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Amatruda M, Carucci NS, Chimenz R, Conti G. Immunoglobulin A vasculitis nephritis: Current understanding of pathogenesis and treatment. World J Nephrol 2023; 12:82-92. [PMID: 37766840 PMCID: PMC10520755 DOI: 10.5527/wjn.v12.i4.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/16/2023] [Accepted: 06/12/2023] [Indexed: 09/20/2023] Open
Abstract
The clinical spectrum of immunoglobulin A vasculitis nephritis (IgAVN) ranges from the relatively common transitory microscopic hematuria and/or low-grade proteinuria to nephritic or nephrotic syndrome, rapidly progressive glomerulonephritis, or even renal failure. Clinical and experimental studies have shown a multifactor pathogenesis: Infection triggers, impaired glycosylation of IgA1, complement activation, Toll-like-receptor activation and B cell proliferation. This knowledge can identify IgAVN patients at a greater risk for adverse outcome and increase the evidence for treatment recommendations.
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Affiliation(s)
- Michela Amatruda
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Nicolina Stefania Carucci
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Roberto Chimenz
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
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Marro J, Williams C, Pain CE, Oni L. A case series on recurrent and persisting IgA vasculitis (Henoch Schonlein purpura) in children. Pediatr Rheumatol Online J 2023; 21:85. [PMID: 37580746 PMCID: PMC10424434 DOI: 10.1186/s12969-023-00872-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) is a small vessel vasculitis that is more common in childhood. Very limited evidence exists on patients who experience an atypical disease course. The aim of this study was to describe a cohort of children diagnosed with recurrent or persisting IgAV to identify any themes associated with their disease course and areas of unmet needs. METHODS A single centre retrospective study of children diagnosed with recurrent or persisting IgAV at Alder Hey Children's Hospital (Liverpool, UK). Clinical data, including features at presentation and during follow up, potential triggers, abnormal laboratory and histology results, treatment and outcome at last clinical review were retrospectively collected. Key themes were identified. RESULTS A total of 13 children met the inclusion criteria (recurrent disease, n = 4; persisting disease, n = 9). Median age at first presentation was 10.2 years [2.6-15.5], female:male ratio 1.2:1. Children in the atypical cohort were significantly older than a larger cohort of children who followed a non-complicated disease course (median age 5.5 years (range [0.6-16.7], p = 0.003)). All children re-presented with a purpuric rash (either recurring or persisting), accompanied by joint involvement in 92% of patients (12/13). Disease-modifying anti-rheumatic drugs (DMARDs) were used in 8/13 (62%) children. The median time from first presentation to diagnosis of atypical disease was 18.4 months [5.3-150.8] and the time from first presentation to treatment was 24.1 months [1.8-95.4]. Use of corticosteroids was significantly higher in children with renal involvement (p = 0.026). During follow up, 8/13 (62%) children were admitted at least once, whilst 10/13 (77%) had re-presented at least once to the emergency department. Five (38%) children were referred to psychology services and 7 (54%) children reported feelings of frustration. CONCLUSIONS This series describes some characteristics of a small cohort of children with atypical IgAV. It also identifies unmet needs in children with atypical IgAV, which includes delays in diagnosis and lengthy waits for treatment, lack of high-quality evidence regarding treatment choices and a high unrecognised disease burden. Further research is needed to study this subgroup of children as evidence is lacking.
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Affiliation(s)
- Julien Marro
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Chloe Williams
- Royal Liverpool and Broadgreeen University Hospital Trusts, Liverpool, UK
| | - Clare E Pain
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Paediatric Nephrology, University of Liverpool Alder Hey Children's NHS Foundation Trust Hospital, Institute in the Park Building, Eaton Road, Liverpool, L12 2AP, UK.
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Yokoyama T, Sakumura N, Inoue N, Matsuda Y, Wada T. IgA Vasculitis in Japanese Patients Harboring MEFV Mutations: A Case Report and Review of the Literature. Cureus 2023; 15:e34876. [PMID: 36923179 PMCID: PMC10010935 DOI: 10.7759/cureus.34876] [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: 02/11/2023] [Indexed: 02/13/2023] Open
Abstract
Immunoglobulin A vasculitis (IgAV) is the most common vasculitis of childhood. However, its etiology remains unknown. In the Mediterranean region, 10% of patients with IgAV harbor homozygous and compound heterozygous mutations in the Mediterranean fever (MEFV) gene. Thus, such mutations may be involved in the development of IgAV. Herein, we present a five-year-old girl presented with IgAV. She experienced prolonged abdominal pain, which was steroid-resistant. When treatment with colchicine was started, her abdominal pain resolved immediately. The serum interleukin (IL)-18 levels of the patient and other patients with IgAV and familial Mediterranean fever (FMF) were evaluated using enzyme-linked immunosorbent assay. The serum IL-18 level of the patient was higher than that of other patients with IgAV and was similar to that of patients with FMF harboring M694I mutation. Moreover, all exons of the MEFV gene were analyzed using the Sanger sequencing and the patient presented with E148Q/M694I mutation. Further, a comprehensive search of Japanese patients with IgAV harboring MEFV gene mutations in PubMed, Ichushi-Web, and Medical Online was conducted to validate the clinical characteristics of Japanese patients with IgAV harboring MEFV gene mutation. In previous studies, only five patients presented with IgAV harboring MEFV gene mutation in Japan. The prevalence of IgAV associated with MEFV gene mutation may be low in Japan. However, MEFV gene mutations should be suspected if the symptoms of IgAV are prolonged or if patients are refractory to treatment. In such case, IL-18 monitoring and colchicine treatment may be useful for IgAV with MEFV gene mutation.
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Affiliation(s)
| | | | | | | | - Taizo Wada
- Pediatrics, Kanazawa University, Ishikawa, JPN
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Yoshida M, Nambu R, Yasuda R, Sakaguchi H, Hara T, Iwama I, Mizuochi T. Dapsone for Refractory Gastrointestinal Symptoms in Children With Immunoglobulin A Vasculitis. Pediatrics 2022; 150:188779. [PMID: 35975615 DOI: 10.1542/peds.2021-055884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV) is a systemic small-vessel vasculitis. Although corticosteroids (CS) are the primary treatment for gastrointestinal manifestations associated with IgAV, some patients develop refractory or recurrent symptoms such as vomiting and abdominal pain despite CS treatment. Dapsone, a synthetic sulfone antimicrobial, has been used to treat cutaneous purpura in IgAV, but few authors have reported its use for refractory gastrointestinal symptoms. In this retrospective observational study, we describe results in 7 children with IgAV who were treated with dapsone for abdominal pain resistant to CS. Dapsone rapidly relieved abdominal pain in all 7 patients, who then were tapered off CS without relapse. Side effects of mild methemoglobinemia and hemolysis appeared to be manageable with planned monitoring and dose adjustment; a single patient who discontinued dapsone had fatigue and hypoxia associated with methemoglobinemia. No side effects were life-threatening. Dapsone may be considered as a therapeutic option for gastrointestinal symptoms refractory to CS in children with IgAV.
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Affiliation(s)
- Masashi Yoshida
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan.,These authors contributed equally to this work
| | - Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan.,These authors contributed equally to this work
| | - Ryosuke Yasuda
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Hirotaka Sakaguchi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Tomoko Hara
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.,These authors contributed equally to this work
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Okura Y, Hiramatsu Y, Shimomura M, Taniguchi K, Nawate M, Takahashi Y, Kobayashi I. Successful Treatment of IgA Vasculitis With Prolonged Cutaneous Manifestation With Colchicine in a 10-Year-Old Boy. Mod Rheumatol Case Rep 2021; 6:97-100. [PMID: 34730811 DOI: 10.1093/mrcr/rxab041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/06/2021] [Accepted: 10/05/2021] [Indexed: 12/17/2022]
Abstract
We report a 10-year-old boy with IgA vasculitis (IgAV) with prolonged cutaneous manifestations who was successfully treated with colchicine. At the age of 9, he was diagnosed as having IgAV by typical purpura, abdominal pain, and hematochezia. Initially, his severe gastrointestinal manifestation subsided by prednisolone 60 mg/day and intravenous methylprednisolone pulse therapy. However, his gastrointestinal manifestation was glucocorticoid-dependent and refractory to factor XIII concentrate, intravenous immunoglobulin G, and mycophenolate mofetil. His abdominal pain and hematochezia responded to the combination therapy with dapsone and low dose of prednisolone 5 mg/day and did not relapse even after discontinuation of dapsone. On the other hands, the effect of dapsone on his cutaneous manifestation was dose-dependent. As well dapsone had no glucocorticoid-sparing effect. Approximately 12 months after onset, colchicine treatment was started, which resulted in remission of his chronic cutaneous manifestation. After prednisolone was tapered off, his cutaneous manifestation is currently well-controlled on colchicine 0.5 mg/day without adverse events. He had never complicated by kidney involvements. In conclusion, colchicine treatment exerts a beneficial effect in IgAV patients with prolonged cutaneous manifestation refractory to multiple drugs.
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Affiliation(s)
- Yuka Okura
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Yasuyoshi Hiramatsu
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Masaki Shimomura
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Kota Taniguchi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Mitsuru Nawate
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Yutaka Takahashi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Ichiro Kobayashi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
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Abstract
Immunoglobulin A (IgA) vasculitis (IgAV), previously called Henoch-Schönlein purpura, is characterized by IgA-dominant immune deposits affecting small vessels and often involves the skin, gastrointestinal tract, joints, and kidneys. IgAV is the most common cause of systemic vasculitis in children. The long-term prognosis is dependent on renal involvement: IgAV with nephritis (IgAVN) can progress to renal failure. IgAVN is an inflammatory disease, providing a rationale for the use of corticosteroids. However, data supporting the use of corticosteroids in patients with established IgAVN of any severity remain limited, although most clinicians use them. Even in patients with severe forms of IgAVN, methylprednisolone pulses added to oral corticosteroids appears to improve renal outcomes. Considering the multihit hypothesis for the pathogenesis of IgAVN, involving many other immune agents, there is a strong rationale for the use of other immunosuppressive drugs in patients with IgAVN, including mycophenolic acid, cyclophosphamide, rituximab, calcineurin inhibitors, and complement inhibitors. Thus, these immunosuppressive treatments have also been evaluated in IgAVN, usually in corticosteroid-dependent or corticosteroid-resistant forms and in small retrospective studies. However, their efficacy has not been proven. Thus, the risk of progression to renal failure and the ongoing debate about the best management of IgAVN justifies the interest in investigating and identifying treatments that can potentially preserve renal function in patients with IgAVN. This review reports on the efficacy of the different drugs currently used for the treatment of IgAVN in adults and children.
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Oku A, Nakai K, Ikenaga T, Sato K, Mitsuoka S, Takahashi S, Tanoue K, Sawada A, Nagami Y, Tsuruta D. Case of afatinib-induced severe purpuric drug eruption with gastrointestinal bleeding. J Dermatol 2021; 48:e534-e535. [PMID: 34390023 DOI: 10.1111/1346-8138.16088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/16/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Aoi Oku
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kozo Nakai
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuhiko Ikenaga
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kanako Sato
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shigeki Mitsuoka
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shunsuke Takahashi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kojiro Tanoue
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akinari Sawada
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Tsuruta
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Ma Y, Zhang S, Chen J, Kong H, Diao J. Henoch-Schönlein Purpura With Scrotal Involvement: A Case Report and Literature Review. J Pediatr Hematol Oncol 2021; 43:211-215. [PMID: 33885039 PMCID: PMC8327932 DOI: 10.1097/mph.0000000000002161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/06/2021] [Indexed: 12/26/2022]
Abstract
Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels, leading to arthritis, abdominal pain, and renal involvement. However, scrotal involvement is a rare complication of HSP and scrotal pain. Swelling is the most frequent clinical presentation and can be easily confused with testicular torsion. If not treated in time, the scrotal inflammation will result in irreversible testicular necrosis. We report a 6-year-old male with HSP and scrotal involvement, characterized by swelling and pain on the left side of the scrotum, rashes on both lower extremities, and epididymitis. He was treated with conservative care, corticosteroids, and antibiotic therapy. We were able to avoid surgical intervention. On the 10 days of treatment, he recovered sufficiently well and was discharged. We have reviewed the literature related to HSP with scrotal involvement, identified 21 cases, and revealed that steroid therapy and/or antibiotics are the first-line of therapy in children with scrotal involvement. Vasculitis in the scrotum may predispose to testicular torsion, which is a complication that should not be overlooked. Clinicians should be aware of the atypical types of HSP. Timely diagnosis and appropriate treatment are essential for achieving the best results.
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Affiliation(s)
- Yue Ma
- Shandong University of Traditional Chinese Medicine
| | | | - Jiye Chen
- Shandong University of Traditional Chinese Medicine
| | - Han Kong
- Shandong University of Traditional Chinese Medicine
| | - Juanjuan Diao
- Department of Pediatrics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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IgA Vasculitis: Etiology, Treatment, Biomarkers and Epigenetic Changes. Int J Mol Sci 2021; 22:ijms22147538. [PMID: 34299162 PMCID: PMC8307949 DOI: 10.3390/ijms22147538] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
IgA, previously called Henoch-Schönlein vasculitis, is an essential immune component that drives the host immune response to the external environment. As IgA has the unique characteristic of a flexible response to broad types of microorganisms, it sometimes causes an autoreactive response in the host human body. IgA vasculitis and related organ dysfunction are representative IgA-mediated autoimmune diseases; bacterial and viral infections often trigger IgA vasculitis. Recent drug developments and the presence of COVID-19 have revealed that these agents can also trigger IgA vasculitis. These findings provide a novel understanding of the pathogenesis of IgA vasculitis. In this review, we focus on the characteristics of IgA and symptoms of IgA vasculitis and other organ dysfunction. We also mention the therapeutic approach, biomarkers, novel triggers for IgA vasculitis, and epigenetic modifications in patients with IgA vasculitis.
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Affiliation(s)
- Stephan Traidl
- Correspondence to: Stephan Traidl, MD, Department of Dermatology and Allergy, Hannover Medical School (MHH), Carl-Neuberg-Str.1, Hannover 30625, Germany.
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Abstract
Vasculitis is a rare cause of skin ulceration. Depending on the size of the affected vessel, the patient's comorbidities and the pathophysiology present, different clinical morphologies can be seen, which can often give preliminary indications of the type of underlying vasculitis. There may be systemic or cutaneous manifestations; thus, a targeted diagnostic workup should be initiated at an early stage. Treatment should be interdisciplinary if there is systemic participation. Vasculopathies (e.g., livedoid vasculopathy), in which occlusion of the vascular lumen is the main pathophysiological feature, should be delimitated from vasculitis. If vasculitic or vasculopathic ulceration is present, stage-appropriate wound management is recommended.
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Affiliation(s)
- C Mitschang
- Klinik fürHautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
| | - T Görge
- Klinik fürHautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
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Suh JS. Dapsone: a steroid-sparing drug for refractory immunoglobulin A vasculitis? Clin Exp Pediatr 2020; 63:178-179. [PMID: 32460461 PMCID: PMC7254175 DOI: 10.3345/cep.2019.01634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/28/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jin-Soon Suh
- Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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