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Nakamura Y, Kikumoto N, Takeuchi H, Kimura T, Nakamori M, Fujiwara K. Combination Biologic Therapy with Mepolizumab and Dupilumab for Severe Eosinophilic Granulomatosis with Polyangiitis and Chronic Rhinosinusitis with Nasal Polyp. Yonago Acta Med 2024; 67:157-162. [PMID: 38803595 PMCID: PMC11128079 DOI: 10.33160/yam.2024.05.005] [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: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 05/29/2024]
Abstract
We report the case of a 55-year-old female with eosinophilic granulomatosis with polyangiitis and chronic rhinosinusitis with nasal polyp. Rhinosinusitis recurred 6 months after full-house endoscopic sinus surgery. Although conventional treatment with azathioprine and mepolizumab with steroids was given, it was difficult to simultaneously control both rhinosinusitis and eosinophilic granulomatosis with polyangiitis. Clinical examinations showed polyps in the olfactory cleft, and the patient's anosmia gradually became persistent. Even after administering mepolizumab for a certain period of time, symptoms did not improve, but when the biologic agent was switched to dupilumab, an improvement in recalcitrant chronic rhinosinusitis with nasal polyp was observed. While dupilumab was administered intermittently for refractory chronic rhinosinusitis with nasal polyp, the rhinosinusitis improved and symptoms such as worsening of eosinophilic granulomatosis with polyangiitis paresthesia were observed. Both symptoms gradually subsided 19 months after starting intermittent administration, leading to the discontinuation of dupilumab administration. Rhinosinusitis in the setting of eosinophilic granulomatosis with polyangiitis may be refractory in some cases, and this case provides findings demonstrating the strong effect of dupilumab on eosinophilic inflammation.
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Affiliation(s)
- Yosuke Nakamura
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Naoki Kikumoto
- Division of Respiratory Medicine, Tottori Seikyo Hospital, Tottori 680-0833, Japan
| | - Hiromi Takeuchi
- Division of Otolaryngology, Tottori Red Cross Hospital, Tottori 680-0017, Japan
| | - Toru Kimura
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Motoki Nakamori
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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2
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Watanabe R, Hashimoto M. Eosinophilic Granulomatosis with Polyangiitis: Latest Findings and Updated Treatment Recommendations. J Clin Med 2023; 12:5996. [PMID: 37762936 PMCID: PMC10532073 DOI: 10.3390/jcm12185996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) causes necrotizing vasculitis and eosinophil-rich granulomatous inflammation in small- to medium-sized vessels, resulting in multiple organ damage. EGPA is classified as an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, with myeloperoxidase-ANCA detected in approximately one-third of the patients. Conventional treatment of EGPA relies on systemic glucocorticoids (GCs) in combination with cyclophosphamide when poor prognostic factors are present; however, the dilemma between disease control and drug-related adverse effects has long been a challenge. Recent studies have revealed that the genetic background, pathophysiology, and clinical manifestations differ between ANCA-positive and ANCA-negative patients; however, mepolizumab, an interleukin (IL)-5 inhibitor, is effective in both groups, suggesting that the IL-5-eosinophil axis is deeply involved in the pathogenesis of both ANCA-positive and ANCA-negative EGPA. This review summarizes the latest knowledge on the pathophysiology of EGPA and focuses on the roles of eosinophils and ANCA. We then introduce the current treatment recommendations and accumulated evidence for mepolizumab on EGPA. Based on current unmet clinical needs, we discuss potential future therapeutic strategies for EGPA.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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3
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Nakamura Y, Fukutomi Y, Sekiya K, Kajiwara K, Kawasaki Y, Fujita N, Nagayama K, Iwata M, Iwamoto K, Yano K, Hamada Y, Watai K, Ryu K, Hayashi H, Kamide Y, Taniguchi M. Low-dose mepolizumab is effective as an add-on therapy for treating long-lasting peripheral neuropathy in patients with eosinophilic granulomatosis with polyangiitis. Mod Rheumatol 2021; 32:387-395. [PMID: 34910206 DOI: 10.1093/mr/roab005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/18/2021] [Accepted: 04/21/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the effectiveness of low-dose mepolizumab as an add-on therapy for treating peripheral neurological symptoms in eosinophilic granulomatosis with polyangiitis (EGPA). METHODS We prospectively studied 13 EGPA patients with conventional treatment-resistant peripheral neuropathy. Their symptoms (pain, numbness, and muscle weakness) were assessed on a visual analogue scale (VAS) before and after 12 months of mepolizumab therapy (100 mg every 4 weeks). Peripheral eosinophil levels and several biomarkers including urinary levels of eosinophil-derived neurotoxin (EDN) were measured before and after therapy. RESULTS VAS scores for pain and numbness significantly improved after 12 months of mepolizumab therapy (from 67.0 to 48.0, P = 0.012, and from 67.0 to 51.0, P = 0.017, respectively). However, the VAS score for muscle weakness did not improve (P = 0.36). There were significant correlations between treatment-related changes in urinary EDN levels from baseline to 6 months later and percent changes in the VAS scores of pain and numbness (r = 0.75, P = 0.020; r = 0.88, P = 0.002). CONCLUSIONS Treatment-resistant peripheral neuropathy in EGPA was significantly improved by low-dose mepolizumab, and effectiveness was correlated with decreased urinary EDN. Because the possibility of a placebo effect cannot be formally excluded, placebo-controlled studies will be required in the future.
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Affiliation(s)
- Yuto Nakamura
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuma Fukutomi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kiyoshi Sekiya
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Keiichi Kajiwara
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Yuichiro Kawasaki
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Norihiro Fujita
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Kisako Nagayama
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Maki Iwata
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Keisuke Iwamoto
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Koichi Yano
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Yuto Hamada
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kentaro Watai
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kai Ryu
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Hiroaki Hayashi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Yosuke Kamide
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Masami Taniguchi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Shonan Kamakura General Hospital Center for Immunology and Allergology, Kamakura, Japan
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4
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Kataoka H, Tomita T, Kondo M, Mukai M. Presence of purpura is related to active inflammation in association with IL-5 in eosinophilic granulomatosis with polyangiitis. Rheumatol Int 2020; 41:449-454. [PMID: 32770271 PMCID: PMC7835155 DOI: 10.1007/s00296-020-04672-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/02/2020] [Indexed: 01/21/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a relatively rare necrotizing vasculitis that causes asthma, nasal involvement, peripheral nerve disturbance, renal disorder, and cutaneous lesions like purpura and is characterized by eosinophil infiltration into the damaged tissue. Purpura is the most common cutaneous lesion, but it remains unknown whether this skin lesion is associated with disease activity of EGPA and laboratory data including interleukin (IL)-5, a target cytokine of this disease. We conducted a search of our hospital electronic records for cases of EGPA from the last 10 years. Symptoms related to EGPA (fever, asthma, nasal and cutaneous manifestations, neuropathy), the Birmingham Vasculitis Activity Score (BVAS), and laboratory parameters, such as eosinophil count, urinalysis, antineutrophil cytoplasmic antibody (ANCA), CRP, IgE and IL-5, before and during treatment were compared among the eligible cases. A total of 28 EGPA patients (21 females and 7 males) were selected. Almost all developed peripheral neuropathy. Fever occurred in 25%, nasal symptoms in 38.1% and purpura in 44%. Glomerulonephritis developed in 7.7%. One patient had cardiac involvement (3.6%). The laboratory data showed a marked increase in peripheral eosinophil count, CRP, serum IgE and serum IL-5. ANCA was positive in 15.4%. In the univariate analysis, presence of purpura was associated with increased CRP and IL-5, and high BVAS score. Multivariate analysis revealed a robust relationship between purpura and CRP. Our findings showed that presence of purpura was associated with increased CRP and IL-5, and high disease activity in EGPA.
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Affiliation(s)
- Hiroshi Kataoka
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan.
| | - Tomoko Tomita
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
| | - Makoto Kondo
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
| | - Masaya Mukai
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
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5
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Marques CC, Fernandes EL, Miquelin GM, Colferai MMT. Cutaneous manifestations of Churg-Strauss syndrome: key to diagnosis. An Bras Dermatol 2018; 92:56-58. [PMID: 29267447 PMCID: PMC5726678 DOI: 10.1590/abd1806-4841.20175522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 08/01/2016] [Indexed: 11/22/2022] Open
Abstract
Churg-Strauss syndrome is a rare systemic vasculitis characterized by asthma and other allergy symptoms as well as eosinophilia and necrotizing vasculitis involving small and medium-sized vessels. Its prevalence in the general population ranges from 1-3 cases per million a year, varying according to the population studied. The authors describe a case of a female patient affected by the disease with important systemic manifestations and not very florid skin lesions.
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Affiliation(s)
- Camila Carneiro Marques
- Dermatology Outpatient Clinic, Universidade de Mogi das Cruzes - Mogi das Cruzes (SP), Brazil
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6
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Cao M, Ferreiro T, Leite BN, Pita F, Bolaños L, Valdés F, Alonso A, Vázquez E, Mosquera J, Trigás M, Rodríguez S. Two cases of atypical hemolytic uremic syndrome (aHUS) and eosinophilic granulomatosis with polyangiitis (EGPA): a possible relationship. CEN Case Rep 2017; 6:91-97. [PMID: 28509134 DOI: 10.1007/s13730-017-0251-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 02/04/2017] [Indexed: 10/20/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by hemolysis, thrombocytopenia, and renal failure. It is related to genetic mutations of the alternative complement pathway and is difficult to differentiate from other prothrombotic microangiopathies. Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome, CSS) is a systemic ANCA-associated vasculitis and a hypereosinophilic disorder where eosinophils seem to induce cell apoptosis and necrosis and therefore, vasculitis. Here, we report the case of two CSS patients with a genetic complement disorder consistent with aHUS diagnosis. Both patients showed histologic features that supported the diagnosis of CSS, and a genetic complement study confirmed the suspected aHUS diagnosis. In the case where eculizumab was administered, the global response was excellent. There is very limited understanding of the genetics and epidemiology of both, atypical HUS and EGPA, but considering our two patients we suggest that an etiopathogenic link exists among patients diagnosed with both entities.
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Affiliation(s)
- Mercedes Cao
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain.
| | - Tamara Ferreiro
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Bruna N Leite
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco Pita
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Luis Bolaños
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco Valdés
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Angel Alonso
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Eduardo Vázquez
- Servicio de Anatomía Patológica, Hospital Universitario A Coruña, A Coruña, Spain
| | - Juan Mosquera
- Servicio de Anatomía Patológica, Hospital Universitario A Coruña, A Coruña, Spain
| | - María Trigás
- Servicio de Medicina Interna, Hospital Arquitecto Marcide, El Ferrol, A Coruña, Spain
| | - Santiago Rodríguez
- Departamento de Medicina Celular y Molecular, Centro de Investigaciones Biológicas (CSIC), Madrid, Spain
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7
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Pecoraro A, Crescenzi L, Carucci L, Genovese A, Spadaro G. Heart failure not responsive to standard immunosuppressive therapy is successfully treated with high dose intravenous immunoglobulin therapy in a patient with Eosinophilic Granulomatosis with Polyangiitis (EGPA). Int Immunopharmacol 2017; 45:13-15. [PMID: 28152445 DOI: 10.1016/j.intimp.2017.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/23/2022]
Abstract
Glucocorticoids and immunosuppressive drugs represent the first-line treatment of eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss syndrome), even though the combined therapy is not successful in achieving the disease remission in some patients with neurological or cardiac involvement. We describe a case of an EGPA male patient with impaired left ventricular function not responsive to glucocorticoid and immunosuppressive therapy. We observed that high-dose (2g/kg/4weeks) intravenous immunoglobulin (IVIG) therapy significantly improved cardiac function, which was deteriorated after reducing IVIG dose at 0.5g/kg/4weeks, and was restored increasing again IVIG dose to 2g/kg/4weeks. The finding highlights the relevance of IVIG as treatment of choice in EGPA patients with cardiac involvement not responsive to the standard glucocorticoid and immunosuppressive therapy. Moreover, at a follow-up of 24months, the continuance of high dose IVIG therapy was required to maintain a sustained remission of the heart failure.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy.
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Laura Carucci
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
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8
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Pagnoux C, Groh M. Optimal therapy and prospects for new medicines in eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Expert Rev Clin Immunol 2016; 12:1059-67. [PMID: 27191665 DOI: 10.1080/1744666x.2016.1191352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The prevalence of eosinophilic granulomatosis with polyangiitis (EGPA; previously known as Churg-Strauss syndrome) is lower than that of other antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV's), and only a few randomized controlled trials have been conducted for this rare disease. However, recent international efforts have helped delineate the best treatment approach. AREAS COVERED At present, EGPA conventional therapy is by default similar to that of other AAVs. Limited, non-severe EGPA can initially be treated with glucocorticoids (GCs) alone. Patients with life-threatening manifestations and/or major organ involvement must receive a combination of GCs and an immunosuppressant, mainly cyclophosphamide. Remission can be achieved in >85% of patients with these first-line treatments, but vasculitis relapses occur in more than one-third of patients, and about 85% cannot stop GC treatment because of GC-dependent asthma and/or ENT manifestations. A few biologic agents, including rituximab or mepolizumab, are now under investigation after interesting preliminary results. Expert commentary: Treatment for EGPA still has several unmet needs. Several biologic agents are now under investigation in randomized controlled trials, but a few others should be considered soon. Their benefit should be demonstrated for devising more EGPA-tailored therapeutic strategies (ideally GC-free).
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Affiliation(s)
- Christian Pagnoux
- a Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital , University Health Network , Toronto , Ontario , Canada.,b CanVasc , Toronto , Ontario , Canada
| | - Matthieu Groh
- c Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases (Vasculitis, Scleroderma), Hôpital Cochin, APHP , Université Paris Descartes , Paris , France
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9
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Enomoto N, Chida K, Suda T, Kaida Y, Taniguchi M, Azuma A, Hayashi H, Ogura T, Kitamura H, Yamaguchi O, Ando M, Sato A, Kudo S. An exploratory trial of intravenous immunoglobulin therapy for idiopathic pulmonary fibrosis: a preliminary multicenter report. CLINICAL RESPIRATORY JOURNAL 2015; 10:746-755. [PMID: 25689162 DOI: 10.1111/crj.12281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/31/2015] [Accepted: 02/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Idiopathic pulmonary fibrosis (IPF) is a fatal disorder without specific treatments. Although the efficacy of intravenous immunoglobulin (IVIG) therapy for autoimmune diseases has been reported, that for IPF remains unknown. This study aims to determine the efficacy and safety of IVIG for IPF. METHODS In an exploratory, multicenter, non-randomized and prospective trial, patients with progressive IPF were enrolled. Patients were treated with IVIG for five consecutive days (5-day IVIG) or once monthly for five consecutive months (5-month IVIG). Changes in the vital capacity (VC), diffusion capacity of the lung for carbon monoxide (DLCO), 6-min walk test (6MWT) and high-resolution computed tomography (HRCT) findings were evaluated. RESULTS A total of 10 patients with IPF were treated with IVIG: 6 were in 5-day IVIG and 4 were in 5-month IVIG group. In 5-day IVIG group, the treatment effects were temporal, and physiological and HRCT findings deteriorated in three of six patients. In 5-month IVIG group, changes in %VC, %DLCO and walk distance in 6MWT at 6 months were -0.9 ± 5.3%, 6.9 ± 12.6% and 79 ± 58 m (mean ± standard deviation), respectively, and the treatment effects were long lasting. The change in VC 6 months after starting IVIG was smaller than that of 6-12 months after starting IVIG (after cessation of IVIG) (-0.02 ± 0.15 vs -0.33 ± 0.14 L, P = 0.022). Ground glass opacities were diminished in two of four patients. Adverse events were mild and tolerable. CONCLUSION This preliminary study shows that once-monthly IVIG treatment may be effective and tolerable in patients with IPF.
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Affiliation(s)
- Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Kingo Chida
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Internal Medicine, Hamamatsu Toyooka Hospital, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yusuke Kaida
- Department of Internal Medicine, Enshu Hospital, Hamamatsu, Japan
| | - Masami Taniguchi
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Arata Azuma
- Internal Medicine, Department of Pulmonary Medicine/Infection and Oncology, Nippon Medical School, Tokyo, Japan
| | - Hiroki Hayashi
- Internal Medicine, Department of Pulmonary Medicine/Infection and Oncology, Nippon Medical School, Tokyo, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ou Yamaguchi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | | | | | - Shoji Kudo
- Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
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Abstract
Churg-Strauss angiitis is a rare vasculitic disorder affecting small- and medium-sized blood vessels. It is clinically characterized by the presence of a wide spectrum of multisystem organ involvement, with allergic rhinitis, asthma and peripheral blood eosinophilia as the most typical manifestations. The authors describe 2 cases of Churg-Strauss angiitis from an urban community of Southern Louisiana, exhibiting an atypical presentation with myocardial ischemia and cerebrovascular complications. Epidemiology, pathophysiology and clinical overview are presented. The therapeutic management is also discussed.
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11
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Umeda A, Yamane T, Takeuchi J, Imai Y, Suzuki K, Yumura W. Marked improvement of Churg-Strauss syndrome neuropathy by intravenous immunoglobulin and cyclophosphamide. Respirol Case Rep 2014; 2:81-4. [PMID: 25473575 PMCID: PMC4184514 DOI: 10.1002/rcr2.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 03/13/2014] [Accepted: 03/13/2014] [Indexed: 11/30/2022] Open
Abstract
A 42-year-old Japanese man developed Churg–Strauss syndrome 7 years after being diagnosed with chronic eosinophilic pneumonia. Prominent eosinophilia, subcutaneous nodules, and neuropathy in the left leg were seen. A pathological diagnosis of necrotizing vasculitis was determined by a biopsy of a subcutaneous nodule. The leg pain was severe and there was prominent atrophy of the thigh and calf, but the muscle weakness was mild. Serum anti-myeloperoxidase anti-neutrophil cytoplasmic antibody was positive. Because the initial treatment with an intravenous methylprednisolone pulse at 1 g/day for 3 days was not sufficient, a onetime treatment with intravenous cyclophosphamide at 15 mg/kg and intravenous immunoglobulin therapy (IVIG) at 400 mg/kg/day for 5 days were administered. Peripheral eosinophilia improved and the leg pain significantly improved. IVIG was repeated 1 month later and symptoms gradually improved further. The early diagnosis of Churg–Strauss syndrome and the early initiation of IVIG with cyclophosphamide were thought to be important.
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Affiliation(s)
- Akira Umeda
- Department of Internal Medicine, Shioya Hospital, International University of Health and Welfare Tochigi, Japan
| | - Tateki Yamane
- Department of Internal Medicine, Shioya Hospital, International University of Health and Welfare Tochigi, Japan
| | - Jin Takeuchi
- Department of Internal Medicine, Shioya Hospital, International University of Health and Welfare Tochigi, Japan
| | - Yasuo Imai
- Department of Pathology, Dokkyo Medical University Koshigaya Hospital Saitama, Japan
| | - Keisuke Suzuki
- Department of Neurology, Dokkyo Medical University Tochigi, Japan
| | - Wako Yumura
- Department of Nephrology, International University of Health and Welfare Hospital Tochigi, Japan
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12
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Umezawa N, Kohsaka H, Nanki T, Watanabe K, Tanaka M, Shane PY, Miyasaka N. Successful treatment of eosinophilic granulomatosis with polyangiitis (EGPA; formerly Churg–Strauss syndrome) with rituximab in a case refractory to glucocorticoids, cyclophosphamide, and IVIG. Mod Rheumatol 2014; 24:685-7. [DOI: 10.3109/14397595.2013.874734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Natsuka Umezawa
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Hitoshi Kohsaka
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Toshihiro Nanki
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
- Department of Pharmacovigilance, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Kaori Watanabe
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
- Department of Pharmacovigilance, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Michi Tanaka
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
- Department of Pharmacovigilance, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Peter Y. Shane
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
| | - Nobuyuki Miyasaka
- Department of Medicine and Rheumatology, Graduate School of Medicine and Dental Science, Tokyo Medical and Dental University,
Tokyo, Japan
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Tsampau D, Buggiani G, Hercogova J, Lotti T. Cutaneous necrotizing vasculitis: a rational therapeutic approach. Dermatol Ther 2013; 25:335-9. [PMID: 22950560 DOI: 10.1111/j.1529-8019.2012.01480.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cutaneous necrotizing vasculitis is a heterogeneous group of disorders characterized clinically by palpable purpura, and histologically by a segmental angiocentric inflammatory condition with fibrinoid necrosis of the vessel wall, endothelial swelling, and nuclear dust of the post capillary venules. Often, the skin seems the only organ apparently damaged, but systemic involvement may occur. In up to 60% of cases of cutaneous necrotizing vasculitis, the cause remains unknown; in others, it may be due to a variety of underlying conditions such as drugs, chemicals, food allergens, infections, chronic inflammatory systemic disorders, or malignant neoplasms. A rational therapeutic approach of vasculitis begins with the identification and stoppage of any suspected underlying condition. This may be all that is required for the treatment, because it is usually followed by the clearing of cutaneous lesions, and systemic signs and symptoms. In other cases, local and/or systemic anti-inflammatory and/or immunosuppressive therapy is recommended.
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Affiliation(s)
- Dionigi Tsampau
- University of Florence School of Medicine, University Unit of Dermatology, Florence, Italy
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14
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15
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Successful treatment of eosinophilic granulomatosis with polyangiitis (EGPA; formerly Churg–Strauss syndrome) with rituximab in a case refractory to glucocorticoids, cyclophosphamide, and IVIG. Mod Rheumatol 2012. [DOI: 10.1007/s10165-012-0808-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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The advantage of specific intravenous immunoglobulin (sIVIG) on regular IVIG: experience of the last decade. J Clin Immunol 2012; 33 Suppl 1:S27-32. [PMID: 23229779 DOI: 10.1007/s10875-012-9842-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 11/21/2012] [Indexed: 12/22/2022]
Abstract
During the last decade it has been shown that some components of intravenous immunoglobulin (IVIG) are responsible for their broadly therapeutic application. Currently, such specific subfractions are defined as specific IVIG (sIVIG) and are affinity-purified from commercial IVIGs that target specific antigens/antibodies related to a specific autoimmune disease. A remarkable example of the therapeutic potential of sIVIG is the proven enhanced anti-inflammatory potency of sialylated and recombinant sialylated IVIG obtained from total IVIG. In other experimental models, it has also been demonstrated that sIVIG work in many other contrivances, such as revealing anti-idiotypic networks blocking pathogenic antibodies ameliorating disease activity. sIVIG has also been shown to exert its action by modulating specific receptors expressed on immune cells in both inflammatory and autoimmune diseases. Indeed, sIVIG has emerged as a novel approach to treat different immune-mediated conditions in a more accurate antigen-specific manner. Herein we review experimental evidence supporting sIVIG-efficacy in treating autoimmune diseases and inflammation.
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Rana AQ, Adlul A. Delay in diagnosis of Churg-Strauss syndrome: a case report. Scott Med J 2012; 57:247. [PMID: 23028173 DOI: 10.1258/smj.2012.012111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Churg-Strauss syndrome (CSS) is a well established disorder of the blood vessels. However, it is still sometimes not diagnosed early enough to avoid serious complications. It is the later stage that carries the more serious complications. Therefore, we emphasize the ways in which the diagnosis can be made early enough to avoid this stage of the disease. We report a case of CSS that was not diagnosed early and so the patient went on to develop severe cardiac and neurological manifestations. In this report we discuss the techniques and the methods to diagnose CSS and discuss their effectiveness in establishing the diagnosis. We also explore late cardiac and neurological complications because these are particularly serious complications later in the disease. We conclude that the criteria established by the American College of Rheumatology for CSS is the best tool available for early diagnosis and that late stage manifestations of CSS carry high rates of morbidity and mortality.
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Affiliation(s)
- A Q Rana
- Parkinson's Clinic of Eastern Toronto and Movement Disorders Centre, Toronto, ON, Canada.
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Alfaro TM, Duarte C, Monteiro R, Simão A, Calretas S, Nascimento Costa JM. Churg-Strauss syndrome: case series. REVISTA PORTUGUESA DE PNEUMOLOGIA 2012; 18:86-92. [PMID: 22240164 DOI: 10.1016/j.rppneu.2011.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 08/29/2011] [Indexed: 11/18/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis of the small and medium vessels, associated with extravascular eosinophilic granulomas, peripheral eosinophilia and asthma. This is a rare syndrome of unknown etiology, affecting both genders and all age groups. CSS patients usually respond well to steroid treatment, although relapses are common after it ends. Timely diagnosis and treatment generally lead to a good prognosis with a 90% survival rate at one year. A brief review of CSS is presented, with particular attention to diagnosis, therapy and recent developments in this area. The authors then report and discuss the clinical, laboratory and imaging characteristics of four patients admitted to an Internal Medicine Department with this diagnosis. The treatment, response and follow-up of the cases are also described.
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Affiliation(s)
- T M Alfaro
- Serviço de Medicina Interna, Hospitais da Universidade de Coimbra, Coimbra, Portugal.
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Watanabe S, Aizawa-Yashiro T, Tsuruga K, Takahashi T, Ito E, Tanaka H. Successful multidrug treatment of a pediatric patient with severe Churg-Strauss syndrome refractory to prednisolone. TOHOKU J EXP MED 2012; 225:117-21. [PMID: 21914976 DOI: 10.1620/tjem.225.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Churg-Strauss syndrome (CSS), which is characterized by systemic small-vessel vasculitis of unknown etiology, is associated with a history of asthma. Although reports of CSS occurring in children are limited, effective treatment of pediatric patients with severe CSS remains challenging. A 10-year-old Japanese boy with a 6-month history of asthma treated with a leukotriene modifier, pranlukast, developed high fever, pleural infiltration, and pericarditis that were associated with marked hypereosinophilia (10,350 eosinophils/µl). Owing to his persistent high fever, mononeuritis multiplex, and severe abdominal pain that was refractory to prednisolone, his general condition progressively deteriorated thereafter. Although intravenous high-dose immunoglobulin administration was transiently effective for mononeuritis multiplex, the recurrent high fever and severe abdominal pain remained refractory. An endoscopic study revealed ulcerative lesions of the total colon. In this context, we treated the patient with an aggressive multidrug immunosuppressive regimen consisting of a high-dose methylprednisolone pulse plus short-course intravenous cyclophosphamide pulse therapy, followed by oral tacrolimus combined with prednisolone. After the rescue multidrug treatment, his severe clinical signs dramatically subsided within a short time, and the concomitantly administered prednisolone was successfully tapered without flare. At present, 12 months after the presentation, he is free from CSS signs or therapy-related toxicity except for an occasional mild asthma attack. Although further close observation should be needed to draw a long-term outcome in this patient, we believe that aggressive multidrug immunosuppressive treatment should be considered as an alternative rescue treatment in selected patients with severe CSS, even with pediatric-onset disease, that is refractory to prednisolone.
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Affiliation(s)
- Shojiro Watanabe
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
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TSUNO H, TAKAHASHI Y, YOSHIDA Y, ARAI N, NAKAMURA Y, YASHIRO S, MAKIZUMI M, YAMASHITA H, KANEKO H, KANO T, MIMORI A. Successful early treatment in a case of Cogan's syndrome. ACTA ACUST UNITED AC 2012; 35:92-6. [DOI: 10.2177/jsci.35.92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hirotaka TSUNO
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Yuko TAKAHASHI
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Yuji YOSHIDA
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Naotoshi ARAI
- Department of Neurology, National Center for Global Health and Medicine
| | - Yousuke NAKAMURA
- Department of Ophthalmology, National Center for Global Health and Medicine
| | - Seiko YASHIRO
- Department of Ophthalmology, National Center for Global Health and Medicine
| | - Masami MAKIZUMI
- Department of Otolaryngology•head and neck surgery, National Center for Global Health and Medicine
| | - Hiroyuki YAMASHITA
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Hiroshi KANEKO
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Toshikazu KANO
- Division of Rheumatic Diseases National Center for Global Health and Medicine
| | - Akio MIMORI
- Division of Rheumatic Diseases National Center for Global Health and Medicine
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Uchiyama M, Mitsuhashi Y, Yamazaki M, Tsuboi R. Elderly cases of Churg-Strauss syndrome: case report and review of Japanese cases. J Dermatol 2011; 39:76-9. [PMID: 22133207 DOI: 10.1111/j.1346-8138.2011.01316.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Churg-Strauss syndrome (CSS) is a vasculitis usually thought to affect comparatively young individuals, however, elderly cases of CSS are being reported increasingly. We report two elderly cases of CSS and review 123 cases of CSS reported in Japan between 2003 and 2010. The two patients showed typical features of CSS such as asthma, chronic sinusitis, purpura and mononeuritis multiplex. The biopsy specimens demonstrated leukocytoclastic vasculitis with infiltration of eosinophils. Both patients responded well to oral prednisolone. The age of the CSS cases we reviewed ranged from the teens to the 80s, with 47.2% of the patients aged 60 years or older. These patients tended more frequently to have complications such as gastrointestinal involvement, and a higher mortality rate. Elderly cases of CSS are not rare. Correct diagnosis at an earlier stage and careful, long-term follow up are of particular importance in preventing a fatal outcome.
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Affiliation(s)
- Masaki Uchiyama
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan.
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A fatal case of Churg-Strauss syndrome presenting with acute polyneuropathy mimicking Guillain-Barré syndrome. Neurol Sci 2011; 32:937-40. [PMID: 21533561 DOI: 10.1007/s10072-011-0591-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 02/16/2011] [Indexed: 10/18/2022]
Abstract
A 64-year-old woman, with asthma and sinusal polyposis in her history, suddenly developed a painful polyneuropathy with diplopia. Nerve conduction studies, performed at the very onset of the neuropathy, could not definitely rule out a Guillain-Barré syndrome (GBS) and high-dose i.v. immunoglobulins were administered. Clinical and laboratory findings subsequently supported the diagnosis of Churg-Strauss syndrome; corticosteroid therapy was started and clinical stabilisation of neuropathy was apparently achieved. No indicators of unfavourable outcome were present at that time. Nevertheless, 30 days after the onset the patient acutely worsened with severe polyneuropathy relapse and fatal systemic diffusion to heart, kidney and mesenteric district, which a single cyclophosphamide pulse failed to control. This case highlights the possibility that a GBS-like onset of Churg-Strauss syndrome neuropathy should be regarded as a part of multiorgan, severe or even life-threatening vasculitic involvement, requiring the most aggressive treatments, regardless of the presence of recognised factors of poor outcome.
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Kobayashi D, Wada Y, Takata T, Koya T, Murakami S, Ozawa T, Aizawa Y, Kuroda T, Nakano M, Narita I. A severe form of Churg-Strauss syndrome complicated with acute cardiac failure and rapidly progressive peripheral neuropathy--a possible effect of intravenous immunoglobulin therapy. Intern Med 2011; 50:925-9. [PMID: 21498944 DOI: 10.2169/internalmedicine.50.4648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of Churg-Strauss syndrome (CSS) complicated by severe cardiac failure and peripheral neuropathy. Two courses of methylprednisolone pulse therapy were unable to control the disease activity. Repeated intravenous administration of high-dose human immunoglobulin (IVIg) was added together with intravenous cyclophosphamide pulse therapy (IVCY), and the patient's cardiac function and neurological symptoms were gradually ameliorated without any adverse event. Although glucocorticoid and cyclophosphamide comprise the standard therapy for patients with CSS, a number of patients with severe complications appear to be resistant to such conventional treatment. IVIg is thought to be an effective therapeutic option for such patients.
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Affiliation(s)
- Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Department of Medicine II, Niigata University Graduate School of Medical and Dental Sciences, Japan.
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An abdominal presentation of churg-strauss syndrome. Case Rep Med 2010; 2010. [PMID: 20814555 PMCID: PMC2931397 DOI: 10.1155/2010/290654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Accepted: 07/03/2010] [Indexed: 11/23/2022] Open
Abstract
Churg-Strauss syndrome is a small and medium vessel vasculitis that is also known as allergic granulomatous angiitis. It most commonly presents with an asthma like symptoms. It was first described in Mount Siani Hospital, New York in 1951 by Jacob Churg and Lotte Stauss and was recognised after the study of a series of 13 patients who had asthma, eosinophilia, granulomatous
inflammation necrotising systemic vasculitis and necrotising glomerulonephritis. We describe a case of Churg-Strauss syndrome presenting with abdominal pain and later during the hospital admission a mono-neuritis multiplex syndrome affecting the lower limbs. The patient presented in such an atypical fashion with abdominal signs and symptoms that they required laparotomy and the diagnosis was made after histological examination of tissue taken at the time of surgery. Treatment with immunosuppression and aggressive rehabilitation achieved a progressive recovery which continued on discharge from hospital.
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25
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Bilateral exudative retinal detachment in Churg-Strauss syndrome controlled with intravenous immunoglobulin. Jpn J Ophthalmol 2010; 54:250-2. [DOI: 10.1007/s10384-009-0789-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 12/28/2009] [Indexed: 10/19/2022]
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Baldini C, Talarico R, Della Rossa A, Bombardieri S. Clinical manifestations and treatment of Churg-Strauss syndrome. Rheum Dis Clin North Am 2010; 36:527-43. [PMID: 20688248 DOI: 10.1016/j.rdc.2010.05.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis affecting small to medium-sized vessels, and characterized by asthma, blood hypereosinophilia, and eosinophil-rich granulomatous inflammation of the respiratory tract. In the past few years the pathogenesis of the disease and its clinical manifestations have been clarified, fostering important advances in the treatment of CSS. Systemic corticosteroids are still considered the cornerstone of treatment. Many issues need to be addressed, such as how to maintain remission, prevent disease relapses, and treat refractory disease. This review provides a clinical overview of CSS and a summary of the current treatments and novel therapies.
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Affiliation(s)
- Chiara Baldini
- Rheumatology Unit, Department of Internal Medicine, University of Pisa, 56126 Pisa, Italy
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Sunami K, Takayama M, Okabe Y, Yamane H, Tochino Y, Kodama T, Negoro N. [A case of Churg-Strauss syndrome following corticosteroid withdrawal]. ACTA ACUST UNITED AC 2009; 112:487-90. [PMID: 19610591 DOI: 10.3950/jibiinkoka.112.487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 56-year-old man with bilateral hearing impairment who had taken betamethasone combined with dexchlorpheniramine maleate for 7 years to treat chronic sinusitis developed a dry cough after discontinuing this medication and was diagnosed with asthma, and after which he sensed impaired bilateral hearing. Based on the presence of numerous eosinophilic leukocytes in otorrehea, we made a diagnosis of eosinophilic otitis media, and he was prescribed predonisolone to control the asthma, but discontinued it on his own. He then developed fever, maniphalanx stiffness, testicular pain, and facial hyperesthesia, eruptions, and the lower-limb numbness. The detection of a positive serum reaction for MPO-ANCA and evaluated of eosinophilic leukocyte levels yielded a definitive diagnosis of CSS, for which the man was treated with predonisolone and cyclophosphamide. His symptoms were relieved, even though the onset of neutropenia, necessitated the discontinuation of cyclophosphamade administration.
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Affiliation(s)
- Kishiko Sunami
- Department of Otorhinolaryngology, Graduate School of Medicine, Osaka City University, Osaka
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Nakamura M, Yabe I, Yaguchi H, Kishimoto R, Mito Y, Fujiki N, Houzen H, Tsuji-Akimoto S, Niino M, Sasaki H. Clinical characterization and successful treatment of 6 patients with Churg-Strauss syndrome-associated neuropathy. Clin Neurol Neurosurg 2009; 111:683-7. [PMID: 19647930 DOI: 10.1016/j.clineuro.2009.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 07/02/2009] [Accepted: 07/04/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To confirm the reported findings and clarify unknown clinical features of Churg-Strauss syndrome (CSS)-associated neuropathy and design appropriate treatment. PATIENTS AND METHODS We assessed the clinical features of 6 patients with CSS-associated neuropathy. RESULTS Mononeuritis multiplex was present in 4 cases and polyneuropathy in the remaining cases. Both groups progressed to sensori-motor polyneuropathy in an acute or subacute course. All cases showed bronchial asthma and eosinophilia. Two cases with serum antineutrophil cytoplasmic antibodies to myeloperoxidase (MPO-ANCA) had an acute clinical course and severe symptoms. Nerve conduction studies (NCS) of these 2 cases revealed conduction blocks at the initial stage, although NCS finally indicated sensori-motor axonopathy at the involved extremities. For treatment, high-dose corticosteroid therapy for 4 cases, and cyclophosphamide combined with corticosteroids for 1 case, were effective. For the remaining case, intravenous immunoglobulin (IVIg) at the chronic phase resulted in a slow improvement of neuropathy in the symptomatic aspect. There was no relapse of neuropathy with low-dose corticosteroid treatment for 14-24 months after the initial treatment, except 1 case. There was also no relapse in the other case that was treated with moderate-dose steroids. CONCLUSION Our study showed that CSS-associated neuropathy is a treatable disorder and that the first choice therapy is high-dose corticosteroid. In cases where corticosteroids are ineffective or for severe cases, immunosuppressive therapy (cyclophosphamide) with steroids should be considered, and IVIg might be a treatment option.
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Affiliation(s)
- Masakazu Nakamura
- Department of Neurology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan
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Abstract
Churg-Strauss syndrome (CSS) is a rare necrotizing small-vessel vasculitis associated with eosinophil-rich granulomatous inflammation of tissues and vessels and is also associated with asthma and eosinophilia. Epidemiologic studies continue to show that CSS is the rarest of the necrotizing small-vessel vasculitides. However, it is not possible to know with any certainty if there has been an increase in incidence. There has been an attempt to divide the patients with CSS into an antineutrophil cytoplasmic antibody-positive and cytoplasmic antibody-negative group. The former group has an increased frequency of renal involvement, parenchymal pulmonary disease, constitutional symptoms, and peripheral and central nervous system involvement, whereas the latter group has more frequent cardiac disease. The role of eosinophils and antineutrophil cytoplasmic antibodies remains poorly defined but provocative. Leukotriene receptor antagonists do not appear to induce CSS but facilitate the tapering of glucocorticoids, which unmasks the condition. Glucocorticoids and cyclophosphamide remain the foundation of treatment for vasculitis, but there are other promising and less toxic alternatives on the horizon.
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Affiliation(s)
- Rafael G Grau
- Indiana University School of Medicine, Division of Rheumatology, 1110 W. Michigan Street, LO-545, Indianapolis, IN 46202, USA.
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Riva N, Cerri F, Butera C, Amadio S, Quattrini A, Fazio R, Comola M, Comi G. Churg Strauss syndrome presenting as acute neuropathy resembling Guillain Barré syndrome: case report. J Neurol 2008; 255:1843-4. [PMID: 19156494 DOI: 10.1007/s00415-008-0035-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 05/05/2008] [Accepted: 06/26/2008] [Indexed: 12/27/2022]
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Taniguchi M, Higashi N, Ono E, Mita H, Akiyama K. Hyperleukotrieneuria in patients with allergic and inflammatory disease. Allergol Int 2008; 57:313-20. [PMID: 18946233 DOI: 10.2332/allergolint.08-rai-0040] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Indexed: 11/20/2022] Open
Abstract
Cysteinyl leukotrienes (CysLTs: leukotrienes C(4), D(4), and E(4)) have long been implicated in the pathogenesis of asthma and several allergic diseases. LTE(4) has been identified as a major metabolite of LTC(4), and urinary LTE(4) (U-LTE(4)) is considered as the most reliable analytic parameter for monitoring the endogenous synthesis of CysLTs. From recent studies on the U-LTE(4) associated with adult stable asthma we identified four factors for hyperleukotrieneuria, namely, aspirin intolerance, eosinophilic nasal polyposis (ENP), vasculitis, and severe asthma. In ENP, there is prominent infiltration of eosinophils in the sinus and polyp tissues, which is linked to adult asthma and aspirin sensitivity, and ENP is the most important factor for the overproduction of CysLTs in asthmatics. We also demonstrated that anaphylaxis and eosinophilic pneumonia (EP) are associated with a marked increase in the U-LTE(4) concentration. Under these disease conditions, U-LTE(4) may be one of the candidate biomarkers. Moreover, the changes in U-LTE(4) concentrations may provide valuable information concerning therapeutic targets.
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Affiliation(s)
- Masami Taniguchi
- Clinical Research Center, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan.
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Ribi C, Cohen P, Pagnoux C, Mahr A, Arène JP, Lauque D, Puéchal X, Letellier P, Delaval P, Cordier JF, Guillevin L. Treatment of Churg-Strauss syndrome without poor-prognosis factors: A multicenter, prospective, randomized, open-label study of seventy-two patients. ACTA ACUST UNITED AC 2008; 58:586-94. [DOI: 10.1002/art.23198] [Citation(s) in RCA: 239] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vrancken AFJE, Hughes RAC, Said G, Wokke JHJ, Notermans NC. Immunosuppressive treatment for non-systemic vasculitic neuropathy. Cochrane Database Syst Rev 2007:CD006050. [PMID: 17253577 DOI: 10.1002/14651858.cd006050.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Non-systemic vasculitic neuropathy is a rare disabling disease that usually has a subacute onset of progressive or relapsing-remitting sensory or sensorimotor deficits. Asymmetry, pain and weakness are key features. The diagnosis can only be made by exclusion of other causes, the absence of systemic vasculitis or other rheumatic diseases, and the demonstration of vasculitis in a nerve or a combined nerve and muscle biopsy. There is a need for efficacious therapy to prevent disease progression and to improve prognosis. OBJECTIVES To assess if immunosuppressive treatment in non-systemic vasculitic neuropathy reduces disability, and ameliorates neurological symptoms, and if such therapy can be given safely. SEARCH STRATEGY The Cochrane Neuromuscular Disease Group Trials Register (March 2006), The Cochrane Library (Issue 1, 2006), MEDLINE, EMBASE, LILACS, and ISI were searched from January 1980 until April 2006. In addition, the reference lists of relevant articles, reviews and textbooks were handsearched. SELECTION CRITERIA All randomised or quasi-randomised trials that examined the efficacy of immunosuppressive treatment for non-systemic vasculitic neuropathy at least one year after the onset of therapy were sought. Participants had to fulfill the following criteria: absence of systemic or neurological disease, exclusion of any recognised cause of the neuropathy by appropriate clinical or laboratory investigations, electrophysiological studies in agreement with axonal neuropathy, confirmation of vasculitis in a nerve or a combined nerve and muscle biopsy. The primary outcome measure was to be improvement in disability. Secondary outcome measures were to be change in the mean disability score, change in muscle strength measured with the Medical Research Council sum score, change in pain or other positive sensory symptoms, number of relapses, and adverse events. DATA COLLECTION AND ANALYSIS Two authors independently reviewed and extracted details of all potentially relevant trials. For included studies pooled relative risks and pooled weighted standardised mean differences were to be calculated to assess treatment efficacy. MAIN RESULTS Fifty-nine studies were identified and assessed for possible inclusion in the review, but all were excluded because of insufficient quality or lack of relevance. AUTHORS' CONCLUSIONS No adequate randomised or quasi-randomised controlled clinical trials have been performed on which to base treatment for non-systemic vasculitic neuropathy. Randomised trials of corticosteroids and other immunosuppressive agents are needed.
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Affiliation(s)
- A F J E Vrancken
- University Medical Center Utrecht, Department of Neurology, The Rudolf Magnus Institute for Neuroscience, Heidelberglaan 100, PO Box 85500, Utrecht, Netherlands, 3508 GA.
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Taniguchi M, Higashi N, Isii T, Yamamoto K, Mita H, Akiyama K. Role of cysteinyl-leukotrienes in the pathogenesis of nasal polyposis in patients with asthma. Inflamm Regen 2007. [DOI: 10.2492/inflammregen.27.565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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