Churg-Strauss syndrome: the clinical features and long-term follow-up of 17 patients

Navigating the complexity of Churg-Strauss syndrome presenting as acute abdomen: a comprehensive review and case report

Introduction and importance

Churg-Strauss syndrome (CSS) is a rare multisystemic condition characterized by asthma, blood and tissue eosinophilia, and vasculitis. The purpose of this work is to present a detailed overview of CSS, focusing on its epidemiology, clinical symptoms, histological criteria, gastrointestinal involvement, and therapy.

Case presentation

The authors report a case of a 40-year-old woman with CSS who had peripheral eosinophilia, small vessel vasculitis, and bronchial asthma. Diagnosed with symmetric polyarthritis six months ago, experienced abdominal pain, vomiting, and loose faeces. Diagnostic tests revealed CSS with systemic involvement. In addition, we undertake a literature analysis to emphasize essential elements of CSS, such as its rarity and the difficulties in diagnosing and managing it.

Clinical discussion

CSS can cause gastrointestinal symptoms including stomach pain, diarrhoea, mucosal ulcers, rectal bleeding, and bowel perforations. Corticosteroids and immunosuppressives are routinely used in treatment, with caution due to the risks of long-term steroid use. The goal of treatment should be to induce remission while minimizing side effects.

Conclusion

CSS is a rare condition, with an annual incidence of 2.4 per million and a prevalence of 1.3 per 100 000. The illness typically presents with necrotizing vasculitis, extravascular granulomas, and eosinophilic tissue infiltration. CSS is a complex and rare condition that requires high clinical suspicion, especially when patients present with gastrointestinal symptoms in addition to asthma and eosinophilia. This case study adds to our understanding of CSS and emphasizes the significance of a holistic strategy for its management.

Multiple hepatic aneurysms and dry gangrene of fingertips in eosinophilic granulomatosis with polyangiitis: a case report

Background

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis mainly affecting small-sized arteries. Involvement of medium-sized vessels is very rare in EGPA. Here we present the case of a patient with EGPA who showed multiple hepatic aneurysms and distal gangrene.

Case presentation

A known EGPA patient visited to the emergency room (ER) with abrupt squeezing abdominal pain. She had suffered from gangrene in the fingertips of both hands for 1 year because of arterial thrombosis associated with hypereosinophilia. However, her absolute eosinophil count in the ER was 1120 cells/µL. An abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe. A celiac angiogram demonstrated multiple sized aneurysms in both hepatic lobes and some aneurysms in S7 and S8 were huge, more than 1 cm in size. The shape of the small aneurysms resembled a string of beads, as in polyarteritis nodosa. Given the clinical situation, emergency embolization was performed. Before this patient visited to the ER, she had been treated with a high dose of systemic corticosteroid, azathioprine, and cyclophosphamide. After addition of mepolizumab, the eosinophil count remained stable state with a near zero percentage of total white blood cell count.

Conclusions

Aneurysm and gangrene resulting from the involvement of medium-sized vessels can occur in EGPA. Destruction of vessels might occur even if eosinophil count is below 1500 cells/µL. If involvement of medium-sized arteries is suspected, thorough investigation to identify the involved organs and prompt management are needed to prevent fatal complications.

Mepolizumab for the treatment of eosinophilic granulomatosis with polyangiitis

INTRODUCTION

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterized by asthma, hypereosinophilia, and progressive multiorgan involvement. Although not fully elucidated, advancement in our understanding of the pathophysiology of EGPA has led to the development of multiple new treatment targets.

AREAS COVERED

Herein we review the epidemiology, clinical manifestations, pathophysiology, treatments, and ongoing research in the management of EGPA. The central role of Interleukin-5 (IL-5) in the development and maintenance of hypereosinophilia will be discussed. The value of mepolizumab, an anti-IL-5 monoclonal antibody, in the treatment of EGPA is reviewed in detail.

EXPERT OPINION

The available literature supports the use of mepolizumab for the induction and maintenance of remission of refractory, relapsing, or glucocorticoid-dependent EGPA with potentially greater benefit in those who are ANCA-positive or those with greater eosinophilia ( ≥ 150 cells/ μ L). Despite these positive results, relapses remain frequent, and the need for both short- and long-term glucocorticoid use remains common. More research is needed to address these needs and determine the precise role of mepolizumab.

Churg-strauss syndrome presented with hearing impairment and facial palsy

Churg-Strauss syndrome (CSS) is a rare systemic necrotizing vasculitis. Cranial nerve involvement is very rare in CSS. A 59-year-old woman had complained of both hearing impairments for eight months and left facial palsy for three months. Left facial and cochlear neuropathies were detected in electrodiagnostic studies. Paranasal sinus computed tomography (CT) showed chronic pansinusitis. Chest CT revealed eosinophilic infiltration in the right upper lobe. Tissue biopsy of the right inferior turbinate displayed necrotizing vasculitis with eosinophilic infiltration. She was diagnosed as CSS, based on the presence of eosinophilia, pulmonary infiltration, paranasal sinusitis, and biopsy containing blood vessels with extravascular eosinophils. She was treated with intravenous and oral steroids and azathioprine, showing relatively good prognosis on facial palsy and hearing impairment. We report a very rare case of CSS presented with hearing impairment and facial palsy.

Churg-Strauss syndrome: a new endotype of severe asthma? Results of 14 Turkish patients

INTRODUCTION

Churg-Strauss syndrome (CSS) is a rare multisystem vasculitis. Considering the variation of autoimmune diseases in different races, it is of interest to determine whether any outstanding features exist for Turkish patients with CSS.

OBJECTIVE

The aim of this study was to evaluate the clinical and serological features of the disease, the treatment, and long-term follow-up details, and to investigate possible etiological factors of Turkish CSS patients.

METHODS

The study included 14 patients who were diagnosed with CSS, and followed by our department between 2004 and 2012. Possible etiological factors, initial symptoms, clinical presentations, treatment, as well as outcomes were documented. The study was approved by the local ethics.

RESULTS

All patients fulfilled the American College of Rheumatology criteria. Initial symptoms were worsening asthma (n = 14; 100%) and skin lesions (n = 6; 43%). All patients had a diagnosis of asthma and nasal polyps, whereas 57.1% had aspirin hypersensitivity at the time of diagnosis. The lungs (100%) and skin (43%) were most commonly involved. Peripheral eosinophilia dominated on initial presentations of all patients. Initial treatments included oral methyl prednisolone in all cases, whereas cyclophosphamide and azathioprine were used in three cases. Relapses were detected in five cases. None of the cases were able to stop the oral corticosteroid treatment. No fatalities were observed.

CONCLUSION

We herein describe a new severe asthma endotype in connection with CSS. We suggest that physicians who deal with uncontrolled severe asthma cases should consider CSS in the presence of nasal polyps, aspirin hypersensitivity, and especially peripheral blood eosinophilia over 10%.

Clinical features and prognostic factors of Churg-Strauss syndrome

BACKGROUND/AIMS

Churg-Strauss syndrome (CSS) is a rare systemic necrotizing small-vessel vasculitis, with accompanying bronchial asthma, eosinophilia, and eosinophilic infiltration of various tissues. The purposes of our study were to characterize the clinical features of CSS and to identify factors associated with CSS prognosis in Koreans.

METHODS

Medical records were reviewed retrospectively for all physician-diagnosed CSS patients in the Seoul National University Hospital between January 1990 and March 2011.

RESULTS

Data from 52 CSS patients were analyzed. The respiratory tract was the most commonly involved organ (90.4%). Renal involvement was less frequent in antineutrophilic cytoplasmic antibody (ANCA)(-) patients than in ANCA(+) patients (p = 0.048). Clinical remission occurred in 95.3% of patients, but 16.3% of them relapsed. Patients who maintained remission for more than 6 months were relatively older (median, 51 years) at diagnosis (p = 0.004), had been diagnosed in earlier stages (p = 0.027), showed more frequent respiratory involvement (p = 0.024) and generalized symptoms (p = 0.039), and showed less frequent cutaneous involvement (p = 0.030) than those who did not achieve persistent (> 6 months) remission. Patients who achieved persistent remission also showed higher C-reactive protein (CRP) levels (p = 0.031) than those who did not.

CONCLUSIONS

ANCA(-) CSS patients showed less frequent renal involvement. Characteristics of good responders were older age, diagnosis at earlier stages, less cutaneous involvement, more respiratory involvement, high CRP values, and more generalized symptoms.

ANCA-associated vasculitis: report from Korea

We investigated the clinical features of Korean patients with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) by reviewing the literature. The characteristics of AAV in Korean patients were as follows: (1) granulomatous and limited disease is prevalent in granulomatosis with polyangiitis (Wegener's) (GPA), (2) ANCA positivity is lower in GPA (56.6-68.9%) and eosinophilic granulomatosis with polyangiitis (EGPA) (5.9-8.3%), whereas it is higher in microscopic polyangiitis (MPA) (69-94%), (3) C-ANCA/proteinase 3 (PR3)-ANCA positivity is 71.5-100% in GPA and P-ANCA/myeloperoxidase (MPO)-ANCA positivity reached 94-100% in patients with MPA, (4) renal involvement or progression to end-stage renal disease was lower in Korean patients with GPA and EGPA than in Caucasians with GPA and EGPA (according to data provided in reports). The data provided here may need to be confirmed in large-scale studies.

Delay in diagnosis of Churg-Strauss syndrome: a case report

Churg-Strauss syndrome (CSS) is a well established disorder of the blood vessels. However, it is still sometimes not diagnosed early enough to avoid serious complications. It is the later stage that carries the more serious complications. Therefore, we emphasize the ways in which the diagnosis can be made early enough to avoid this stage of the disease. We report a case of CSS that was not diagnosed early and so the patient went on to develop severe cardiac and neurological manifestations. In this report we discuss the techniques and the methods to diagnose CSS and discuss their effectiveness in establishing the diagnosis. We also explore late cardiac and neurological complications because these are particularly serious complications later in the disease. We conclude that the criteria established by the American College of Rheumatology for CSS is the best tool available for early diagnosis and that late stage manifestations of CSS carry high rates of morbidity and mortality.

Cutaneous manifestations of Churg-Strauss syndrome: report of two cases and review of the literature

Churg-Strauss syndrome (CSS) is a small-vessel vasculitis characterized by severe asthma, lung/tissues infiltrates, extravascular necrotizing granulomas, and eosinophilia. Cutaneous involvement is common but may not be highly suggestive. Two typical cases of CSS with cutaneous involvement are herein reported, both females, 37 and 54 years old, presenting with lower limbs palpable purpura and urticarial lesions of the neck, respectively. A comprehensive review of the literature showed that cutaneous manifestations occurred in 40-81% of CSS patients and were the presenting sign in 14% of the patients. Moreover, a total of 68 cases of CSS with a detailed description of the cutaneous lesions have been published. In the majority of these patients, skin lesions allowed for the histopathological diagnosis of CSS. The most common clinical features were papulo-nodules with the histological picture of extravascular Churg-Strauss granuloma followed by purpuric and/or necrotic lesions in the lower limbs corresponding to small-vessel vasculitis with eosinophils. Less common lesions included urticarial lesions and livedo reticularis. Therefore, a high index of suspicion on skin lesions and the proper lesion selection for histological examination may be very important for early diagnosis of CSS. Clinical-pathological correlation is essential, as both clinical and histological features are not pathognomonic.

Clinical manifestations and treatment of Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis affecting small to medium-sized vessels, and characterized by asthma, blood hypereosinophilia, and eosinophil-rich granulomatous inflammation of the respiratory tract. In the past few years the pathogenesis of the disease and its clinical manifestations have been clarified, fostering important advances in the treatment of CSS. Systemic corticosteroids are still considered the cornerstone of treatment. Many issues need to be addressed, such as how to maintain remission, prevent disease relapses, and treat refractory disease. This review provides a clinical overview of CSS and a summary of the current treatments and novel therapies.

Difficult-to-control asthma management through the use of a specific protocol

The present study is a critical review of difficult-to-control asthma, highlighting the characteristics and severity of the disease. It also presents a protocol for the management of patients with this asthma phenotype. The protocol, which was based on relevant studies in the literature, is described and analyzed.

[Churg-Strauss Vasculitis. Description of 9 cases]

INTRODUCTION

Churg-Strauss Síndrome (SCS) is a necrotizing vasculitis affecting small to medium-sized vessels, characterized by lung involvement, asthma and peripheral blood eosinophilia, and pathologically by the presence of granulomas and eosinophilic infiltrates.

OBJECTIVES

This report analizes the characteristics of 9 patients with SCS diagnosed in an university referral center.

PATIENTS AND METHODS

Retrospective study. Between 1984 and 2007 nine patients with SCS were diagnosed in our center. Epidemiological, clinical, laboratory test as well as pathologic studies and treatment required were retrospectively analyzed.

RESULTS

Nine patients (7 males). The mean age at the time of diagnosis was 51 years (range 23-76 years). Eight of these patients had history of asthma. The more frequent organs involved were the skin (66%), musculoesqueletical system (66%), peripheral nervous system (55%) and the lung (55%). All patients presented peripheral eosinophilia. ANCA positivity was demonstrated in 6 patients (66%), most of the patients with the p-ANCA pattern. All patients were treated with corticosteroids, and in 8 immunosupressant treatment was required, mainly cyclophosphamide.

CONCLUSIONS

In this report, 9 patients with SCS are presented. Clinical characteristics are similar with the observed in other reports. We observed a major positivity of ANCA. Most of the patients were treated with corticosteroids and inmunosupresants, but the treatment should be tailored depending on the involvement of the patient.

Eosinophilia and thrombophilia in churg strauss syndrome: a clinical and pathogenetic overview

During the past decade, there has been an increased description of Churg Strauss syndrome (CSS) characterized by vascular occlusions possibly linked to the thrombogenic potential of the eosinophil that is poorly appreciated. The purpose of this overview is 3-fold: the first to evaluate the available prevalence of thrombosis in Churg Strauss series, the second to demonstrate that any vascular district may be affected, and the third to describe the pathogenesis of thrombosis in CSS. A Pubmed, EMBASE, and Google search of CSS series from 1951 to date revealed a prevalence of arterial occlusion ranging between 3.1% and 18.7% and a prevalence of venous occlusion between 5.8% and 30%, whereas a specific survey for venous thromboembolism in CSS yielded a prevalence of 8.1%. Eosinophils store and release tissue factor as well as other cationic proteins: the former initiates coagulation while the latter inhibits natural anticoagulant activity and activate platelets eventually culminating in excessive thrombin generation and clot formation. In addition, antineutrophil cytoplasmic antibodies may shift the endothelial lining to proadhesive and prothrombotic surface. It is hoped that the review will represent a basis to foster novel research on this topic.

An asthmatic adolescent with a rash and eosinophilia

Children frequently visit emergency departments with asthma exacerbations. Many of these asthmatic children may have fever and/or pneumonia, but when associated with eosinophilia or evidence of vasculitis, other diagnoses should be considered. Churg-Strauss syndrome is a rare form of systemic vasculitis, which usually occurs in patients with asthma in association with eosinophilia. The diagnosis of Churg-Strauss syndrome can be difficult because this syndrome may arise at first as a common association between asthma and allergic rhinitis. A delay in diagnosis and treatment may increase the morbidity from the complications of vasculitis. We report a young asthmatic adolescent who presented with vasculitis, eosinophilia, and peripheral neuropathy.

Administration of anti-IgE to a Churg-Strauss syndrome patient

BACKGROUND

Treatment of the Churg-Strauss syndrome (CCS) remains a challenge. Many patients relapse after achieving remission, and a substantial proportion of them present adverse drug reactions with relevant morbidity. In most patients, severe asthma and upper respiratory symptoms persist, requiring continuous therapy. The aim of the present study is to describe a patient with CSS who was administered anti-IgE.

CASE REPORT

A 46-year-old male patient with CSS followed up for 17 years is described. Upon treatment, CSS showed remission but asthma failed to improve despite high-dose inhaled corticosteroids, long-acting beta2-agonists and several courses of systemic steroids. In order to better control asthma, anti-IgE was administered. Following omalizumab administration, asthma symptoms (according to clinical features and lung function tests) and eosinophilia improved.

CONCLUSIONS

Anti-IgE offers the potential not only to decrease asthma activity but also to reduce the risk of morbidity that can result from currently available treatment options. Whether it can also affect the activity of other CSS components is an open question. As far as we know, there are no published reports about the prescription of omalizumab to patients with CSS and with non-allergic asthma. Anti-IgE improved our patient's asthma and decreased the eosinophil blood count but did not worsen the outcome of CSS. However, large and long-term studies are necessary before a more widespread utilization of anti-IgE in CSS patients can be implemented.

Churg-Strauss syndrome

PURPOSE OF REVIEW

Churg-Strauss syndrome is a small-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, extravascular necrotizing granulomas and hypereosinophilia. The most recent clinical studies on its pathogenesis and therapeutic management are reviewed here.

RECENT FINDINGS

French and Italian clinical studies found that the clinical characteristics of patients with Churg-Strauss syndrome differed according to their antineutrophil cytoplasmic autoantibody status: cardiomyopathy predominated in antineutrophil cytoplasmic autoantibody-negative patients while necrotizing glomerulonephritis was more often observed in antineutrophil cytoplasmic autoantibody-positive patients. These histologically documented findings suggest the existence of different Churg-Strauss syndrome subtypes, characterized by the predominance of distinct pathogenetic mechanisms. To date, following the therapeutic recommendations for Churg-Strauss syndrome (i.e. corticosteroids and, when required, immunosuppressants), patient outcomes are good, with 5-year survival exceeding 90%, but often with the need to continue low-dose corticosteroids to control residual asthma.

SUMMARY

The precise pathogenetic mechanisms of Churg-Strauss syndrome are only partly elucidated. Recent results suggest that antineutrophil cytoplasmic autoantibodies are probably more involved in the vasculitic manifestations of Churg-Strauss syndrome (e.g. glomerulonephritis) whereas eosinophil tissue infiltration and associated cytotoxicity would be responsible for cardiomyopathy. If confirmed, these results could support individual therapeutic stratification according to the clinical pattern. Furthermore, some patients may benefit from new biologic therapies under development, for example antiinterleukin-5 or antiimmunoglobulin E monoclonal antibodies.