M, Yoshioka K, Yamagami K, Morikawa T, Konishi Y, Hayashi N, Himuro K, Imanishi M. Reversible posterior leukoencephalopathy syndrome: a possible manifestation of Wegener’s granulomatosis-mediated endothelial injury. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0052-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shovman O, Langevitz P, Gilburd B, Shoenfeld Y. Coincidence of granulomatosis and polyangiitis with atypical clinical manifestation and antiphospholipid syndrome. Lupus 2013; 22:320-3. [PMID: 23439472 DOI: 10.1177/0961203313475692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Granulomatosis and angiitis (GPA) is a multisystemic disease characterized by a granulomatous inflammation, tissue necrosis, and vasculitis of small and medium-sized blood vessels. Although the disease has a predilection for the upper respiratory tract, lungs, and kidneys, any organ system may be affected. Here, we present a case of generalized GPA manifested initially by necrotizing isolated parotitis and later by pulmonary-renal syndrome. Simultaneously with pulmonary hemorrhage, our patient developed an antiphospholipid syndrome (APS) presenting with deep vein thrombosis and strongly positive lupus anticoagulant. To the best of our knowledge the coincidence of parotitis and pulmonary-renal syndrome due to GPA and APS has never been reported previously. Concomitant venous thromboembolism may be life-threatening in a patient with GPA. Early diagnosis and institution of the proper therapy are critical in order to prevent organ damage.
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Affiliation(s)
- O Shovman
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, Israel
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Galesic K, Ljubanovic D, Horvatic I. Treatment of renal manifestations of ANCA-associated vasculitis. J Nephropathol 2013; 2:6-19. [PMID: 24475421 PMCID: PMC3886180 DOI: 10.5812/nephropathol.8971] [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: 10/01/2013] [Accepted: 10/25/2013] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Vasculitis is a clinicopathological entity characterized by inflammation and necrosis of blood vessels. EVIDENCE ACQUISITIONS Directory of Open Access Journals (DOAJ), Google Scholar, Pubmed (NLM), LISTA (EBSCO) and Web of Science have been searched. RESULTS Two major autoantigens for ANCA are myeloperoxidase (MPO) and proteinase 3 (PR3), which are proteins in the primary granules of neutrophils and in the lysosomes of monocytes. They are expressed in mature neutrophils of patients with ANCA, while absent in healthy subjects. CONCLUSIONS The kidney is the most commonly affected vital organ in ANCA-associated vasculitis, and patient outcomes are largely determined by the severity of renal disease at diagnosis and by its response to treatment.
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Affiliation(s)
- Kresimir Galesic
- Department of Nephrology, Dubrava University Hospital, Zagreb Medical School, Zagreb, Croatia
| | - Danica Ljubanovic
- Department of Pathology, Dubrava University Hospital, Zagreb Medical School, Zagreb, Croatia
| | - Ivica Horvatic
- Department of Nephrology, Dubrava University Hospital, Zagreb Medical School, Zagreb, Croatia
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Joseph M, Charles AG. Early extracorporeal life support as rescue for Wegener granulomatosis with diffuse alveolar hemorrhage and acute respiratory distress syndrome: a case report and literature review. Pediatr Emerg Care 2011; 27:1163-6. [PMID: 22158275 DOI: 10.1097/pec.0b013e31823b01a2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The study's objective was to report a case and review the literature on the use of extracorporeal life support in the face of severe pulmonary hemorrhage for acute respiratory distress syndrome. STUDY SELECTION This study is a single case report of a pediatric patient who was successfully managed on venovenous extracorporeal life support for severe acute respiratory distress syndrome with acute pulmonary hemorrhage secondary to Wegener disease. CONCLUSIONS Extracorporeal life support can be used successfully in selected patients with respiratory failure with pulmonary hemorrhage. The cautious use of anticoagulation should be balanced with the risk of bleeding, mindful of the need for other measures to mitigate severe bleeding if this should occur.
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Affiliation(s)
- Mark Joseph
- Division of Trauma and Critical Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599-7228, USA.
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Berthoux E, Padilla M, Chavez L, Colombe B, Bosseray A, Massot C. Unusual evolution in Wegener's granulomatosis: recovery of pulmonary involvement while renal disease progressed to end-stage. Ren Fail 2011; 33:1032-6. [PMID: 21864201 DOI: 10.3109/0886022x.2011.610547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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).
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Affiliation(s)
- Emilie Berthoux
- Clinique de Médecine Interne, Hôpital Michallon, CHU de Grenoble, Grenoble, France.
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Current World Literature. Curr Opin Rheumatol 2010; 22:97-105. [DOI: 10.1097/bor.0b013e328334b3e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gómez-Puerta JA, Hernández-Rodríguez J, López-Soto A, Bosch X. Antineutrophil Cytoplasmic Antibody-Associated Vasculitides and Respiratory Disease. Chest 2009; 136:1101-1111. [DOI: 10.1378/chest.08-3043] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Pulmonary renal syndrome associated with Wegener’s granulomatosis: a case report and review of literature. Clin Exp Nephrol 2009; 14:80-4. [DOI: 10.1007/s10157-009-0223-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 08/13/2009] [Indexed: 10/20/2022]
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Nishio M, Yoshioka K, Yamagami K, Morikawa T, Konishi Y, Hayashi N, Himuro K, Imanishi M. Reversible posterior leukoencephalopathy syndrome: a possible manifestation of Wegener's granulomatosis-mediated endothelial injury. Mod Rheumatol 2008; 18:309-14. [PMID: 18415039 DOI: 10.1007/s10165-008-0052-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2007] [Accepted: 01/30/2008] [Indexed: 11/25/2022]
Abstract
We present the case of a 15-year-old girl who had Wegener's granulomatosis with severe intestinal involvement. During the clinical course, she developed generalized seizures and was diagnosed with reversible posterior leukoencephalopathy syndrome (RPLS). Plasma exchange combined with steroid pulse therapy was initiated and showed marked improvement. This is one of the few cases of RPLS without severe hypertension or renal failure, suggesting that RPLS is likely to be a manifestation of Wegener's granulomatosis-mediated endothelial injury.
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Affiliation(s)
- Minako Nishio
- Department of Internal Medicine, Osaka City General Hospital, 2-13-22 Miyakojima-Hondori, Miyakojima-ku, Osaka, Japan.
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