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Nishihara M, Suzuki M, Asatani S, Nagasawa Y, Tsukamoto M, Akiya K, Kobayashi H, Kitamura N, Nakamura H. Anti-neutrophil Cytoplasmic Antibody-negative Eosinophilic Granulomatosis with Polyangiitis Complicated with Peripheral Neuropathy that Underwent Remission Induction with Mepolizumab Monotherapy. Intern Med 2023; 62:2895-2900. [PMID: 36725044 PMCID: PMC10602846 DOI: 10.2169/internalmedicine.1001-22] [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] [Received: 09/13/2022] [Accepted: 12/14/2022] [Indexed: 02/03/2023] Open
Abstract
A 72-year-old woman was admitted to our hospital with numbness in her lower extremities and hypereosinophilia. She was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). On admission, she was suspected of being complicated with pneumonia and sepsis; therefore, treatment with mepolizumab monotherapy was begun, resulting in partial improvement. After the possibility of a complicating infection was ruled out, corticosteroids were initiated, followed by intravenous gamma globulin therapy. Although the induction of remission of EGPA with mepolizumab monotherapy is not usually recommended, induction with mepolizumab monotherapy may be an option in terms of safety and clinical efficacy in some cases.
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Affiliation(s)
- Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Midori Suzuki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Shinya Asatani
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Masako Tsukamoto
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Kumiko Akiya
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
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Takeuchi H, Kawamura K, Kawasaki T, Oka N. Distinct features of hypereosinophilic syndrome with neuropathy from eosinophilic granulomatosis with polyangiitis. Front Neurol 2022; 13:1057767. [PMID: 36457867 PMCID: PMC9705778 DOI: 10.3389/fneur.2022.1057767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/28/2022] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA) have overlapping clinical considerations, which frequently involve peripheral neuropathy. The current study aimed to discriminate between the clinicopathological features of HES and EGPA, focusing on the mechanism of peripheral nerve damage. METHODS A total of 53 patients who underwent nerve biopsies at our laboratory were examined: nine patients with idiopathic HES (iHES), three patients with reactive HES, 14 patients with myeloperoxidase-anti-neutrophil cytoplasmic antibody (ANCA)-positive EGPA, and 27 patients with negative EGPA. Nerve biopsies were performed using light and electron microscopy. RESULTS Polyneuropathy was more common than mononeuritis multiplex in iHES, which differed from that in ANCA-negative EGPA groups (p = 0.012). Nerve biopsies showed that iHES was associated with neuropathy features such as rare vasculitis and non-vasculitic eosinophilic infiltrates, which differed from those of ANCA-negative EGPA. Fibrinoid necrosis was found only in the reactive HES and ANCA-positive groups. The percentage of endoneurial vessels occluded with eosinophils tended to be higher in iHES (1.8%) than in ANCA-positive EGPA (0%) and negative EGPA (0.7%). In a patient with ANCA-negative EGPA, the endoneurial vessels were occluded with platelets, fibrinoid materials, and eosinophils, demonstrating the morphology of eosinophil extracellular traps. CONCLUSION iHES with neuropathy showed a pattern more similar to polyneuropathy than mononeuritis multiplex, which is dominant in ANCA-negative EGPA, and tended to show vasculitis in the peripheral nerves less frequently compared with EGPA. Eosinophilic infiltration and endoneurial vascular occlusion by eosinophils may cause nerve damage.
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Affiliation(s)
- Hiroki Takeuchi
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
| | - Kazuyuki Kawamura
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
| | - Teruaki Kawasaki
- Kyoto Clinical and Translational Research Center for Neurocognitive Disorders, Kyoto, Japan
| | - Nobuyuki Oka
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
- Department of Neurology, Kyoto Konoe Rehabilitation Hospital, Kyoto, Japan
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Bond M, Fagni F, Moretti M, Bello F, Egan A, Vaglio A, Emmi G, Dejaco C. At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement. Curr Rheumatol Rep 2022; 24:337-351. [PMID: 36194339 DOI: 10.1007/s11926-022-01087-1] [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: 07/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of existing literature on pathogenetic and clinical aspects of cardiac and vascular involvement in eosinophilic granulomatosis with polyangiitis (EGPA). RECENT FINDINGS In EGPA, cardiac and vascular involvement are more common than previously thought. However, no international recommendations on the topic are available yet. Herein, we summarize the existing evidence on the topic and propose a diagnostic approach for cardiac involvement in EGPA. The prevalence of cardiovascular involvement in patients with EGPA varies greatly among published studies, ranging between 3.1-18.7% for occlusive arterial disease, 5.8-30% for venous thrombosis and 17-92% for heart involvement. Cardiac involvement in EGPA is associated with high mortality even though manifestations are heterogeneous. In principle, every anatomical structure of the heart can be involved, and EGPA-related heart disease may be completely asymptomatic at first. A careful diagnostic work-up for early detection and prompt treatment initiation is therefore required. While cardiac manifestations are more common in anti-neutrophil cytoplasmic antibodies (ANCA)-negative patients, arterial and venous thrombotic events are not linked to ANCA status but correlate closely with disease activity and accumulate at disease onset. Thrombotic events (mainly venous) are considerably more frequent in EGPA than in the general population contributing substantially to morbidity and highlighting the importance of developing specific prevention strategies for patients who are diagnosed with EGPA.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michele Moretti
- Department of Cardiology - Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Allyson Egan
- Vasculitis & Lupus Unit, Department of Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy. .,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
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Koga Y, Yoshimi S, Harada T, Suzuki S, Ohtsuka T, Dobashi K, Hisada T. Long-term Safety and Efficacy of Benralizumab for Eosinophilic Granulomatosis with Polyangiitis Complicated with Severe Neuropathy. Intern Med 2022; 62:1553-1556. [PMID: 36171130 DOI: 10.2169/internalmedicine.0613-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The efficacy of benralizumab, as well as mepolizumab, to granulomatosis with polyangiitis (EGPA) involved with mononeuritis multiplex remains unclear. We experienced a case of EGPA presenting neuropathy with severe asthma. Muscle weakness due to neuropathy involved with gait disturbance was partly ameliorated by intravenous immunoglobulin therapy. Mepolizumab (100 mg/day) did not promote further improvement of neuropathy. However, the administration of benralizumab instead of mepolizumab improved neuropathy quickly and enabled walking alone. The efficacy of benralizumab for EGPA and its complication has been maintained for over four years. Benralizumab may be a possible treatment for EGPA presenting neuropathy with severe asthma.
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Affiliation(s)
- Yasuhiko Koga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Japan
| | - Seishi Yoshimi
- Department of Respiratory medicine, Tone-chuo Hospital, Japan
| | - Takashi Harada
- Department of Respiratory medicine, Tone-chuo Hospital, Japan
| | - Satoshi Suzuki
- Department of General medicine, Tone chuo Hospital, Japan
| | | | | | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, Japan
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Yorishima A, Yoshida Y, Nanao Y, Oka N, Masuda S, Sugimoto T, Hirata S. Bilateral facial nerve palsy responded to immunosuppressive therapy in a patient with eosinophilic granulomatosis with polyangiitis. Rheumatol Adv Pract 2022; 6:rkac073. [PMID: 36133961 PMCID: PMC9486985 DOI: 10.1093/rap/rkac073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ai Yorishima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
- Department of Rheumatology, Hiroshima Prefectural Hospital , Hiroshima, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
| | - Yuta Nanao
- Postgraduate Clinical Training Center, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
| | - Naoya Oka
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
| | - Sho Masuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
- Department of Rheumatology, Hiroshima Prefectural Hospital , Hiroshima, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital , Hiroshima, Hiroshima, Japan
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Honda M, Takeshita Y, Koga M, Sato R, Omoto M, Kanda T. [Neuropathy presenting conduction block in ANCA-negative eosinophilic granulomatosis with polyangiitis]. Rinsho Shinkeigaku 2021; 61:613-617. [PMID: 34433740 DOI: 10.5692/clinicalneurol.cn-001564] [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: 11/05/2022]
Abstract
A 74-year-old woman with a history of asthma and allergic rhinitis rapidly developed multiple mononeuropathy. Although anti-neutrophil cytoplasmic antibodies were negative, the presence of eosinophilia and eosinophilic infiltrations in the sural nerve led to a diagnosis of eosinophilic granulomatosis with polyangiitis. A motor nerve conduction study on admission revealed conduction block, which promptly disappeared after initiating immunotherapy without findings suggestive for remyelination or axonal degeneration. This electrophysiological change distinct from that of Wallerian degeneration. A biopsy of the sural nerve showed many eosinophil infiltrations and degranulation of eosinophilic cationic protein within nerve fascicles, whereas findings of necrotizing vasculitis were absent. These findings suggest that a direct effect of eosinophilic cationic protein, rather than ischemic damage due to vasculitis, was the main mechanism of transient nerve conduction failure in this patient.
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Affiliation(s)
- Masaya Honda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Yukio Takeshita
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Ryota Sato
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Masatoshi Omoto
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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Ueda R, Imai K, Yamamoto A, Ioku T, Kadoya M, Hamanaka M. [Eosinophilic granulomatosis with polyangiitis presenting with Guillain-Barré syndrome-like acute course. A case report]. Rinsho Shinkeigaku 2021; 61:624-629. [PMID: 34433743 DOI: 10.5692/clinicalneurol.cn-001601] [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: 11/05/2022]
Abstract
A 57-years-old man with a history of bronchial asthma and pansinusitis developed acute progressive muscle weakness and sensory disturbance of the distal limbs after upper respiratory infection. On day 15 after onset of sensory disturbance and muscle weakness, the patient admitted to our hospital. A neurological examination revealed asymmetry weakness of both proximal and distal muscles, "glove and stocking type" hypoesthesia, and paresthesia without obvious pain. Blood tests and a nerve conduction study demonstrated eosinophilia and elevation of MPO-ANCA, axonal multiple mononeuropathy, respectively. The cerebrospinal fluid was normal. Eosinophilic granulomatosis with polyangiitis (EGPA) or Guillain-Barré syndrome (GBS) were suspected. So intravenous immunoglobulin therapy (IVIg) and high dose methylprednisolone pulse therapy (HDMP) followed by oral prednisolone were started. However, neurological symptoms did not improve. Sural nerve biopsy on day 31 revealed varying myelinating fiber loss at every nerve bundle and perivascular lymphocytic infiltration. The results did not fulfill the pathologic criteria for EGPA, but supported the changes of vasculitis. Cyclophosphamide (CPA) pulse therapy was administered for the additional therapy. Neurological symptoms did not improve and worsened again after decreasing oral prednisolone; therefore, combined therapy with IVIg, HDMP, and CPA was administered. Neurological symptoms then diminished gradually and the MPO-ANCA level and number of eosinophils normalized. This case suggests the importance of early nerve biopsy to obtain pathological findings supportive of EGPA diagnosis to allow introduction of aggressive immunosuppressive therapy such as CPA in a case with acute progressive motor-sensory neuropathy due to EGPA mimicking GBS.
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Affiliation(s)
- Ryota Ueda
- Department of Neurology and Stroke Treatment, Kyoto Daiichi Red Cross Hospital
| | - Keisuke Imai
- Department of Neurology and Stroke Treatment, Kyoto Daiichi Red Cross Hospital
| | - Atsushi Yamamoto
- Department of Neurology and Stroke Treatment, Kyoto Daiichi Red Cross Hospital
| | - Tetsuya Ioku
- Department of Neurology and Stroke Treatment, Kyoto Daiichi Red Cross Hospital
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8
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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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Olson LC, Lelli GJ, Patel SS, Magro CM. Conjunctival Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss) in a Young Adult Male With Persistent Ptosis. J Clin Rheumatol 2021; 27:e53-e58. [PMID: 30048387 DOI: 10.1097/rhu.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Fagni F, Bello F, Emmi G. Eosinophilic Granulomatosis With Polyangiitis: Dissecting the Pathophysiology. Front Med (Lausanne) 2021; 8:627776. [PMID: 33718405 PMCID: PMC7943470 DOI: 10.3389/fmed.2021.627776] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/18/2021] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare multisystemic disease classified both amongst hypereosinophilic disorders and ANCA-associated vasculitis. Vessel inflammation and eosinophilic proliferation are the hallmarks of the disease and main effectors of organ damage. Two distinct disease phenotypes have classically been described according to ANCA-status: the ANCA-negative subset with eosinophil-driven manifestation and the ANCA-positive one with vasculitic manifestations. An analogous dichotomization has also been backed by histological findings and a distinct genetic background. EGPA is typically consider a Th2-mediated disease and blood and tissue eosinophilia represent the cornerstone of diagnosis. Besides, ANCA are known for inducing endothelial injury and vascular inflammation by activating the circulating neutrophils. Thus, the pathogenesis of EGPA seems to be mediated by two coexisting mechanisms. However, the verbatim application of this strict dualism cannot always be translated into routine clinical practice. In the present review we describe the current knowledge on the eosinophilic and ANCA-mediated aspects of EGPA pathogenesis. Finally, we review the rationale of the currently proposed EGPA dichotomy and future research perspectives.
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Affiliation(s)
| | | | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
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11
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Berti A, Boukhlal S, Groh M, Cornec D. Eosinophilic granulomatosis with polyangiitis: the multifaceted spectrum of clinical manifestations at different stages of the disease. Expert Rev Clin Immunol 2020; 16:51-61. [PMID: 31762336 DOI: 10.1080/1744666x.2019.1697678] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) usually occurs in patients with late-onset asthma and sustained peripheral blood eosinophilia and classically presents with a clinical multifaceted spectrum of manifestations, which may vary at the different stages of the natural history of the disease.Areas covered: We reviewed EGPA clinical presentation, focusing on clinical manifestations at three different phases of the disease: 1/before the development of overt vasculitis, 2/at vasculitis diagnosis and 3/during the long-term follow-up. An update on current classification criteria and recent therapeutic advances has been provided as well.Expert opinion: Asthma, chronic rhinosinusitis and blood eosinophilia could anticipate the overt vasculitis for years. An atopic background may be present in a subset of patients (25-30%), while ANCA presence varies between 10 and 40%. Systemic vasculitis rapidly occurs and clinical features demonstrating vasculitis processes (neuropathy, purpura, scleritis, alveolar hemorrhage and glomerulonephritis) develop along with systemic symptoms (50%). After vasculitis resolution, asthma remains severe in up to 50% of patients and incidence of isolated-asthma and rhinosinus exacerbations remains constantly high. Different sets of classification criteria have been published so far, and DCVAS diagnostic criteria will be presented soon. Interleukin-5 blockers seem to be promising to control the disease and to spare corticosteroids.
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Affiliation(s)
- Alvise Berti
- Department of Rheumatology, Santa Chiara Hospital, Trento, Italy.,Department of Cellular, Computational and Integrative Biology-CIBIO, University of Trento, Trento, Italy
| | - Sara Boukhlal
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Matthieu Groh
- Department of Internal Medicine, Hôpital Foch, National Referral Center for Hypereosinophilic Syndrome (CEREO), Suresnes, France
| | - Divi Cornec
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, CHU de Brest, Brest, France
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12
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Overall Disability Sum Score for Clinical Assessment of Neurological Involvement in Eosinophilic Granulomatosis With Polyangiitis. J Clin Rheumatol 2019; 24:197-202. [PMID: 29652700 DOI: 10.1097/rhu.0000000000000713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study was to verify the application of Overall Disability Sum Score (ODSS) for standardized clinical assessment of neurological involvement in patients with eosinophilic granulomatosis with polyangiitis (EGPA) and its correlation with treatment response and long-term outcomes. METHODS Consecutive EGPA patients referred to our tertiary vasculitis center were retrospectively evaluated. Patients' neurological damage and disability were systematically assessed with Vasculitis Damage Index and ODSS. RESULTS Fifty EGPA patients were included in the study with a median follow-up of 75 months (9-180 months). Twenty-five (50%) developed peripheral neuropathy, 17 (68%) presented mononeuritis multiplex, whereas 8 (32%) had symmetric polyneuropathy. Patients with neurological involvement were older (56.3 ± 13.4 vs. 44.4 ± 12.1 years, P < 0.0009), more frequently antineutrophil cytoplasmic antibody positive (48% vs. 16%, P = 0.015), and were more likely to have renal involvement (24% vs. 0%, P = 0.022). An early clinical response to therapy was observed within 6 months of treatment, resulting in a significant decrease in ODSS, which fell from the baseline value of 4.2 ± 2.4 to 2.9 ± 1.5 (P = 0.0001), whereas only a slow decreasing pattern was noted over the long-term period. However, all subjects developed neurological impairment and disability despite remission from active vasculitis. Patients with ODSS of greater than 3 at baseline (n = 13 [52%]) retained a higher score at the last examination (P < 0.001), predicting a low therapeutic response. Furthermore, ODSS of greater than 3 was found associated with more neurological relapses (53.8% vs. 0%, P = 0.027). CONCLUSION Overall Disability Sum Score could be a rapid, simple, reliable instrument to evaluate the severity of disability and nerve damage due to neurological involvement caused by vasculitis and to predict, at presentation, improvement and risk of neurological worsening.
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13
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Berti A, Specks U, Keogh KA, Cornec D. Current and Future Treatment Options for Eosinophilic Granulomatosis With Polyangiitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0073-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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14
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Lavin J, Min JY, Lidder AK, Huang JH, Kato A, Lam K, Meen E, Chmiel JS, Norton J, Suh L, Mahdavinia M, Hulse KE, Conley DB, Chandra RK, Shintani-Smith S, Kern RC, Schleimer RP, Tan BK. Superior turbinate eosinophilia correlates with olfactory deficit in chronic rhinosinusitis patients. Laryngoscope 2017; 127:2210-2218. [PMID: 28322448 DOI: 10.1002/lary.26555] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/02/2017] [Accepted: 01/27/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate if molecular markers of eosinophilia in olfactory-enriched mucosa are associated with olfactory dysfunction. STUDY DESIGN Cross-sectional study of tissue biopsies from 99 patients, and an additional 30 patients who underwent prospective olfactory testing prior to sinonasal procedures. METHODS Tissue biopsies were processed for analysis of inflammatory markers using quantitative real time polymerase chain reaction (qRT-PCR). Ipsilateral olfactory performance was assessed using the Sniffin' Sticks (Burghart, Wedel, Germany) threshold component and the University of Pennsylvania Smell Identification Test (Sensonics, Haddon Heights, NJ). Age-adjusted data was correlated with inflammatory marker expression and clinical measures of obstruction from computed tomography and endoscopy. RESULTS Gene expression of the eosinophil marker CLC (Charcot Leyden crystal protein) was elevated in superior turbinate (ST) tissue in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) compared to ST and inferior turbinate tissue in CRS without nasal polyps (CRSsNP) and control patients (all P < 0.001, respectively). CLC in ST tissue was correlated with IL-5 and eotaxin-1 expression (all P < 0.001; P = 0.65, and 0.49, respectively). CLC expression was strongly correlated with eosinophilic cationic protein levels (P < 0.001; r = -0.76), and ST CLC expression was inversely related to olfactory threshold (P = 0.002, r = -0.57) and discrimination scores (P = 0.05, r = -0.42). In multiple linear regression of CLC gene expression, polyp status, and radiographic and endoscopic findings with olfactory threshold, CLC was the only significantly correlated variable (P < 0.05). CONCLUSION Markers of eosinophils are elevated in the ST of patients with CRSwNP and correlate with olfactory loss. These findings support the hypothesis that olfactory dysfunction in CRS correlates local eosinophil influx into the olfactory cleft. LEVEL OF EVIDENCE NA. Laryngoscope, 127:2210-2218, 2017.
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Affiliation(s)
- Jennifer Lavin
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jin-Young Min
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Alcina K Lidder
- University of Rochester School of Medicine and Dentistry, Rochester, New York, U.S.A
| | - Julia He Huang
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Atsushi Kato
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Kent Lam
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Eric Meen
- Department of Otolaryngology-Head and Neck Surgery, University of Manitoba, Winnipeg, Canada
| | - Joan S Chmiel
- Department of Preventive Medicine-Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - James Norton
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Lydia Suh
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Mahboobeh Mahdavinia
- Division of Allergy and Immunology, Rush Medical College, Chicago, Illinois, U.S.A
| | - Kathryn E Hulse
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - David B Conley
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Rakesh K Chandra
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, U.S.A
| | - Stephanie Shintani-Smith
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Robert C Kern
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Robert P Schleimer
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,University of Rochester School of Medicine and Dentistry, Rochester, New York, U.S.A
| | - Bruce K Tan
- Department of Otolaryngology-Head and Neck SurgeryDivision of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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15
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Takeuchi H, Kawasaki T, Shigematsu K, Kawamura K, Oka N. Neutrophil extracellular traps in neuropathy with anti-neutrophil cytoplasmic autoantibody-associated microscopic polyangiitis. Clin Rheumatol 2017; 36:913-917. [PMID: 28124760 DOI: 10.1007/s10067-017-3546-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/12/2017] [Accepted: 01/14/2017] [Indexed: 12/31/2022]
Abstract
To clarify the roles of neutrophils in anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitic neuropathy, we studied neutrophil extracellular traps (NETs) in peripheral nerve vasculitis. Stored nerve samples from 17 patients with microscopic polyangiitis (MPA) were immunohistochemically analyzed using antibodies for citrullinated histone H3 (citH3) and various neutrophil enzymes. We defined merged citH3 and extracellularly released myeloperoxidase (MPO) as NET formation. We also compared NET formation between MPO-ANCA-positive/negative MPA and rheumatoid arthritis (RA)-associated vasculitic neuropathy. NETs were identified mostly in vasculitic small arterioles of 6 of 12 MPO-ANCA-positive MPA patients, and their frequency was higher (p < 0.05) than in ANCA-negative patients. NETs were not found in vasculitic neuropathy with RA or patients with chronic inflammatory demyelinating polyradiculoneuropathy. NETs were also observed in the peripheral nervous system of MPA patients as well as in the lung and kidney. These results suggest that NETs may be involved in the pathogenesis of MPA neuropathy.
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Affiliation(s)
- Hiroki Takeuchi
- Department of Neurology, National Hospital Organization Minami-Kyoto National Hospital, Joyo-shi, Kyoto, 610-0113, Japan.
| | - Teruaki Kawasaki
- Center of Neurological and Cerebrovascular Diseases, Takeda Hospital, Kyoto, Japan
| | - Kazuo Shigematsu
- Department of Neurology, National Hospital Organization Minami-Kyoto National Hospital, Joyo-shi, Kyoto, 610-0113, Japan
| | - Kazuyuki Kawamura
- Department of Neurology, National Hospital Organization Minami-Kyoto National Hospital, Joyo-shi, Kyoto, 610-0113, Japan
| | - Nobuyuki Oka
- Department of Neurology, National Hospital Organization Minami-Kyoto National Hospital, Joyo-shi, Kyoto, 610-0113, Japan
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16
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Cottin V, Bel E, Bottero P, Dalhoff K, Humbert M, Lazor R, Sinico RA, Sivasothy P, Wechsler ME, Groh M, Marchand-Adam S, Khouatra C, Wallaert B, Taillé C, Delaval P, Cadranel J, Bonniaud P, Prévot G, Hirschi S, Gondouin A, Dunogué B, Chatté G, Briault C, Pagnoux C, Jayne D, Guillevin L, Cordier JF. Revisiting the systemic vasculitis in eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Autoimmun Rev 2017; 16:1-9. [DOI: 10.1016/j.autrev.2016.09.018] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/08/2016] [Indexed: 12/17/2022]
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17
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Cho HJ, Yune S, Seok JM, Cho EB, Min JH, Seo YL, Lee BJ, Kim BJ, Choi DC. Clinical Characteristics and Treatment Response of Peripheral Neuropathy in the Presence of Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): Experience at a Single Tertiary Center. J Clin Neurol 2017; 13:77-83. [PMID: 28079316 PMCID: PMC5242145 DOI: 10.3988/jcn.2017.13.1.77] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic small-vessel vasculitis accompanied by asthma, eosinophilia, and eosinophilic inflammation of various tissues including the peripheral nerves. This study investigated the clinical course and long-term outcomes of peripheral neuropathy in patients with EGPA. Methods Seventy-one patients with physician-diagnosed EGPA were identified at Samsung Medical Center between January 1995 and April 2014. Sixty-one of these patients were followed-up for more than 1 year and received corticosteroid therapy with or without intravenous cyclophosphamide pulse therapy for 6 to 18 months. Medical records of the 61 patients including demographic data, clinical features, laboratory and pathological findings, treatments, and outcomes were reviewed. Results Peripheral neuropathy as a manifestation of EGPA was present in 46 (75%) of the 61 patients. The mean follow-up duration of the patients with neuropathy was 6.4 years (range 1.2–18.8 years). The scores on the neurological functional disability scale before and after the combination treatment with corticosteroid and cyclophosphamide were 2.43±0.86 and 0.54±0.95 (mean±SD; p<0.001), respectively. The peripheral neuropathy relapsed in one patient. Conclusions The long-term clinical outcome of peripheral neuropathy in patients with EGPA receiving initial corticosteroid and cyclophosphamide combination therapy was favorable with a very low relapse rate.
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Affiliation(s)
- Hye Jin Cho
- Department of Neurology, The Catholic University of Korea College of Medicine, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sehyo Yune
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Myoung Seok
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Eun Bin Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Ju Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Yeon Lim Seo
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Jae Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Seoul, Korea.
| | - Dong Chull Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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18
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Groh M, Dunogué B, Guillevin L. Pharmacological approach to treating eosinophilic granulomatosis with polyangiitis (Churg–Strauss). Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1025748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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Eosinophilic granulomatosis with polyangiitis presenting as acute sciatic nerve neuropathy resembling lumbar disease. J Orthop Sci 2015; 20:224-8. [PMID: 23982429 DOI: 10.1007/s00776-013-0437-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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20
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Reply. J Allergy Clin Immunol 2012. [DOI: 10.1016/j.jaci.2012.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Ramentol-Sintas M, Martínez-Valle F, Solans-Laqué R. Churg-Strauss Syndrome: an evolving paradigm. Autoimmun Rev 2012; 12:235-40. [PMID: 22796280 DOI: 10.1016/j.autrev.2012.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
Abstract
The Churg-Strauss Syndrome is an ANCA-associated vasculitis, an inflammatory multisystem disease with preference to the respiratory tract. Peripheral and tissue eosinophilia are the pathological hallmarks of this condition. The etiopathogenesis is unknown but some cytokines appear to play a central role and could be targets for new therapies.
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Affiliation(s)
- Marc Ramentol-Sintas
- Research Unit in Systemic Autoimmune Diseases, Vall D'hebron Research Institute, Hospital Vall D'hebron, Barcelona, Spain
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