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Gilvaz VJ, Treaba D, Cunha JS. Fifty-Nine-Year-Old Male Patient Presenting With Ulcerating Palatal Lesions. Arthritis Care Res (Hoboken) 2024; 76:753-759. [PMID: 38508703 DOI: 10.1002/acr.25324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/17/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Vinit J Gilvaz
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Diana Treaba
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joanne S Cunha
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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2
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Teames C, Highland J, Cox D, Elstad M, Koening C, Smith M. The Diagnosis of Granulomatosis With Polyangiitis When Serology and Biopsies are Negative. OTO Open 2024; 8:e138. [PMID: 38751426 PMCID: PMC11094516 DOI: 10.1002/oto2.138] [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: 07/13/2023] [Accepted: 08/09/2023] [Indexed: 05/18/2024] Open
Abstract
Objective Granulomatosis with polyangiitis (GPA) is a potentially fatal condition which often manifests in the head and neck. Currently, diagnosis relies on antineutrophil cytoplasmic autoantibody (c-ANCA) serology and mucosal or renal biopsy. However, a significant proportion of patients with GPA limited to the head and neck are seronegative and biopsy negative. This study evaluates the role of clinical diagnosis of GPA in the absence of positive laboratory findings. Study Design Case series with chart review. Setting Academic Tertiary Medical Center. Methods This was a retrospective review of 143 patients treated in an outpatient otolaryngology clinic at a tertiary care hospital for known or suspected GPA from 1998 to 2021. Presenting symptoms, C-ANCA status at initial presentation, biopsy results, long-term serology results, and time to initiation of treatment were analyzed. Results Twenty-six of 143 (18.2%) patients were seronegative; only 3 of these patients (12%) had positive biopsies. Seventeen (73.9%) of these patients presented with nasal and sinus disease and 12 (52.2%) presented with airway involvement. Only 4 (17.4%) patients had renal involvement. Delay in treatment of patients with negative laboratory workup ranged from 0 months to 11 years. All patients who were seronegative and/or biopsy negative at presentation responded clinically to immunosuppressive therapy. Conclusion GPA cases are often limited to the upper respiratory tract, making diagnosis difficult, particularly in seronegative patients. These results suggest that, when GPA is suspected, despite negative serology, the diagnosis of GPA should be made on clinical grounds, and empiric therapy encouraged to prevent delay in treatment.
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Affiliation(s)
- Charles Teames
- Spencer Fox Eccles School of MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Julie Highland
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Daniel Cox
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Mark Elstad
- Department of Internal MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Curry Koening
- Department of Internal MedicineUniversity of Texas at AustinAustinTexasUSA
| | - Marshall Smith
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
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3
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Alameri M, Alnuaimi A, Martin NM, Meeran K, Gontsarova A, Barwick TD, Ellis S, McAdoo S, Tomlinson J, Wernig F. Pituitary hypophysitis in granulomatosis with polyangiitis (GPA): a case series. Pituitary 2024; 27:230-237. [PMID: 38296897 PMCID: PMC11009729 DOI: 10.1007/s11102-023-01378-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 02/02/2024]
Abstract
Granulomatosis with polyangiitis (GPA) rarely involves the pituitary gland. Pituitary involvement has been reported in ~ 1% of all cases of GPA. Most commonly, pituitary swelling and inflammation results in symptoms due to pituitary mass effect and arginine vasopressin deficiency. To date, there are no pituitary-specific treatment guidelines for this rare condition. We present three patients with GPA-related hypophysitis highlighting the spectrum of pituitary involvement. All three patients were successfully treated with immunosuppressive regimens that included rituximab (RTX). Following remission induction with high-dose glucocorticoids, patients received 6 monthly RTX for remission maintenance. RTX was well tolerated without significant side effects.
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Affiliation(s)
- Majid Alameri
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Abdulla Alnuaimi
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Niamh M Martin
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Tara D Barwick
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Spencer Ellis
- Department of Rheumatology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Stephen McAdoo
- Department of Renal Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Immunology & Inflammation, Imperial College London, London, UK
| | - James Tomlinson
- Department of Renal Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK.
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4
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Rimmer J, Lund VJ. Non-Eosinophilic Granulomatous Disease and the Unified Airway. Otolaryngol Clin North Am 2023; 56:83-95. [DOI: 10.1016/j.otc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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5
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[Biopsy diagnostics of ANCA-associated vasculitides in the ENT tract]. Z Rheumatol 2023; 82:53-55. [PMID: 36542099 PMCID: PMC9894962 DOI: 10.1007/s00393-022-01303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
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6
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Chevet B, Cornec D, Casal Moura M, Cornec-Le Gall E, Fervenza FC, Warrington KJ, Specks U, Berti A. Diagnosing and treating ANCA-associated vasculitis: an updated review for clinical practice. Rheumatology (Oxford) 2022; 62:1787-1803. [PMID: 36315063 DOI: 10.1093/rheumatology/keac623] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/14/2022] [Accepted: 10/05/2022] [Indexed: 03/29/2023] Open
Abstract
Abstract
ANCA-associated vasculitides (AAV) are a group of rare, primary, systemic necrotizing small-vessel vasculitides. Granulomatosis with polyangiitis and microscopic polyangiitis account for ∼80–90% of all AAV. Exposure to silica dust, farming and chronic nasal Staphylococcus aureus carriage are associated with increased risk of developing AAV. When a diagnosis of AAV is suspected, as in patients with multisystem organ dysfunction or those with features such as chronic recurrent rhinosinusitis, cavitated lung nodules, palpable purpura or acute kidney injury, then appropriate further investigations are needed, including ANCA testing. In this scenario, a structured clinical assessment should be conducted, evaluating all the organs possibly involved, and tissue biopsy may be necessary for confirmation of the diagnosis. Therapeutic algorithms vary based on the severity of AAV, the clinical diagnosis/ANCA specificity, and the patient’s age, weight, comorbidities and prognosis. Recent data favour rituximab as a preferable option for both induction and maintenance of remission. In addition, regimens with less glucocorticoids are equally effective and safer in inducing remission compared with conventional regimens, and avacopan is an effective glucocorticoid-sparing option. In contrast, there is not compelling evidence to support the routine use of plasma exchange in addition to standard remission-induction therapy in AAV. ANCA and other biomarkers can be helpful in association with clinical assessment to guide diagnosis and treatment decisions. Patients should be frequently evaluated during follow-up for possible disease relapses or treatment-related morbidity, and for monitoring damage accrual, especially metabolic and cardiovascular damage.
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Affiliation(s)
- Baptiste Chevet
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Divi Cornec
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Marta Casal Moura
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | | | | | - Ulrich Specks
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Italy
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7
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What to Know About Biopsy Sampling and Pathology in Vasculitis? Curr Rheumatol Rep 2022; 24:279-291. [PMID: 35895226 DOI: 10.1007/s11926-022-01082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize the histologic findings of vasculitis, and to give some practical considerations on biopsy samples. RECENT FINDINGS The larger use of imaging and the discoveries of serological markers in the diagnosis of vasculitis have increased the clinical recognition of these entities. Nevertheless, biopsy remains the gold standard for diagnosis in most cases. So far, biopsies are also useful to obtain information about prognosis and to guide a more specific treatment. In recent years, less invasive diagnostic approaches have become available, lowering the risks related to the procedure and permitting a definite diagnosis in most cases. Histological examination permits a definite diagnosis of vasculitis. However, the findings may be nonspecific if not evaluated in the proper clinical setting. The interaction between clinicians and pathologists is crucial to obtain a definite diagnosis.
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Cruz J, Vargas D, Goecke A, Molina ML. An unusual extranodal natural killer/T-cell lymphoma presenting as chronic laryngitis: A case report. Medicine (Baltimore) 2021; 100:e26314. [PMID: 34160395 PMCID: PMC8238288 DOI: 10.1097/md.0000000000026314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Nasal-type, extranodal natural killer (NK)/T-cell lymphoma is a rare lymphoma. The tumor usually shows ulcerative and necrotic lesions in the nasal cavities and sinuses. Tissue involvement outside the nasal cavity is uncommon. PATIENT CONCERN We describe a 30-year-old man with a 2-month history of hoarseness, weight loss, and dyspnea. DIAGNOSIS Magnetic resonance image (MRI) showed edema of the larynx with obliteration of the airway. Laryngoscopic examination described necrotic tissue in the glottis and larynx. The biopsy showed chronic, necrotizing laryngitis, with no granulomas, vasculitis, or atypical cells. The immunologic and microbiologic study was negative. Later, after immunosuppressive therapy, the patient presented erythema and diffuse enlargement of the right arm. MRI showed myositis of the biceps and brachial muscles. Infection was rule out, and direct microscopy showed an extensive muscle infiltration by mononuclear cells and abundant mitosis. Immunohistochemistry was positive for CD3, CD8, Ki 67 (90%), and CD56 compatible with extranodal NK/T cell lymphoma. INTERVENTIONS The patient initially received immunosuppression treatments (corticoids, cyclofosfamide, and Rituximab) with relapsing episodes. When lymphoma was diagnosed, chemotherapy was started. OUTCOMES The patient died during chemotherapy. LESSONS Nasal-type, extranodal NK/T-cell lymphoma should be suspected even when there are no classical findings of neoplasms on histology. Immunohistochemistry is mandatory to rule it out.
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9
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Coates ML, Martinez Del Pero M. Updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for the ENT surgeon. Clin Otolaryngol 2020; 45:316-326. [PMID: 32145151 DOI: 10.1111/coa.13524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/13/2020] [Accepted: 02/29/2020] [Indexed: 12/31/2022]
Abstract
ENT involvement is common in ANCA-associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.
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10
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Echeagaray H, Tona G, Rivera-Rosales RM, Ruiz N, Castorena-Maldonado A, Flores-Suárez LF. Airway Biopsy Results From Patients With Suspected Granulomatosis With Polyangiitis (2005-2015): Clinicopathological Correlation and Proposal of an Algorithm to Improve Diagnosis. Ann Otol Rhinol Laryngol 2019; 128:708-714. [PMID: 30924348 DOI: 10.1177/0003489419839092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to review the histologic diagnostic yield of airway biopsies with a suspected granulomatosis with polyangiitis (GPA) diagnosis at a single center devoted to respiratory diseases using previously published criteria. A secondary aim was to apply the algorithm proposed by the European Medicines Agency to determine whether more biopsies were confidently identified as having GPA diagnoses. METHODS From a total of 132 airway biopsies (2005-2015), 50 were randomly selected for second review by an expert pathologist, and previously published criteria were applied. Thereafter, antineutrophil cytoplasm autoantibody testing results and the European Medicines Agency algorithm were applied. RESULTS Repeat review and application of the published criteria resulted in an increase from 16 to 25 diagnoses of GPA. This increased to 35 of 50 when antineutrophil cytoplasm autoantibody results and the European Medicines Agency algorithm were applied. Interobserver correlation was 57.5% among pathologists (κ = 0.19), which was likely due to missing clinical information and inadequate tissue samples. Patients with generalized disease were 2.6 times more likely to obtain diagnostic GPA airway biopsy results than those with limited disease (airway only). CONCLUSIONS An increase in the diagnostic yield of this malady could be attained by following an algorithm that incorporates carefully retrieved clinical, endoscopic, and serologic data, coupled with systematic histopathologic sample review.
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Affiliation(s)
- Héctor Echeagaray
- 1 Instituto Nacional de Enfermedades Respiratorias, Mexico, Mexico City, Mexico
| | - Gabriel Tona
- 1 Instituto Nacional de Enfermedades Respiratorias, Mexico, Mexico City, Mexico
| | | | - Natllely Ruiz
- 1 Instituto Nacional de Enfermedades Respiratorias, Mexico, Mexico City, Mexico
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11
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Yoo J, Ahn SS, Jung SM, Song JJ, Park YB, Lee SW. Should nasal biopsy inevitably be performed for classifying granulomatosis with polyangiitis in patients with rhinosinusitis? A retrospective chart review study. Rheumatol Int 2019; 39:885-892. [PMID: 30887162 DOI: 10.1007/s00296-019-04282-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/12/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Juyoung Yoo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea. .,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, South Korea.
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12
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Lyndon D, Lansley JA, Evanson J, Krishnan AS. Dural masses: meningiomas and their mimics. Insights Imaging 2019; 10:11. [PMID: 30725238 PMCID: PMC6365311 DOI: 10.1186/s13244-019-0697-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/15/2019] [Indexed: 02/08/2023] Open
Abstract
Meningiomas are the most common dural tumour. They are regularly being seen as an incidental finding on brain imaging and treated conservatively. However, there are many other dural masses which mimic their appearances, including primary neoplastic processes, metastases, granulomatous diseases and infection. While some of these are rare, others such as metastases and tuberculosis arise relatively frequently in practice. Although not pathognomonic, key features which increase the probability of a lesion being a meningioma include intralesional calcifications, skull hyperostosis, local dural enhancement and increased perfusion. It is important to have an awareness of these entities as well as their main imaging findings, as they have a wide range of prognoses and differing management strategies. This review outlines several of the most important mimics along with their imaging findings on both standard and advanced techniques with key features which may be used to help differentiate them from meningiomas.
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Affiliation(s)
- Daniel Lyndon
- Department of Neuroradiology, St Bartholomew's and the Royal London Hospitals, Whitechapel, London, E1 1BB, UK.
| | - Joseph A Lansley
- Department of Neuroradiology, St Bartholomew's and the Royal London Hospitals, Whitechapel, London, E1 1BB, UK
| | - Jane Evanson
- Department of Neuroradiology, St Bartholomew's and the Royal London Hospitals, Whitechapel, London, E1 1BB, UK
| | - Anant S Krishnan
- Department of Neuroradiology, St Bartholomew's and the Royal London Hospitals, Whitechapel, London, E1 1BB, UK
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13
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Beltrán Rodríguez-Cabo O, Reyes E, Rojas-Serrano J, Flores-Suárez LF. Increased histopathological yield for granulomatosis with polyangiitis based on nasal endoscopy of suspected active lesions. Eur Arch Otorhinolaryngol 2017; 275:425-429. [DOI: 10.1007/s00405-017-4841-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
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Abstract
Vasculitides comprise several diseases affecting vessels of different sizes, mainly arteries, but also capillaries and veins. Antineutrophil cytoplasm antibody-associated vasculitides (AAVs) belong to the systemic necrotizing small-vessel vasculitis group that comprises granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Internists often see AAV patients, and although their outcomes are usually good, the disease can be responsible for morbidity and mortality. Herein, after reviewing the literature, we concentrate on selected aspects important for the internist, including classification, diagnostic dilemmas, treatment novelties, and follow-up.
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Affiliation(s)
- Benjamin Chaigne
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
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15
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Abstract
Systemic and odontogenic etiologies of chronic rhinosinusitis, although rare, are an integral consideration in the comprehensive management of patients with sinonasal disease. Proper knowledge and timely recognition of each disease process, with referrals to appropriate consultants, will facilitate treatment, because many of these conditions require both local and systemic therapy. In some instances, medical therapy plays a pivotal role, with surgery being a supplemental treatment technique. We review the most commonly encountered systemic etiologies of chronic rhinosinusitis and odontogenic sinusitis, including clinical presentation, diagnosis, management, and treatment outcomes.
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Affiliation(s)
- Edward C Kuan
- Department of Head and Neck Surgery, University of California, Los Angeles (UCLA) Medical Center, 10833 Le Conte Avenue, 62-132 CHS, Los Angeles, CA 90095, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, University of California, Los Angeles (UCLA) Medical Center, 10833 Le Conte Avenue, 62-132 CHS, Los Angeles, CA 90095, USA.
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16
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Wojciechowska J, Krajewski W, Krajewski P, Kręcicki T. Granulomatosis With Polyangiitis in Otolaryngologist Practice: A Review of Current Knowledge. Clin Exp Otorhinolaryngol 2016; 9:8-13. [PMID: 26976020 PMCID: PMC4792240 DOI: 10.21053/ceo.2016.9.1.8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/16/2015] [Accepted: 02/23/2015] [Indexed: 12/27/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an idiopathic vasculitis of medium and small arteries, characterized by necrotizing granulomatous inflammation. GPA typically affects upper and lower respiratory tract with coexisting glomerulonephritis. This disease is generally characterized by antineutrophil cytoplasm antibodies (ANCA), nevertheless, there are rare cases with negative ANCA. GPA affects people at any age, with predominance of the sixth and seventh decade of life. In 80%-95% of the patients the first symptoms of GPA are otorhinolaryngological manifestations of head and neck including nose/sinuses, ears, eyes, larynx/trachea, oral cavity, and salivary glands. Diagnosis of GPA is based on Criteria of the American College of Rheumatology. In clinical practice diagnosis, the presence of distinctive ANCA antibodies and biopsy of affected organ are crucial. GPA must be differentiated from neoplastic, infectious or inflammatory ulcerative lesions of the head and neck. The standard treatment procedure is divided into two essential phases, induction and maintenance. The induction phase is based on combination of systemic corticosteroid and immunosuppressant therapy, whereas the maintenance phase comprises corticosteroids and azathioprine/methotrexate supplementation. Surgical treatment ought to be considered for patients who are not responding to pharmacotherapy.
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Affiliation(s)
| | | | - Piotr Krajewski
- Department of Urology, Wrocław Medical University, Wrocław, Poland
| | - Tomasz Kręcicki
- Department and Clinic of Otolaryngology-Head and Neck Surgery, Wrocław, Poland
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17
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Choe AR, Kim IJ, Lee J, Sung SH. Outcome of Localized Granulomatosis with Polyangiitis: A Case Study. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.3.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- A Reum Choe
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - In Je Kim
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sun Hee Sung
- Department of Pathology, Ewha Womans University School of Medicine, Seoul, Korea
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18
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Rosenbaum JT, Sibley CH, Choi D, Harrington CA, Planck SR. Molecular diagnosis: Implications for ophthalmology. Prog Retin Eye Res 2015; 50:25-33. [PMID: 26608807 DOI: 10.1016/j.preteyeres.2015.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/11/2015] [Accepted: 11/13/2015] [Indexed: 12/21/2022]
Abstract
The effort to subdivide diseases and to individualize therapies based on characteristics of the patient has been labeled precision medicine. Jameson and Longo define precision medicine as "treatments targeted to the needs of individual patients on the basis of genetic, biomarker, phenotypic or psychosocial characteristics that distinguish a given patient from other patients with similar clinical presentations" (Jameson and Longo, 2015). We illustrate how molecular diagnosis can be applied to orbital inflammatory disease to achieve the goals of precision medicine.
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Affiliation(s)
- James T Rosenbaum
- Devers Eye Institute, Legacy Health Systems, 1040 NW 22nd Avenue, Portland, OR 97210, USA; Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Cailin H Sibley
- Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Dongseok Choi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; OHSU-PSU School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Christina A Harrington
- Integrated Genomics Laboratory, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Stephen R Planck
- Devers Eye Institute, Legacy Health Systems, 1040 NW 22nd Avenue, Portland, OR 97210, USA; Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
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19
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McGeoch L, Twilt M, Famorca L, Bakowsky V, Barra L, Benseler SM, Cabral DA, Carette S, Cox GP, Dhindsa N, Dipchand CS, Fifi-Mah A, Goulet M, Khalidi N, Khraishi MM, Liang P, Milman N, Pineau CA, Reich HN, Samadi N, Shojania K, Taylor-Gjevre R, Towheed TE, Trudeau J, Walsh M, Yacyshyn E, Pagnoux C. CanVasc Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitides. J Rheumatol 2015; 43:97-120. [DOI: 10.3899/jrheum.150376] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 01/14/2023]
Abstract
Objective.The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties and researchers with expertise in vasculitis. One of its aims is to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada.Methods.Diagnostic and therapeutic questions were developed based on the results of a national needs assessment survey. A systematic review of existing non-Canadian recommendations and guidelines for the diagnosis and management of AAV and studies of AAV published after the 2009 European League Against Rheumatism/European Vasculitis Society recommendations (publication date: January 2009) until November 2014 was performed in the Medline database, Cochrane library, and main vasculitis conference proceedings. Quality of supporting evidence for each therapeutic recommendation was graded. The full working group as well as additional reviewers, including patients, reviewed the developed therapeutic recommendations and nontherapeutic statements using a modified 2-step Delphi technique and through discussion to reach consensus.Results.Nineteen recommendations and 17 statements addressing general AAV diagnosis and management were developed, as well as appendices for practical use, for rheumatologists, nephrologists, respirologists, general internists, and all other healthcare professionals more occasionally involved in the management of patients with AAV in community and academic practice settings.Conclusion.These recommendations were developed based on a synthesis of existing international guidelines, other published supporting evidence, and expert consensus considering the Canadian healthcare context, with the intention of promoting best practices and improving healthcare delivery for patients with AAV.
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20
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Rosenbaum JT, Choi D, Wilson DJ, Grossniklaus HE, Harrington CA, Sibley CH, Dailey RA, Ng JD, Steele EA, Czyz CN, Foster JA, Tse D, Alabiad C, Dubovy S, Parekh PK, Harris GJ, Kazim M, Patel PJ, White VA, Dolman PJ, Korn BS, Kikkawa DO, Edward DP, Alkatan HM, al-Hussain H, Yeatts RP, Selva D, Stauffer P, Planck SR. Orbital pseudotumor can be a localized form of granulomatosis with polyangiitis as revealed by gene expression profiling. Exp Mol Pathol 2015; 99:271-8. [PMID: 26163757 PMCID: PMC4591186 DOI: 10.1016/j.yexmp.2015.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 01/05/2023]
Abstract
Biopsies and ANCA testing for limited forms of granulomatosis with polyangiitis (GPA) are frequently non-diagnostic. We characterized gene expression in GPA and other causes of orbital inflammation. We tested the hypothesis that a sub-set of patients with non-specific orbital inflammation (NSOI, also known as pseudotumor) mimics a limited form of GPA. Formalin-fixed, paraffin-embedded orbital biopsies were obtained from controls (n=20) and patients with GPA (n=6), NSOI (n=25), sarcoidosis (n=7), or thyroid eye disease (TED) (n=20) and were divided into discovery and validation sets. Transcripts in the tissues were quantified using Affymetrix U133 Plus 2.0 microarrays. Distinct gene expression profiles for controls and subjects with GPA, TED, or sarcoidosis were evident by principal coordinate analyses. Compared with healthy controls, 285 probe sets had elevated signals in subjects with GPA and 1472 were decreased (>1.5-fold difference, false discovery rate adjusted p<0.05). The immunoglobulin family of genes had the most dramatic increase in expression. Although gene expression in GPA could be readily distinguished from gene expression in TED, sarcoidosis, or controls, a comparison of gene expression in GPA versus NSOI found no statistically significant differences. Thus, forms of orbital inflammation can be distinguished based on gene expression. NSOI/pseudotumor is heterogeneous but often may be an unrecognized, localized form of GPA.
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Affiliation(s)
- James T Rosenbaum
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA; Devers Eye Institute, Legacy Health Systems, Portland, OR 97210, USA.
| | - Dongseok Choi
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA; Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
| | - David J Wilson
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA.
| | | | - Christina A Harrington
- Integrated Genomics Laboratory, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Cailin H Sibley
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Roger A Dailey
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA.
| | - John D Ng
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Eric A Steele
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Craig N Czyz
- Division of Ophthalmology, Ohio University, Columbus, OH 43228, USA.
| | - Jill A Foster
- Department of Ophthalmology, The Ohio State University, Columbus, OH 43215, USA.
| | - David Tse
- Department of Ophthalmology, University of Miami, FL 33101, USA.
| | - Chris Alabiad
- Department of Ophthalmology, University of Miami, FL 33101, USA.
| | - Sander Dubovy
- Department of Ophthalmology, University of Miami, FL 33101, USA.
| | | | - Gerald J Harris
- Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | - Michael Kazim
- Department of Ophthalmology, Columbia University, New York, NY 10032, USA.
| | - Payal J Patel
- Department of Ophthalmology, Columbia University, New York, NY 10032, USA.
| | - Valerie A White
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia V5Z 3N9, Canada.
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia V5Z 3N9, Canada.
| | - Bobby S Korn
- Department of Ophthalmology, University of California, San Diego, CA 92037, USA.
| | - Don O Kikkawa
- Department of Ophthalmology, University of California, San Diego, CA 92037, USA.
| | - Deepak P Edward
- Research Department, King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia.
| | - Hind M Alkatan
- Research Department, King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia.
| | - Hailah al-Hussain
- Research Department, King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia.
| | - R Patrick Yeatts
- Department of Ophthalmology, Wake Forrest University, Winston-Salem, NC 27103, USA.
| | - Dinesh Selva
- Ophthalmology Network, Royal Adelaide Hospital, Adelaide 5000, Australia.
| | - Patrick Stauffer
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Stephen R Planck
- Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA; Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA; Devers Eye Institute, Legacy Health Systems, Portland, OR 97210, USA.
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21
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McConnell B, Said MS, Ramakrishnan VR. Nasal septal perforation associated with pyoderma gangrenosum. ALLERGY & RHINOLOGY 2015; 6:122-4. [PMID: 26302733 PMCID: PMC4541633 DOI: 10.2500/ar.2015.6.0118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Pyoderma gangrenosum (PG) is a skin condition characterized by necrotic ulcers and most commonly occurs on the legs in association with inflammatory bowel disease and rheumatoid arthritis; however, PG rarely involves the head and neck, and very rarely causes nasal septal perforation. Objective: Here, we describe a case report of PG causing nasal septal perforation in a 71-year-old male with truncal lesions in the absence of either inflammatory bowel disease or autoimmune arthritis. Methods: Case report with histologic description. Results: Histology from nasal mucosal biopsies showed chronic inflammation and reactive change without evidence of malignancy. Together with serologic and nonserologic testing, as well as clinical evaluation, we were able to rule out other causes of septal perforation including Wegener's granulomatosis, lymphoma, and vasculitis, and concluded that the cause of nasal septal perforation was most likely PG. Conclusion: Septal perforation etiology should include a complete history and physical to evaluate for systemic etiologies, including rare ones such as PG.
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Affiliation(s)
- Brook McConnell
- Department of Otolaryngology, University of Colorado, Aurora, Colorado, USA
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22
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Janisiewicz AM, Klau MH, Keschner DB, Lehmer RR, Venkat KV, Medhekar SS, Chang PK, Badran K, Leary R, Garg R, Nguyen AA, Lee JT. Higher Antineutrophil Cytoplasmic Antibody (C-ANCA) Titers are Associated with Increased Overall Healthcare Use in Patients with Sinonasal Manifestations of Granulomatosis with Polyangiitis (GPA). Am J Rhinol Allergy 2015; 29:202-6. [DOI: 10.2500/ajra.2015.29.4147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by necrotizing granulomatous airway inflammation and vasculitis. Sinonasal involvement occurs in more than 80% cases, with antineutrophil cytoplasmic antibody (C-ANCA) titers used as a marker of disease severity. The purpose of this study was to determine whether C-ANCA levels impact radiographic findings and healthcare use in patients with sinonasal GPA. Methods A retrospective review was performed on GPA patients evaluated in a multidisciplinary rheumatologic/otolaryngologic clinic from 2008 to 2013. Data were collected with respect to age, gender, clinical presentation, C-ANCA titers, Lund-Mackay (LM) scores, surgical interventions, and healthcare use, the latter of which were determined by assessing the number of rheumatology/otolaryngology clinic visits, computed tomography (CT) scans, and email/telephone encounters. Results A total of 44 patients were identified, 11 male and 33 female. Sinonasal manifestations were evident in 70.4%, with chronic rhinosinusitis (CRS) (41.9%), septal perforation (38.7%), and crusting (32.2%) the most common findings. No significant differences in number of CT scans (p = 0.10) or mean LM scores (p = 0.47) were found between patients with more than or equal to 1:80 and less than 1:80 C-ANCA titers, respectively. However, overall healthcare use was increased in the more than or equal to 1:80 C-ANCA group (n = 28) compared with less than 1:80 (n = 16), with a significantly greater number of rheumatologic/otolaryngologic encounters (mean 121 versus 69.2, p = 0.03) noted. When otolaryngologic healthcare use was specifically examined, the average number of encounters was also higher in more than or equal to 1:80 C-ANCA patients (31.9 versus 22.9), but this difference was not statistically significant (p = 0.16). Conclusion Sinonasal GPA patients with presenting C-ANCA titers more than or equal to 1:80 demonstrated significantly greater overall healthcare use than their lower C-ANCA level counterparts (less than 1:80). However, no significant differences in otolaryngology resource use or LM scores were evident between the two titer groups.
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Affiliation(s)
| | - Marc H. Klau
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - David B. Keschner
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Randy R. Lehmer
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Kumar V. Venkat
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Swati S. Medhekar
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Parke K. Chang
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Karam Badran
- University of California, Irvine School of Medicine, Irvine, California
| | - Ryan Leary
- University of California, Irvine School of Medicine, Irvine, California
| | - Rohit Garg
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Andrew A. Nguyen
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Jivianne T. Lee
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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23
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Trimarchi M, Bozzolo E, Pilolli F, Bertazzoni G, Campochiaro C, Sabbadini MG, Bussi M. Nasal mucosa narrow band imaging in granulomatosis with polyangiitis (Wegener granulomatosis): A preliminary study. Am J Rhinol Allergy 2015; 29:170-4. [PMID: 25781561 DOI: 10.2500/ajra.2015.29.4169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Narrow band imaging (NBI) endoscopy is a technique that allows for real-time visualization of mucosal and submucosal vascular patterns. OBJECTIVE Because granulomatosis with polyangiitis (GPA) (Wegener granulomatosis) is an autoimmune disease defined by vascular inflammation, we examined patients with GPA and with NBI to evaluate whether disease-specific mucosal vascular patterns were present. To the best of our knowledge, the use of NBI endoscopy for assessment of an immune system disease such as GPA has never been previously attempted. METHODS We conducted a prospective observational study by performing an endoscopic evaluation of upper airways with NBI on patients diagnosed with GPA; on patients with symptoms and signs suggestive for GPA, who were scheduled to undergo nasal biopsy to confirm diagnosis; on patients affected by chronic rhinosinusitis with nasal polyps; and on healthy controls. RESULTS We enrolled 69 patients. NBI vascular patterns in patients with GPA were consistently and recognizably different from healthy mucosal patterns in 53% of our cases. In patients with GPA, biopsy and NBI results were for the most part comparable, except for three cases. CONCLUSION Nasal mucosa NBI endoscopy can be considered a promising rapid and noninvasive live imaging technique for nasal mucosa GPA that, based on further study, could become a supplementary diagnostic tool in the complex workup of GPA and vasculitis.
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Affiliation(s)
- Matteo Trimarchi
- Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy
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Lally L, Spiera R. Current Landscape of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Rheum Dis Clin North Am 2015; 41:1-19, vii. [DOI: 10.1016/j.rdc.2014.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Dimitrijevic I, Edvinsson L. Increased endothelin 1 type B receptors in nasal lesions of patients with granulomatosis with polyangiitis. Am J Rhinol Allergy 2014; 27:444-50. [PMID: 24274217 DOI: 10.2500/ajra.2013.27.3954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endothelin 1 (ET-1) is a locally produced vasoactive peptide with proinflammatory capabilities. Systemic levels of ET-1 seem elevated in granulomatosis with polyangiitis (GPA). The aim of this study was to examine the involvement of the endothelin system in patients with GPA using nasal mucosal biopsies. METHODS Formalin-fixed and paraffin-embedded nasal mucous membranes from eight patients with GPA and eight controls were analyzed for ET-1 type A receptor (ETAR) and type B receptor (ETBR) expression using immunohistochemistry. RESULT ETAR immunostaining was localized only to a few inflammatory cells and to multinucleate giant cells (MGCs) in the nasal mucosa in GPA subjects. Intense ETBR immunostaining was localized to lymphocytes and MGC in the nasal granulomatous lesions in GPA. CD3(+), CD4(+), CD8(+), and CD68(+) lymphocytes expressed ETBRs in GPA subjects. CONCLUSION This observation shows that ETBR(+) lymphocyte expression predominates in nasal granulomatous lesions in GPA compared with ETAR. ETBR immunostaining is located to T cells, CD68(+) cells, and MGCs. ETBR may play an active role in the progression of granulomatous lesions in GPA.
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Affiliation(s)
- Ivan Dimitrijevic
- Department of Medicine, Institute of Clinical Sciences Lund University, Lund, Sweden
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