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Mertz P, Wollenschlaeger C, Chasset F, Dima A, Arnaud L. Rheumatoid vasculitis in 2023: Changes and challenges since the biologics era. Autoimmun Rev 2023; 22:103391. [PMID: 37468085 DOI: 10.1016/j.autrev.2023.103391] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Significant changes in the epidemiology and natural history of rheumatoid vasculitis (RV) have occurred with the introduction of biological therapies such as TNF inhibitors (TNFi) and rituximab. PURPOSE This scoping review aims to address the key current challenges and propose updated criteria for RV. This will aid future descriptive observational studies and prospective therapeutic trials. METHODOLOGY The MEDLINE database was searched for eligible articles from inception through December 2022. Articles were selected based on language and publication date after 1998, corresponding to the approval of the first TNFi in rheumatic diseases. RESULTS Sixty articles were included in the review. The mean incidence of RV has decreased since the approval of biologic therapies in RA, from 9.1 (95% CI: 6.8-12.0) per million between 1988 and 2000 to 3.9 (95% CI: 2.3-6.2) between 2001 and 2010, probably due to significant improvement in RA severity and a decrease in smoking habits. Factors associated with an increased risk of RV include smoking at RA diagnosis, longer disease duration, severe RA, immunopositivity, and male gender (regardless of age). Homozygosity for the HLA-DRB104 shared epitope is linked to RV, while the presence of HLA-C3 is a significant predictor of vasculitis in patients without HLA-DRB104. Cutaneous (65-88%), neurologic (35-63%), and cardiac (33%) manifestations are common in RV, often associated with constitutional symptoms (70%). Histologic findings range from small vessel vasculitis to medium-sized necrotizing arteritis, but definite evidence of vasculitis is not required in the 1984 Scott and Bacon diagnostic criteria. Existing data on RV treatment are retrospective, and no formal published guidelines are currently available. CONCLUSION The understanding of RV pathogenesis has improved since its initial diagnostic criteria, with a wider range of clinical manifestations identified. However, a validated and updated criteria that incorporates these advances is currently lacking, impeding the development of descriptive observational studies and prospective therapeutic trials. PRIMARY FUNDING SOURCE This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Philippe Mertz
- Service de rhumatologie, INSERM UMR-S1109, Hôpital de Hautepierre, 1 Avenue Molière BP 83049, 67098 Strasbourg Cedex, France; Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA, France.
| | - Clara Wollenschlaeger
- Dermatology Clinic, Hôpitaux Universitaires et Université de Strasbourg, 1 Place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine, Service de dermatologie et Allergologie, AP-HP, hôpital Tenon, et INSERM U1135, CIMI, Paris
| | - Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Laurent Arnaud
- Service de rhumatologie, INSERM UMR-S1109, Hôpital de Hautepierre, 1 Avenue Molière BP 83049, 67098 Strasbourg Cedex, France; Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA, France
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Diagnosis and Management of a Chronic Lower-Limb Wound in a Patient with Felty Syndrome. Adv Skin Wound Care 2022; 35:1-4. [PMID: 35723962 DOI: 10.1097/01.asw.0000831076.19727.a0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The authors report the case of a 55-year-old patient with a chronic lower-limb wound thought to be secondary to vasculitis. This case illustrates the importance of maintaining a high index of suspicion for vasculitic ulcers in patients with autoimmune disease. Management considerations in this context are also discussed.
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Treatment of an Intractable Forefoot Ulcer Using Realignment Osteotomy in a Patient with Rheumatoid Arthritis. Case Rep Orthop 2020; 2020:8817456. [PMID: 32802537 PMCID: PMC7403941 DOI: 10.1155/2020/8817456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/03/2020] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
Forefoot deformities are common among patients with rheumatoid arthritis (RA). Herein, we describe a case of intractable ulceration on the dorsomedial aspect of the right 5th digit, secondary to forefoot deformity, in a 76-year-old woman with a 35-year history of RA. The ulcer was due to a persistent subcutaneous infection. Although the infection was controllable with antibiotics, there was concern of relapse because of the abnormal pressure on the skin due to an overlap of the 4th and 5th digits. We proceeded with surgical correction of the forefoot alignment, including shortening oblique osteotomy of metatarsals 2 through 5, rather than amputation of the 5th digit. Following surgery, targeted antibiotic treatment was provided. The postoperative course was unremarkable, and the patient recovered weight-bearing function without recurrence of pain or ulceration. Forefoot realignment is a feasible option that should be considered for treating intractable foot pain and ulceration secondary to long-lasting RA.
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Hussin N, Ghazali AI. Lumbar sympathetic block for pain relief and healing of chronic vascular ulcer on lower limb in patient with antiphospholipid syndrome and immune thrombocytopenic purpura. INDIAN JOURNAL OF PAIN 2019. [DOI: 10.4103/ijpn.ijpn_33_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Avishai E, Yeghiazaryan K, Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. EPMA J 2017; 8:23-33. [PMID: 28620441 PMCID: PMC5471802 DOI: 10.1007/s13167-017-0081-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/29/2017] [Indexed: 12/14/2022]
Abstract
Whereas the physiologic wound healing (WH) successfully proceeds through the clearly defined sequence of the individual phases of wound healing, chronic non-healing wounds/ulcers fail to complete the individual stages and the entire healing process. There are many risk factors both modifiable (such as stress, smoking, inappropriate alcohol consumption, malnutrition, obesity, diabetes, cardio-vascular disease, etc.) and non-modifiable (such as genetic diseases and ageing) strongly contributing to the impaired WH. Current statistics demonstrate that both categories are increasingly presented in the populations, which causes dramatic socio-economic burden to the healthcare sector and society at large. Consequently, innovative concepts by predictive, preventive and personalised medicine are crucial to be implemented in the area. Individual risk factors, causality, functional interrelationships, molecular signature, predictive diagnosis, and primary and secondary prevention are thoroughly analysed followed by the expert recommendations in this paper.
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Affiliation(s)
- Eden Avishai
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Kristina Yeghiazaryan
- Radiological Clinic, Medical Faculty, Friedrich-Wilhels-University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
| | - Olga Golubnitschaja
- Radiological Clinic, Medical Faculty, Friedrich-Wilhels-University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
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Abstract
In this review, unusual causes of leg ulcers are examined with an emphasis on pathophysiology, clinical presentation, and epidemiology. Cutaneous ulcers due to malignancy of unusual leg ulcers with hematologic disorders, vasculitis, sarcoidosis, calciphylaxis, Buerger’s disease, and pyoderma gangrenosumare discussed.
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Barwell JR, Ghauri ASK, Taylor M, Deacon J, Wakely C, Poskitt KR, Whyman MR. Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers. Phlebology 2016. [DOI: 10.1177/026835550001500202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To identify independent risk factors for delayed healing and increased recurrence of chronic venous leg ulcers. Design: Prospective study. Setting: Community-based leg ulcer service. Patients: Six hundred and thirty-three limbs in 587 consecutive patients with an ankle-brachial pressure index (ABPI) ≥0.85. Method: Potential risk factors were initially assessed in a one-stop clinic incorporating clinical evaluation, ABPI and venous duplex imaging. Limbs were treated within a defined protocol. Twenty-four-week healing and 3-year ulcer recurrence rates were determined. Results: Of 12 potential risk factors age ( p< 0.001), ulcer chronicity ( p< 0.001) and popliteal vein reflux ( p< 0.005) were independent risks for delayed healing. Of 13 potential risk factors rheumatoid arthritis ( p<0.005) and healing time ( p < 0.05) were independent risks for ulcer recurrence. Isolated superficial venous reflux treated by saphenous vein surgery predicted reduced ulcer recurrence ( p< 0.005). Conclusion: Targeting in primary care of ulcer patients with specific characteristics might encourage earlier referral and appropriate resource management. Leg ulcer patients with superficial venous reflux might benefit from surgical correction.
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Affiliation(s)
- J. R. Barwell
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - A. S. K. Ghauri
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - M. Taylor
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - J. Deacon
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - C. Wakely
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - K. R. Poskitt
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - M. R. Whyman
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
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Obara H, Matsubara K, Fujimura N, Sekimoto Y, Kitagawa Y. Preliminary Report of Endovascular Treatment for Critical Limb Ischemia Patients with Connective Tissue Disease: Cases Series and Review of the Literature. Int J Angiol 2015; 24:137-42. [PMID: 26060386 DOI: 10.1055/s-0035-1547516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Only few studies have addressed the surgical revascularization in patients with both connective tissue disease (CTD) and critical limb ischemia (CLI), and the evidence for the endovascular treatment (EVT) is lacking in such patients. The main purpose of this study is to assess our outcome of EVT in patients with CTD and ischemic leg ulcers and review the current situation of the revascularization in such patients. Medical records of 10 consecutive patients with coexistent CTD and CLI-related leg ulcers (in 11 limbs) treated endovascularly at our institution between 2009 and 2013 were reviewed retrospectively. The patients had rheumatoid arthritis (n = 5), systemic lupus erythematosus (n = 1), progressive systemic scleroderma (n = 3), or polyarteritis nodosa (n = 1). EVT was technically successful in all the cases. No procedure-related morbidity or mortality occurred. During the mean follow-up period of 26 months, there were no major amputations, and sustained clinical improvement (ulcer healing and reduction in Rutherford category) was observed in eight limbs. The overall 1-year rates of amputation-free survival and freedom from reintervention were 89 and 81%, respectively. In our series of patients with CTD and ischemic leg ulcers, EVT had acceptable outcomes and may be recommended as a safe and reasonably effective initial treatment option for such patients.
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Affiliation(s)
- Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Fujimura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhito Sekimoto
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Jebakumar AJ, Udayakumar PD, Crowson CS, Gabriel SE, Matteson EL. Occurrence and effect of lower extremity ulcer in rheumatoid arthritis -- a population-based Study. J Rheumatol 2014; 41:437-43. [PMID: 24429171 DOI: 10.3899/jrheum.130392] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the occurrence, risk factors, morbidity, and mortality associated with lower extremity (LE) ulcers in patients with rheumatoid arthritis (RA). METHODS Retrospective review of Olmsted County, Minnesota, USA, residents who first fulfilled the 1987 American College of Rheumatology criteria for RA in 1980-2007 with followup to death, migration, or April 2012. Only LE ulcers that developed after the diagnosis of RA were included. RESULTS The study included 813 patients with 9771 total person-years of followup. Of them, 125 developed LE ulcers (total of 171 episodes), corresponding to a rate of occurrence of 1.8 episodes per 100 person-years (95% CI: 1.5, 2.0 per 100 person-yrs). The cumulative incidence of first LE ulcers was 4.8% at 5 years after diagnosis of RA and increased to 26.2% by 25 years. Median time for the LE ulcer to heal was 30 days. Ten of 171 episodes (6%) led to amputation. LE ulcers in RA were associated with increased mortality (HR 2.42; 95% CI 1.71, 3.42), adjusted for age, sex, and calendar year. Risk factors for LE ulcers included age (HR 1.73 per 10-yr increase; 95% CI 1.47, 2.04), rheumatoid factor positivity (HR 1.63; 95% CI 1.05, 2.53), presence of rheumatoid nodules (HR 2.14; 95% CI 1.39, 3.31), and venous thromboembolism (HR 2.16; 95% CI 1.07, 4.36). CONCLUSION LE ulcers are common among patients with RA. The cumulative incidence increased by 1% per year. A significant number require amputation. Patients with RA who have LE ulcers are at a 2-fold risk for premature mortality.
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Affiliation(s)
- Adlene J Jebakumar
- From the Department of Health Sciences Research and the Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Hasegawa M, Nagai Y, Sogabe Y, Hattori T, Inoue C, Okada E, Tago O, Ishikawa O. Clinical analysis of leg ulcers and gangrene in rheumatoid arthritis. J Dermatol 2013; 40:949-54. [DOI: 10.1111/1346-8138.12359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 10/13/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Michiko Hasegawa
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Yayoi Nagai
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Yoko Sogabe
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Tomoyasu Hattori
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Chizuru Inoue
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Etsuko Okada
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Osamu Tago
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Osamu Ishikawa
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
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Chia HY, Tang MBY. Chronic leg ulcers in adult patients with rheumatological diseases - a 7-year retrospective review. Int Wound J 2012; 11:601-4. [PMID: 23237056 DOI: 10.1111/iwj.12012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Chronic leg ulcers in patients with rheumatological diseases can cause significant morbidity. We performed a retrospective case review to describe the epidemiology, clinical features and outcome of chronic leg ulcers in this group of patients. Twenty-nine patients with underlying rheumatological conditions, such as, rheumatoid arthritis (15 patients), systemic lupus erythematosus (8 patients), overlap syndromes (3 patients), systemic sclerosis (1 patient) and ankylosing spondylitis (1 patient) were included. The ulcers were mostly located around the ankle (55·2%) and calves (37·9%). The predominant aetiology of the ulcers, in decreasing order of frequency, was venous disease, multifactorial, vasculitis or vasculopathy, infective, pyoderma gangrenosum, ischaemic microangiopathy and iatrogenic. Treatment modalities included aggressive wound bed preparation, compression therapy (17 patients), changes in immunosuppressive therapy (15 patients), hyperbaric oxygen therapy (4 patients) and cellular skin grafting (2 patients). Management of chronic leg ulcers in rheumatological patients is challenging and the importance of careful clinicopathological correlation and treatment of the underlying cause cannot be overemphasised.
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Affiliation(s)
- Hui Y Chia
- Dermatology, National Skin Centre, Singapore, Singapore
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Shanmugam VK, Schilling A, Germinario A, Mete M, Kim P, Steinberg J, Attinger CE. Prevalence of immune disease in patients with wounds presenting to a tertiary wound healing centre. Int Wound J 2011; 9:403-11. [PMID: 22168783 DOI: 10.1111/j.1742-481x.2011.00899.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Chronic leg ulcers are a significant cause of morbidity and mortality and account for considerable healthcare and socioeconomic costs. Leg ulcers are a recognised complication of immune disease, and the purpose of this study was to establish the prevalence of immune disease in a cohort of patients with chronic wounds, and to compare wound outcomes in the subjects with and without immune disease. Retrospective chart review was completed on consecutive patients scheduled with the plastic surgeon in the Georgetown University Center for Wound Healing between 1 January 2009 and 31 March 2009. Of the 520 patients scheduled for appointments, 340 were eligible for inclusion. The prevalence of immune disease was higher than expected with 78 of 340 patients (23%) having associated immune disease. At presentation, wounds in patients with immune disease had a significantly larger mean surface area [33·4 cm(2) (69·05) compared to 22·5 cm(2) (63·65), P = 0·02]. Split thickness skin graft (STSG) and bioengineered alternative tissue (BAT) graft data was available on 177 grafts from 55 subjects. There was a significantly lower response rate to STSG in subjects with immune disease (50% compared to 97%, P = 0·0002), but response rates to BAT were not different. The association between immune diseases and chronic wounds may provide unique insights into pathways of wound healing, and warrants further study.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, Washington, DC 20007, USA.
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Shanmugam VK, DeMaria DM, Attinger CE. Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression. Clin Rheumatol 2011; 30:849-53. [PMID: 21340497 PMCID: PMC3128869 DOI: 10.1007/s10067-011-1710-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/12/2011] [Accepted: 02/01/2011] [Indexed: 11/26/2022]
Abstract
Lower extremity ulcers are a recognized complication of rheumatoid arthritis (RA). Their prevalence has not been assessed since the advent of more aggressive disease modifying antirheumatic therapies. The purpose of this study was to establish the period prevalence of lower extremity ulcers in a modern-day unselected cohort of patients with RA, and to report the features associated with ulcer development and response to therapy. Between June 2007 and June 2010, 366 RA patients were evaluated at the Georgetown Division of Rheumatology. Data were collected and analyzed retrospectively on demographics, antibody and prothrombotic profile, comorbidities, disease activity, and outcomes. The period prevalence of ulcers in this cohort of 366 patients with RA followed over 3 years was 4.37%. Patients with ulcers were predominantly female (81.25%) and more commonly African American (56.2%). The mean disease duration at ulcer development was 25.9 years. All patients with ulcers had erosive disease and 63% were seropositive. Only five patients (31.25%) healed over a mean follow-up of 22.8 months. However, in this small sample, treatment with anti-tumor necrosis factor-α (anti-TNFα) therapy was associated with significantly higher likelihood of healing (p = 0.039). In this modern-day cohort of patients with RA, we found a prevalence of lower extremity ulcers of 4.37% over 3 years. Only 31.25% of patients healed after a mean 22.8 months of follow-up. However, treatment with a biologic agent was associated with a significant increased likelihood of healing (RR 3.27, 95% CI 0.59-18.29, p = 0.039).
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, NW Washington, DC 20007, USA.
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Körber A, Lehnen M, Rietkötter J, Grabbe S, Dissemond J. [Successful therapy of a rheumatoid leg ulcer with intravenous immunoglobulins]. Hautarzt 2007; 57:1106-10. [PMID: 16425069 DOI: 10.1007/s00105-005-1073-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease. Leg ulcers in rheumatoid arthritis may be caused by vasculitis and are an interdisciplinary therapeutic challenge. A 69 year old women with rheumatoid arthritis and many other medical problems presented with widespread vasculitis-induced therapy-resistant ulceration on her right lower leg. Since previous therapeutic efforts had a negative effect on wound healing, we administered intravenous immunoglobulins which led to complete healing of the ulcer was achieved. Both the serological and rheumatologic features of her rheumatoid arthritis also improved. Intravenous immunoglobulins represented an effective therapeutic option with fewer side effects in the therapy of vasculitis-induced leg ulceration in this patient with rheumatoid arthritis.
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Affiliation(s)
- A Körber
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstrasse 55, 45122 Essen
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Burks EJ, Loughran TP. Pathogenesis of neutropenia in large granular lymphocyte leukemia and Felty syndrome. Blood Rev 2006; 20:245-66. [PMID: 16530306 DOI: 10.1016/j.blre.2006.01.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
T-cell large granular lymphocyte leukemia (TLGL) is an atypical chronic lymphoproliferative disorder derived from cytotoxic T-cells (CTL). Unlike most forms of leukemia, the pattern of bone marrow infiltration in TLGL may be subtle and the cytopenias are often lineage specific, with neutropenia dominating. Both granulocytic survival and proliferation defects are observed and are mediated by humoral and cell-mediated mechanisms respectively. Splenic production of immune complexes induces a neutrophil survival defect, where as Fas expression by leukemic CTL results in a marrow based proliferation defect. These humoral and cell-mediated pathways induce granulocytic apoptosis through independent intracellular mechanisms which are not mutually exclusive and may be observed concurrently in individual patients with either TLGL or FS. A variety of therapeutic interventions have been utilized in the management of TLGL and Felty syndrome, including methotrexate, cyclosporine A, cyclophosphamide, glucocorticoids, myeloid colony stimulating factors and splenectomy. Their efficacy and mechanisms of action are reviewed.
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Affiliation(s)
- Eric J Burks
- Harvard School of Medicine, Brigham and Women's Hospital, Department of Pathology, Boston, MA 02115, USA.
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Firth J. Tissue viability in rheumatoid arthritis. J Tissue Viability 2005; 15:12-8. [PMID: 16104470 DOI: 10.1016/s0965-206x(05)53003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The 4-layer bandage was originally designed to provide sustained leg compression to patients with venous leg ulcers. Since then, the practice of 4-layer bandaging has become widespread in the United Kingdom. Ulcer healing rates vary for a number of reasons. This review, by a member of the original design team, seeks to discuss reasons of varying success and offers advice for its appropriate usage.
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Affiliation(s)
- Christine Moffatt
- Wolfson Institute for Health Sciences, Thames Valley University, London.
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Knab J, Goos M, Dissemond J. Successful treatment of a leg ulcer occurring in a rheumatoid arthritis patient under leflunomide therapy. J Eur Acad Dermatol Venereol 2005; 19:243-6. [PMID: 15752303 DOI: 10.1111/j.1468-3083.2005.01118.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We report the case of a leg ulcer in a rheumatoid arthritis (RA) patient under treatment with leflunomide, discuss the influence of the drug on the aetiopathogenesis of the ulcer and describe its successful treatment. CASE SUMMARY A 68-year-old woman with a 12-year history of RA developed a leg ulcer after 4 months of leflunomide treatment. Other ulcerogenic factors were ruled out. There were some clinical hints for rheumatoid vasculitis. The ulcer was resistant to ambulant conservative phase adapted wound bed preparation and a split skin transplantation failed. After omission of leflunomide and washout procedure with cholestyramine a second split skin transplantation resulted in complete healing. DISCUSSION Leflunomide inhibits the division of activated T cells and thus inhibits among others the production of proinflammatory cytokines and the adhesion of cells to the endothelium. These mechanisms may partly explain the possible influence of leflunomide on the perpetuation of the ulcer. Until now, occurrence of vasculitis and leg ulcers has been described in one case each for the novel immunomodulator leflunomide. No successful treatment of a leg ulcer under leflunomide has been described yet. Omission of leflunomide and a washout treatment in our case led to a complete healing. This may indicate a critical role of leflunomide in the maintenance of this slow healing ulcer. CONCLUSIONS An association between leflunomide intake, occurrence of leg ulcers in RA patients and delayed wound healing should be considered.
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Affiliation(s)
- J Knab
- Department of Dermatology, University of Essen, Germany
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Armitage M, Roberts J. Caring for patients with leg ulcers and an underlying vasculitic condition. Br J Community Nurs 2004; Suppl:S16-22. [PMID: 15655493 DOI: 10.12968/bjcn.2004.9.sup5.17250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
It is not uncommon for nurses in the community to encounter patients with leg ulceration combined with rheumatic disease, particularly rheumatoid arthritis (RA). The aetiology of the leg ulcers in these cases is rarely straightforward, and the management of the ulcers is correspondingly complex. Management may be further complicated in the presence of vasculitis, an uncommon disorder in which inflammatory changes cause degradation of blood vessels. Rapid deterioration and pain are the main challenges with these cases. This article discusses the aetiology of vaculitic ulcers, and presents two case studies which were successfully managed using a new hydrogel dressing.
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Re: Giant Leg Ulcer in Wegenerʼs Granulomatosis Treated with Plasmapheresis and Skin Graft. Dermatol Surg 2004. [DOI: 10.1097/00042728-200408000-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Santana ANC, Takagaki TY, Barros JM, Antunes T, Parra ER, Capelozzi VL, Barbas CSV. Re: giant leg ulcer in Wegener's granulomatosis treated with plasmapheresis and skin graft. Dermatol Surg 2004; 30:1182-3. [PMID: 15274718 DOI: 10.1111/j.1524-4725.2004.30353.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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22
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Henke PK, Sukheepod P, Proctor MC, Upchurch GR, Stanley JC. Clinical relevance of peripheral vascular occlusive disease in patients with rheumatoid arthritis and systemic lupus erythematosus. J Vasc Surg 2003; 38:111-5. [PMID: 12844099 DOI: 10.1016/s0741-5214(03)00074-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Peripheral vascular occlusive disease (PVOD) and rheumatologic disease (RD) are common in older patients. The effect that coexistence of these diseases may have on patient health has not been rigorously investigated. The present study was undertaken in an attempt to characterize patients with PVOD plus RD in terms of inflammatory serologic disorders, medications, and procedures, and their relation to limb salvage. METHODS Medical records were reviewed retrospectively for all patients with diagnosed coexistent PVOD and non-arteritis RD treated over 15 years at the University of Michigan Hospital. Demographics, operative and medical therapies, and serologic studies were analyzed. Univariate and multivariate analysis and the Kaplan-Meier method were used to assess these variables in relation to limb salvage. RESULTS Forty-one patients (34 women, 7 men), with mean age of 67 years, were studied. Mean antinuclear antibody titer was 274, C-reactive protein concentration was 3.1 mg/mL, and sedimentation rate was 49. Twenty-nine percent of patients had claudication, 49% had rest pain, and 32% had tissue loss. Mean ankle brachial index was 0.55. Medications included nonsteroidal anti-inflammatory drugs (67% of patients), corticosteroids (54%), and specific immunosuppressive agents (27%). Operative therapy included aortofemoral bypass grafting (n = 4), infrainguinal bypass grafting (n = 14), embolectomy (n = 4), and primary amputation (n = 7). Overall 5-year limb salvage rate was 70% in patients undergoing bypass surgery. Comparison of surgical with nonsurgical patients showed no significant differences in baseline risk factors, serologic disorders, or anatomic location of vascular disease. Multivariate analysis revealed that rest pain and lack of immunosuppression were significantly predictive of need for revascularization or amputation (P <.05). CONCLUSION Patients with RD should receive treatment on the basis of standard criteria for limb ischemia, in that surgical revascularization outcomes are satisfactory. Immunosuppressive agents may confer a protective effect against progression of PVOD.
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Affiliation(s)
- Peter K Henke
- Section of Vascular Surgery and the Jobst Vascular Research Laboratory, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA.
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Abstract
Chronic ulceration of the lower leg is a frequent condition, with a prevalence of 3-5% in the population over 65 years of age. The incidence of ulceration is rising as a result of the ageing population and increased risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes. Ulcers can be defined as wounds with a 'full thickness depth' and a 'slow healing tendency'. In general, the slow healing tendency is not simply explained by depth and size, but caused by an underlying pathogenetic factor that needs to be removed to induce healing. The main causes are venous valve insufficiency, lower extremity arterial disease and diabetes. Less frequent conditions are infection, vasculitis, skin malignancies and ulcerating skin diseases such as pyoderma gangrenosum. But even rarer conditions exist, such as the recently discovered combination of vasculitis and hypercoagulability. For a proper treatment of patients with leg ulcers, it is important to be aware of the large differential diagnosis of leg ulceration.
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Affiliation(s)
- J R Mekkes
- Departments of Dermatology and Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Oien RF, Håkansson A, Hansen BU. Leg ulcers in patients with rheumatoid arthritis--a prospective study of aetiology, wound healing and pain reduction after pinch grafting. Rheumatology (Oxford) 2001; 40:816-20. [PMID: 11477288 DOI: 10.1093/rheumatology/40.7.816] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To study the aetiology of leg ulcers in patients with rheumatoid arthritis (RA) and to study healing and pain relief after pinch grafting. METHODS Twenty patients with RA and leg ulcers were studied. Diagnosis of the ulcers was founded on the clinical picture and measurements of the ankle-brachial pressure index. To detect vasculitis, skin biopsies were taken for immunohistochemistry and histopathology. Pain severity was assessed pre- and post-operatively using a visual analogue scale. RESULTS Ten of the 20 patients had ulcers with multifactorial aetiology. Fifteen had signs of venous insufficiency, 11 had histopathological evidence of vasculitis, four had reduced arterial circulation and two patients had diabetes. Healing after pinch grafting was found in eight patients, all of whom had an ulcer area less than 15 cm(2). Eleven out of 18 patients had pain reduction after pinch grafting. CONCLUSION The causation of leg ulcers in patients with RA was found to be multifactorial, with vasculitis and venous insufficiency as the main determinants. Pinch grafting seems to be a good alternative to conservative treatment for minor leg ulcers for these patients, regarding both wound healing and pain relief.
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Affiliation(s)
- R F Oien
- Lyckeby Health Centre, S-371 62 Lyckeby, and Department of Community Medicine, Malmö University Hospital, S-205 02 Malmö, Sweden
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Hafner J, Schneider E, Burg G, Cassina PC. Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease. J Vasc Surg 2000; 32:322-9. [PMID: 10917993 DOI: 10.1067/mva.2000.106942] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We assessed the etiology and the prevalence of peripheral arterial and venous disease in leg ulcers in patients with rheumatoid arthritis and systemic sclerosis and analyzed the outcome after treatment of macrovascular disease. METHODS A clinical study on 15 consecutive patients with chronic leg ulcers in collagen vascular disease (nine patients with rheumatoid arthritis, six patients with systemic sclerosis) was carried out in a referral center. Angiography was used when the ankle-arm index was less than 0.8; venography was used when venous reflux was detectable by means of a hand-held Doppler examination. Therapies included percutaneous transluminal angioplasty (seven patients), femoropopliteal bypass grafting surgery (one patient), saphenectomy of the greater saphenous vein (six patients), and split skin graft (11 patients). RESULTS All patients with rheumatoid arthritis exhibited a multifactorial etiology of their ulcers: four of nine patients had peripheral arterial disease, and five of nine patients had venous insufficiency. In one of these patients, arterial and venous disease was combined. Five of six patients with systemic sclerosis exhibited a multifactorial etiology of their ulcers: three of six patients had peripheral arterial disease, and three of six patients had venous insufficiency. One of these patients had both arterial and venous disease. In patients with rheumatoid arthritis, healing was achieved in six of nine patients, and marked improvement occurred in two of nine patients. A below-knee amputation was necessary in one patient with rheumatoid vasculitis. In patients with systemic sclerosis, healing was achieved in three of six patients, and marked improvement occurred in the other three patients. CONCLUSION Most leg ulcers in patients with rheumatoid arthritis and systemic sclerosis disclose a multifactorial etiology. Relevant arterial and venous disease can be found in approximately half the patients. Our study suggests that revascularization and vein surgery improve the healing of leg ulcers in patients with collagen vascular disease. A prospective trial is now required to confirm these results.
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Affiliation(s)
- J Hafner
- Department of Dermatology, the Angiology Unit, Department of Internal Medicine, and the Department of Surgery, University Hospital, Zurich, Switzerland
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26
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Abstract
Patients with rheumatoid arthritis appear to be at increased risk of developing chronic leg ulcers. This review identifies the factors that predispose these patients to leg ulceration and highlights how this problem can be managed and the risk of recurrence reduced.
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Affiliation(s)
- E R McRorie
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK
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Schuppe H, Richter-Hintz D, Stierle HE, Homey B, Ruzicka T, Lehmann P. Topical tacrolimus for recalcitrant leg ulcer in rheumatoid arthritis. Rheumatology (Oxford) 2000; 39:105-6. [PMID: 10662882 DOI: 10.1093/rheumatology/39.1.105] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pritchard V. Treatment of a patient with a deep leg ulcer using Biatain Adhesive. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 1999; 8:1164-7. [PMID: 10897699 DOI: 10.12968/bjon.1999.8.17.6493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article looks at the use of Biatain Adhesive, a new foam dressing from Coloplast which is manufactured by incorporating 3D polymer structures within the central pad. It is now available on the Drug Tariff. The article discusses the treatment of exuding wounds and highlights the benefits of Biatain Adhesive by focusing on the case of an 84-year-old woman who had a history of long-standing leg ulcers where previous dressings had failed to promote healing.
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Colagiovanni DB, Shopp GM. Evaluation of interleukin-1 receptor antagonist (IL-1RA) and tumor necrosis factor binding protein (TNF-BP) in a rodent abscess model of host resistance. Immunopharmacol Immunotoxicol 1996; 18:397-419. [PMID: 8872492 DOI: 10.3109/08923979609052743] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Modulation of pro-inflammatory cytokine responses can alter the normal protective mechanisms against invading pathogens. The cytokines interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) are crucial in the inflammatory cascade for upregulation of adhesion molecule expression, neutrophil recruitment, and additional cytokine induction. To determine if the cytokine antagonists interleukin-1 receptor antagonist (IL-1ra) and tumor necrosis factor-binding protein (TNF-bp) alter host resistance mechanisms they were evaluated in a rodent abscess model. It has previously been shown that subcutaneous Staphylococcus aureus injections induce abscess formation in rats. These abscesses can be examined over a pre-determined time course for evaluation of size, severity and time to resolution. Treatment with immunosuppressive drug therapy can modify the normal course of abscess formation and/or resolution. IL-1ra and TNF-bp were administered either alone or in combination. Also, the effects of these cytokine antagonists in combination with dexamethasone were tested. Results indicated TNF-bp at any dose examined did not adversely alter any parameter of abscess formation or resolution. In contrast, high doses of IL-1ra increased abscess severity, while more clinically relevant doses did not. Combination treatment with IL-1ra and TNF-bp did not alter abscess parameters above individual findings. Dexamethasone, given in combination with either cytokine antagonist, significantly increased severity grading scores above dexamethasone given alone. Overall the data indicated high dosing regimens of IL-1ra or TNF-bp only caused transient impacts on this host resistance model, while more clinically relevant doses did not impact any aspect of the abscess. These findings demonstrate that these anti-cytokine therapies do not alter general host resistance.
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Abstract
Patients with venous leg ulcers have a readily recognized clinical syndrome of shallow ulcers, oedema, leg pain, venous ankle blush, lipodermatosclerosis, varicose veins, hyperpigmentation, and atrophie blanche, and they are assumed to have venous abnormalities. We examined 43 patients with venous leg ulcers, and compared those with obvious venous abnormalities (defined as historical or clinical evidence of deep venous thrombosis or varicose veins) with those with presumed venous abnormalities (defined as lacking any such evidence), to see if they presented with different clinical features. We found that both groups had similar clinical features, with the exception that lipodermatosclerosis was present more frequently in those patients with obvious venous abnormalities (94 vs. 36%, P < 0.001). Most patients with presumed venous abnormalities had musculoskeletal conditions which might cause calf pump dysfunction (91%). Using air plethysmography, we were unable to confirm that all patients with presumed venous abnormalities did have intrinsic venous abnormalities. We propose that ulcers occurring in this clinical syndrome be designated as calf pump dysfunction ulcers (CPD ulcers), rather than venous ulcers.
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Affiliation(s)
- E A Gross
- University of Pennsylvania School of Medicine, Department of Dermatology, Philadelphia 19104
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