Morphologic change of the internal elastic lamina in Buerger's disease

Neutrophil, NETs and Behçet's disease: A review

Behçet's disease (BD) is a chronic systemic vasculitis characterized by recurrent oral and genital ulcers, skin lesions, articular, neurological, vascular and sight-threatening ocular inflammation. BD is thought to share both autoimmune and autoinflammatory disease features. BD is triggered by environmental factors such as infectious agents in genetically predisposed subjects. Neutrophils seem to play an instrumental role in BD and recent works regarding the role of neutrophils extracellular traps (NETs) provides new insight in the pathophysiology of BD and the mechanisms involved in immune thrombosis. This review provides a recent overview on the role of neutrophils and NETs in the pathogenesis of BD.

Buerger’s Disease May be a Chronic Rickettsial Infection with Superimposed Thrombosis: Literature Review and Efficacy of Doxycycline in Three Patients

Buerger’s disease (BD) is a chronic inflammatory vasculitis of unknown etiology. The infectious etiology of BD was proposed by Buerger in 1914. Furthermore, there are scattered reports insisting that BD may be related to rickettsial infection, first asserted by Goodman since 1916, followed by Giroud and other French investigators from the 1940s through the 1960s, Nicolau in the 1960s, Bartolo (1980s), and Fazeli (2010s). However, their causal relationship has hardly been accepted because rickettsial infections are known to be acute febrile, vector-borne illnesses, whereas BD is a chronic afebrile illness. In this article we review the relevant literature on the chronic nature of Rickettsia and Orientia infections and on the rickettsial etiology of BD. Excellent initial responses to doxycycline in three patients with BD are briefly described. Based on these findings, we hypothesize that BD patients acquired a rickettsial infection far before the onset of BD. Over years, the infected area expands to become a segment of the infected vessel. Subsequently, thrombus develops on the luminal surface of the infected endothelial cells, which produces the vascular obstructive manifestations of BD. Collectively, it is postulated that BD is a chronic infection with a member of the family Rickettsiaceae with superimposed thrombosis.

Molecular mechanisms regulating immune responses in thromboangiitis obliterans: A comprehensive review

Thromboangiitis obliterans (TAO) is a thrombotic-occlusive as well as an inflammatory peripheral vascular disease with unknown etiology. Recent evidence has supported the immunopathogenesis of the disease, however, the factors contributing to the altered immune function and vascular tissue inflammation are still unclear. This review was intended to collate the more current knowledge on the regulatory molecules involved in TAO from an immunoreactive perspective. The homeostasis of the immune system as well as a variety of progenitor cell populations appear to be affected during TAO and these alterations are associated with intrinsic signaling defects that are directing to an improved understanding of the crosstalk between angiogenesis and the immune system, as well as the potential of new co-targeting strategies applying both immunotherapy and angiogenic therapy.

Pathogenesis of thromboangiitis obliterans: Gene polymorphism and immunoregulation of human vascular endothelial cells

Thromboangiitis obliterans (TAO) is a nonatherosclerotic, segmental, inflammatory vasculitis, which commonly affects the small- and medium-sized arteries of the upper and lower extremities. Despite its discovery more than a century ago, little progress has been made in its treatment. Unless the pathogenesis is elucidated, therapeutic approaches will be limited. The purpose of this review article is to collate current knowledge of mechanisms for the pathogenesis of thromboangiitis obliterans and to propose potential mechanisms from a genetic and immunoreactive point of view for its inception. Therefore, we discuss the possibility that the pathogenesis of this disease is due to a type of gene polymorphism, which leads to an immunological inflammatory vasculitis associated with tobacco abuse, highly linked to T cells, human vascular endothelial cells (HVECs), and the TLR-MyD88-NFκB pathway, distinct from arteriosclerosis obliterans and other vasculitides.

Buerger's disease: providing integrated care

Buerger’s disease, also known as thromboangiitis obliterans (TAO), is a segmental inflammatory disease affecting small- and medium-sized vessels, which is strongly associated with tobacco use. Although the etiology is still unknown, recent studies suggest an immunopathogenesis. Diagnosis is based on clinical and angiomorphologic criteria, including age, history of smoking, clinical presentation with distal extremity ischemia, and the absence of other risk factors for atherosclerosis, autoimmune disease, hypercoagulable states, or embolic disease. Until now, no causative therapy exists for TAO. The most important therapeutic intervention is smoking cessations and intravenous prostanoid infusions (iloprost). Furthermore, effective analgesia is crucial for the treatment of ischemic and neuropathic pain and might be expanded by spinal cord stimulation. Revascularization procedures do not play a major role in the treatment of TAO due to the distal localization of arterial occlusion. More recently, immunoadsorption has been introduced eliminating vasoconstrictive G-protein-coupled receptor and other autoantibodies. Cell-based therapies and treatment with bosentan were also advocated. Finally, a consequent prevention and treatment of wounds and infections are essential for the prevention of amputations. To achieve better clinical results, integrated care in multidisciplinary and trans-sectoral teams with emphasis on smoking cessation, pain control, wound management, and social care by professionals, social workers, and family members is necessary.

The role of autoimmunity in thromboangiitis obliterans (Buerger's disease)

Thromboangiitis obliterans (TAO), or Buerger's disease, is a nonatherosclerotic segmental vasculitis that affects the small- and medium-sized arteries and veins of the extremities and is strongly associated with tobacco exposure. The immunopathogenesis of TAO remains largely unknown. In the acute phase of the disease, macrophages and occasional giant cells are observed in the characteristic intraluminal thrombus with a relatively mild infiltration of CD4(+) and CD8(+) T cells and macrophages in the internal lamina. VCAM-1, ICAM-1, and E-selectin expression on the surface of vascular endothelial cells is increased. A variety of circulating autoreactive antibodies targeting endothelial cells and vessel wall components are associated with active disease. One recent report suggests that removal of circulating antibodies by immunoadsorption may decrease disease severity. TAO has been associated positively and negatively with various MHC class 1 and 2 genes; however, genetic testing is not currently used for clinical diagnosis or management. The possible links between tobacco exposure and loss of tolerance for vascular tissues, current management strategy for patients with TAO, and opportunities for translational science are discussed.

Antibiotic-associated eosinophilic and occlusive arteritis in calves complicating preclinical studies of left ventricular assist devices

Repeated bolus intravenous (IV) administration of large doses of beta-lactams and aminoglycosides has previously been associated with the development of eosinophilic and occlusive arterial lesions limited to the lungs in calves. Reviewing 13 years worth of records from left ventricular assist device implantation studies, morphologically identical segmental arterial lesions were present in 32 of the 56 calves receiving IV antibiotics, affecting lungs (6/50), kidneys (12/56), or lungs and kidneys (14/50). In 16 of these calves, renal arterial lesions spatially colocalized with renal cortical infarctions. Lesions were noted in additional abdominal organs in 4 of the 50 calves and were exclusively present in the liver in a single calf. Similar arterial lesions were also noted in the lungs (3/4), kidneys (1/4), liver (1/4), and spleen (1/4) of unimplanted calves receiving similar IV antibiotic regimens for bacterial infections. Lesions were observed with therapeutic IV doses of cephalosporins with or without aminoglycosides over shorter intervals than previously implicated. Lesions were significantly associated with increased peripheral eosinophil counts and mildly elevated, not reduced, arterial pulse pressures. This report documents the features of an idiosyncratic drug reaction with features strongly suggestive of an acute type-I hypersensitivity in this species.

Targeting novel antigens in the arterial wall in thromboangiitis obliterans

Thromboangiitis obliterans is an inflammatory disease possibly resulting from cigarette smoking as a primary etiologic factor, perhaps as a delayed type of hypersensitivity or toxic angiitis. As little is known about the pathogenesis of the disease, we aimed to determine novel antigens that might be responsible from the local inflammatory reactions and structural changes observed in this disease. An indirect immunoperoxidase technique is used to examine the tissue samples obtained from the dorsalis pedis artery of affected individuals with twenty monoclonal antibodies. Among these several antigens which are not previously reported in TAO like CD34, CD44 and CD90 were determined in the tissue samples examined. On the other hand, many other antigens like cytokine/chemokine receptors, several enzymes and leukocyte/lymphocyte antigens were lacking giving some clues about the local pathological reactions. We briefly discussed our findings for several critical antigens those first described in the present work, possibly having roles in the development of the disease. Expression of the CD90/CD11c receptor/ligand pair seems to play an important role in mononuclear cell recruitment to the damage site. Vascular invasion of not only tunica intima but also the tunica media in affected vessels is clearly demonstrated using endothelial cell specific antigens.

Thromboangiitis obliterans in the 21st century--a new face of disease

Thromboangiitis obliterans (TAO) is a relatively rare disease of peripheral blood vessels, affecting small and medium sized arteries and veins. Although the first description of the disease was given by Winiwarter almost 130 years ago, etiology of TAO remains not elucidated. Smoking is considered as a precipitating factor of the disease. We emphasised some particular features of the new face of TAO - significant decrease in incidences, increased disease prevalence among women and coexistence of other than smoking atherosclerotic risk factors (especially disturbances of glucose metabolism). Contemporary methods of treatment were also discussed.

Calcification of the internal elastic lamina of coronary arteries

Two well-recognized patterns of calcification occur in large- and medium-sized arteries, intimal calcification associated with atherosclerosis and medial calcification described by Mönckeberg. Calcification limited to the internal elastic lamina is a third pattern of calcification not previously reported in coronary arteries. Here we describe 19 cases of coronary artery internal elastic lamina calcification. We serially sectioned and examined the coronary arteries of 66 patients with advanced AIDS and 27 HIV- controls with other chronic illnesses. We observed calcification of the internal elastic lamina in 10 HIV+ patients and 9 controls. HIV- patients with internal elastic lamina calcification were significantly older than HIV- patients without it (P=0.008) and HIV+ patients with it (P=0.006). Occasionally, calcification encroached on adjacent intimal or medial tissue with mild fibrosis. There was frequent disruption of the internal elastic lamina but no evidence of inflammation. Calcification was the dominant histologic feature in all cases. Von Kossa, Alizarin red, and trichrome/elastic stains confirmed these findings. Patients with internal elastic lamina calcification often had extensive medical histories but did not suffer from chronic renal failure or other conditions known to cause calcium dysregulation. We describe coronary internal elastic lamina calcification in HIV+ patients and older HIV- adults. The clinical significance of this finding is unknown. It could lead to arterial stiffening and increased pulse pressure and could be mistaken for intimal calcification on coronary imaging. Internal elastic lamina calcification may result from premature aging due to HIV disease and chronic illness or from metabolic disorders in HIV+ patients.

Buerger's disease: What has the last decade taught us?

Thrombangiitis obliterans (TAO), or Buerger's disease, is most likely an endarteritis that is introduced by T-cell-mediated cellular immunity and B-cell-mediated humoral immunity associated with the activation of macrophages or dendritic cells in the intima. There is no specific marker of the disease, and the diagnosis is based on clinical and angiographic criteria. The disease spontaneously leads to tissue loss and major amputations and is self-limiting in the 5th to 6th decades of life. Patients should quit smoking and be offered treatment with prostaglandin or prostacyclin, modern wound management, and pain-relieving drugs. Surgical revascularization may be indicated in elective patients, and amputation should only be the last option. It has been suggested that environmental factors may play a major role in the modification of the disease process. TAO is a typical lower class disease, the social and psychological components of which are widely unexplored. Unfortunately, the last decade has not taught us anything to enable us to improve the treatment of TAO patients.

Different immunophenotypes in Buerger's disease

Recently, we reviewed the morphology of 31 specimens of thromboangiitis obliterans (TAO, Buerger's disease) in a multivariate analysis and showed that certain novel features of the affected vessels are different from arteriosclerosis obliterans (ASO) and thromboembolism. However, the pathogenic concept of TAO is still controversial. We applied immunohistochemistry to 58 amputated lower extremities and five autopsy controls. At specific sites of the diseased vessels, different cellular components were immunotyped by CD3, CD4, CD20, CD31, CD68, actin and desmin. These results were carefully compared among different diagnostic groups of vasoocclusive lesions by statistical methods. Some unique characteristics of TAO were identified when compared with ASO or thromboembolism. Consistent with a primary inflammatory and immunogenic lesion, lymphocytes and especially CD4+ T cells emerged significantly in TAO vessels and their adventitia. In the subset of definite TAO cases defined by all clinical criteria, the linear arrangement of macrophages, and B- and T-lymphocytes along vascular elastic fibers was the most striking additional finding, suggesting elastic fibers are an important immunogen. However, this feature was not apparent in closely related cases, otherwise similar to TAO and different from ASO and thromboembolism. Thus, our results indicate a heterogeneous group of TAO diseases, suggesting that damage to elastic fibers may be a secondary change to primary inflammation.

Immunobiologic analysis of arterial tissue in Buerger's disease

INTRODUCTION

the cause of thromboangiitis obliterans (TAO) still remains unknown. We have reported that immunologic injury associated with T lymphocytes infiltration might be the initial etiologic mechanism in TAO. The present study was undertaken to examine further the mechanism of immune injury.

METHODS

arterial walls affected by TAO were obtained from eight patients with eight non-pulsatile arteries and one patent artery. Immunohistochemical and TUNEL studies were performed for phenotyping of the infiltrating cells with CD4 (helper T cell), CD8 (cytotoxic T cell), CD56 (natural killer cell), and CD68 (macrophage), for identification of cell activation with VCAM-1 and i -NOS, for the presence of cell death with TUNEL analysis, and for inflammatory cytokine detection with RT-PCR.

RESULTS

the characteristic features were luminal obliteration, together with a varying degree of recanalization. T cells infiltrated mainly in thrombus, intima, and adventita. Among infiltrating cells, CD4 T cells greatly outnumbered CD8 cells. VCAM-1 and i -NOS were expressed in endothelial cells around the intima (patent segment) or vaso vasorum (occluded segment). Endothelial cells in vaso vasorum stained positive with TUNEL. Interferon-gamma mRNA was detected in two specimens.

CONCLUSIONS

our results suggest that T cell mediated immune inflammation is a significant event in the development of TAO.