Polyarteritis nodosa diagnosed in a young male after COVID-19 vaccine: A case report

In response to the coronavirus disease 2019 pandemic, the coronavirus disease 2019 vaccine was rapidly developed and the effectiveness of the vaccine has been established. However, various adverse effects have been reported, including the development of autoimmune diseases. We report a case of new-onset polyarteritis nodosa in a 32-year-old male following the coronavirus disease 2019 vaccination. The patient developed limb pain, fever, pulmonary embolism, multiple subcutaneous nodules, and haematomas. Skin biopsy revealed necrotising inflammation accompanied by fibrinoid necrosis and high inflammatory cell infiltration in the walls of medium to small arteries. The symptoms resolved following corticosteroid treatment. Although it is difficult to prove a relationship between the vaccine and polyarteritis nodosa, similar cases have been reported and further reports and analyses are therefore necessary.

Clinical features and long-term outcomes of patients with systemic polyarteritis nodosa diagnosed since 2005: Data from 196 patients

BACKGROUND

The landscape of polyarteritis nodosa (PAN) has substantially changed during the last decades. Recent data regarding causes, characteristics, and prognosis of systemic PAN in the modern era are lacking.

METHODS

This retrospective study included patients with systemic PAN referred to the French Vasculitis Study Group between 2005 and 2019. Characteristics, associated conditions and outcomes were collected, and predictors of relapse and death were analyzed.

RESULTS

196 patients were included. Main clinical symptoms were constitutional (84%), neurological (59%), skin (58%) and musculoskeletal (58%) manifestations. Secondary PAN accounted for 55 (28%) patients, including myelodysplastic syndrome (9%), solid cancer (7%), lymphoma (4%) and autoinflammatory diseases (4%). No patient had active HBV infection. All treated patients (98.5%) received glucocorticoids (GCs), alone (41%) or in combination with immunosuppressants (59%), with remission achieved in 90%. Relapses were independently associated with age >65 years (HR 1.85; 95% CI1.12-3.08), gastrointestinal involvement (1.95; 95% CI1.09-3.52) and skin necrotic lesions (HR 1.95; 95%CI 1.24-3.05). One-, 5- and 10-year overall survival rates were 93%, 87% and 81%, respectively. In multivariate analyses, age >65 years (HR 2.80; 95%CI 1.23-6.37), necrotic purpura (HR 4.16; 95%CI 1.62-10.70), acute kidney injury (HR 4.89; 95% 1.71-13.99) and secondary PAN (HR 2.98; 95%CI 1.29-6.85) were independently associated with mortality.

CONCLUSION

Landscape of PAN has changed during the last decades, with the disappearance of HBV-PAN and the emergence of secondary PAN. Relapse rate remains high, especially in aged patients with gastrointestinal and cutaneous necrosis, as well as mortality.

The same mutation in a family with adenosine deaminase 2 deficiency

The deficiency of adenosine deaminase 2 (DADA2) has recently been defined as a monogenetic autosomal recessive autoinflammatory disease. DADA2 is mainly characterized by high fever, livedo racemose, early-onset stroke, mild immunodeficiency and clinically polyarteritis nodosa (PAN)-like symptoms. Mutations in CECR1 (cat eye syndrome chromosome region, candidate 1) are responsible for DADA2. Livedoid racemose, lacunar infarct due to involvement in small vessel of the central nervous system, peripheral neuropathy, digital ulcers and loss of fingers are predominantly seen in the disease which could progress to end-stage organ failure and death in some patients. A wide spectrum of severity in phenotype as well as in the age of onset has been reported in the literature. This phenotypic variability is also found in our clinical practice even in patients with the same mutation. Here, we present a family diagnosed with DADA2, with the previously reported p.Gly47Arg mutation in CECR1.

[The changing face of medium-sized vasculitis]

Polyarteritis nodosa is a systemic necrotizing vasculitis which predominantly affects medium-sized arteries. It is a rare disease nowadays. Both the nomenclature and the classification of polyarteritis nodosa was amended several times in the past. Currently, there is a distinction between the primary form described as classical polyarteritis nodosa and other forms that are associated with their probable cause e.g. with viral hepatitis B, C or HIV infection. Moreover, polyarteritis-like necrotizing vasculitis can appear in the course of genetic diseases caused by mutations in single genes. The pathogenesis of idiopathic polyarteritis nodosa is still unclear, but a dominant role of the adaptive immune system disorders is suggested. Interestingly, in the hepatitis B virus-related vasculitis development, immune complexes are believed to play a crucial role. The spectrum of clinical manifestations of polyarteritis nodosa is wide, from involving a single organ to the polyvisceral failure. In the course of polyarteritis nodosa nearly each organ can be involved, however the disease never affects the lungs. Special forms of polyarteritis nodosa include a single-organ disease and a cutaneous form. The diagnosis of polyarteritis nodosa requires integration of clinical, angiographic and biopsy findings. Recognizing the form of polyarteritis nodosa, determining affected organs and the progression of the disease is very important since those are deciding factors when choosing treatment strategies.

[NODULAR POLYARTERITIS ASSOCIATED WITH HEPATITIS B VIRUS (A CASE STUDY)]

This study is focused on a case of nodular polyarteritis associated with hepatitis B virus successfully treated by immunosuppressive and antiviral agents.

Ischemic necrosis with sigmoid perforation in a patient with Systemic Lupus Erythematosus (SLE): case report

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory rheumatic disease which affects the connective tissue. Its etiology is as yet unknown, while its pathogenesis involves the immune system. Both genetic and environmental and hormonal factors play a key role in the impaired immune regulation. A correlation with estrogens is demonstrated by the fact that the greatest incidence is found in young women, when estrogen secretion is at its highest. The disease is also reported to worsen in women taking oral contraceptives. It is therefore believed that the components of oral contraceptives, estrogens (ethinyl estradiol) and progestins, can affect the immune profile. Of the various complications attributed to systemic lupus erythematosus, gastrointestinal disorders are less common but potentially by far the most serious. We report a case of ischemic necrosis with sigma perforation in a patient with SLE. Signs and symptoms of acute abdomen in patients with SLE are rare (0.2%), but serious. Most patients require an exploratory laparotomy, as the causes are often linked with vasculitis.

Pulmonary hypertensive necrotizing arteritis: an unusual case of unilateral involvement in an infant with congenital heart disease

Pulmonary hypertension is clinically defined as a pulmonary arterial pressure greater than 25 mmHg at rest or greater than 30 mmHg during exercise. We report a unique case of an infant with congenital heart disease causing pulmonary hypertension and necrotizing pulmonary arteritis but affecting only one lung. In conclusion, in pulmonary valve atresia, the lungs may be supplied via aortopulmonary collaterals. Necrotizing pulmonary arteritis is a severe lesion seen in irreversible pulmonary hypertension.

[Causes and mechanisms of systemic vasculitides]

Multiple mechanisms contribute to the pathogenesis of systemic vasculitides: 1. vasculitides resulting from the deposition of circulating immune complexes, comprising polyarteritis nodosa associated with hepatitis B virus infection, cryoglobulinemia associated systemic with vasculitides, mainly the consequence of hepatitis C virus infection, and Schonlein Henoch purpura, which results from the deposition in the mesangium and vessels of IgA forming complexes; 2. vasculitides associated with anti-neutrophil cytoplasm antibodies (ANCA), comprising Wegener's granulomatosis associated with anti-proteinase 3 ANCA, and microscopic polyangiitis and Churg-Strauss syndrome, associated with anti-myeloperoxydase ANCA. The pathogenic role of ANCA has been demonstrated in vitro and in vivo in the case of anti-myéloperoxydase antibodies, whereas it has only been demonstrated in vitro in the case of anti-proteinase 3 antibodies; 3. polyarteritis nodosa unrelated to viral infection results from rheologic phenomenon that explain the localisation of vasculitis lesions at the bifurcation of arteries and the presence of microaneurysm.

[Treatment of systemic vasculitides]

The treatment of necrotizing vasculitides may be based on several drugs, depending on the disease itself, its severity, its etiology and the expected prognosis. In practice, the least severe forms, associated with a prognostic score of 0, may be treated with corticosteroids only, while the ones associated with severity factors should be treated with an association of corticosteroids and immunosuppressants. The first-line treatment of viral-associated vasculitides should be based on antiviral drugs. The treatment duration of non-infectious vasculitides is typically 18 to 24 months. The improvement in prognosis is due to the treatment as well as to anti-infectious prophylaxis and careful management of potential complications.

[Hepatitis B associated polyarteriitis nodosa with cerebral vasculitis]

HISTORY AND ADMISSION FINDINGS

A 53-year-old male was admitted with an acute brainstem syndrome. He developed a severe fluctuating psychosis. Because of the worsening neurological symptoms he was admitted to our neurological clinic five months after onset of the disease. On admission he showed signs of a productive psychosis in addition to akinetic-rigid parkinsonism and cerebellar symptoms.

INVESTIGATIONS

Laboratory tests revealed a HBeAg-negative hepatitis B. The initial neuroradiolgical studies showed multiple supratentorial and periventricular ischemic and hemorrhagic lesions. MR-angiography and conventional cerebral angiography demonstrated multiple irregularities of the intracranial vessels and vascular occlusions, findings which were compatible with cerebral vasculitis.

DIAGNOSIS, THERAPY AND COURSE

The laboratory and neuroradiological studies indicated a hepatitis B-associated polyarteriitis nodosa and cerebral vasculitis. He was given oral immunsuppressive therapy (prednisolone 60 mg daily) and virostatic drug (lamivudine 100 mg daily). When the steroid dosis was reduced to 40 mg prednisolon a severe relapse of the encephalopathy occurred which was treated with the atypical antipsychotic drug risperidon, 3 mg daily, and intravenous methylprednisolone plus plasmaphereses. Later he was given prednisolone (60 mg daily) and lamivudine (100 mg daily) again which has so far stabilized the clinical course.

CONCLUSION

The main treatment of the rare hepatitis B-associated polyarteriitis nodosa with cerebral vasculitis consists of oral steroids in combination with antiviral drugs. Depending on the course of the disease an escalating steroid pulse administration and plasmaphereses should be considered.

[A case of interstitial pneumonia preceding microscopic polyangiitis]

We encountered a case of interstitial pneumonia preceding microscopic polyangiitis (MPA). A 64-year-old asymptomatic woman was found to have interstitial pneumonia on a chest radiograph taken during a work-up before an operation for cataract. Six months later she presented with non-productive cough, low grade fever and renal dysfunction. Interstitial pneumonia worsened with new lesions. The test for MPO-ANCA was positive, though it had been negative six months previously. The histopathology of the lung by video-assisted lung biopsy showed the usual interstitial pneumonitis pattern and small vessel pulmonary vasculitis. Renal biopsy showed necrotizing glomerulonephritis. She was given a diagnosis of MPA and was immediately treated with methylprednisolone pulse therapy and a combination of prednisolone and cyclophosphamide. She has remained stable for two years. This positive inversion of MPO-ANCA, while interstitial pneumonia advanced, was of interest concerning the etiology of MPA. We discuss the important topic of the mechanism of the development of MPA.

[Vasculitis and liver disease]

Extrahepatic manifestations of liver diseases especially the hepatitis B virus (HBV)-infection and hepatitis C virus (HCV)-infection may occur during acute and/or chronic viral hepatitis. Besides a serum like illness with fever, arthralgia and urticaria, haematological disorders with transient bone marrow suppression and cryoglobulinemia have been described. Vasculitis is a rare complication of viral hepatitis. However, HCV can trigger a cryoglobulinemic vasculitis and may clinically present with purpura, arthritis, neuropathy, glomerulonephritis and fatigue. Panarteritis nodosa is frequently associated with HBV infection, which is caused by deposits of immune complexes in the arterial wall. Therapy of both types of vasculitis depends on the severity of disease and may include immunosuppressive agents as well as antivirals.

Classic polyarteritis nodosa presenting rare clinical manifestations in a patient with hemophilia A

A 35-year-old patient with hemophilia A presented with rapidly progressive polyarteritis nodosa (PAN). He had been infected with hepatitis B virus (HBV) by repeated transfusion and was positive for hepatitis B surface antigen but negative for hepatitis B surface antibody. The patient presented symptoms of acute epididymitis followed by emergency admission because of acute appendicitis. On day 7 of admission, he complained of severe back pain, and computerized tomography (CT) showed massive perirenal hematoma. On day 49, mild monoplegia in the left arm suddenly developed, and CT and magnetic resonance imaging revealed multiple cerebral infarctions. Factor VIII replacement therapy was attenuated; however, cerebral infarction was progressive and extended throughout the cerebral hemispheres. He was diagnosed with classic polyarteritis nodosa (cPAN), and pulse methylprednisolone was continued. The patient died of supratentorial herniation, and autopsy revealed that vasculitis associated with intimal thickening was present in the liver, pancreas, intestine, kidneys, and larger-sized cerebral arteries. The development of cPAN appeared to have originated from chronic HBV infection, and this is the first report of cPAN in hemophilia patients. Concomitant hemorrhagic and thrombotic manifestations of cPAN are hardly treatable in patients with coagulation disorders, and the current case may represent a rare transfusion-related complication in hemophilia patients.

Polyarteritis nodosa revisited

Polyarteritis nodosa (PAN), the prototype of systemic vasculitis, is a rare condition characterized by necrotizing inflammation of medium-sized or small arteries without glomerulonephritis or vasculitis in arterioles, capillaries, or venules. Signs and symptoms of this disease are primarily attributable to diffuse vascular inflammation and ischemia of affected organs. Virtually any organ with the exception of the lungs may be affected, with peripheral neuropathy and symptoms from osteoarticular, renal artery, and gastrointestinal tract involvement being the most frequent clinical manifestations. A clear distinction between limited versus systemic disease and idiopathic versus hepatitis B related PAN should be done because there are differences in the implicated pathogenetic mechanisms, their treatment, and prognosis. Currently, corticosteroids plus cyclophosphamide is the standard of care for idiopathic PAN, in particular for patients with adverse prognostic factors (more severe disease), in whom this combination prolonged survival. In contrast for hepatitis B related PAN treatment consists of schemes that include plasmapheresis and antiviral agents.

Hepatitis B virus-associated polyarteritis nodosa: clinical characteristics, outcome, and impact of treatment in 115 patients

Hepatitis B virus-associated polyarteritis nodosa (HBV-PAN) is a typical form of classic PAN whose pathogenesis has been attributed to immune-complex deposition with antigen excess. We conducted the current study to 1) analyze the frequency of HBV infection in patients with PAN, in light of the classification systems described since 1990; 2) describe the clinical characteristics of HBV-PAN; 3) compare the evolution according to conventional or antiviral treatment; and 4) evaluate long-term outcome. One hundred fifteen patients were included in therapeutic trials organized by the French Vasculitis Study Group and/or referred to our department for HBV-PAN between 1972 and 2002. To determine the frequency of HBV-PAN during the 30-year period, we analyzed a control group of patients with PAN without HBV infection, followed during the same period and diagnosed on the same bases. Depending on the year of diagnosis, different treatments were prescribed. Before the antiviral strategy was established, some patients were given corticosteroids (CS) with or without cyclophosphamide (CY). Since 1983, treatment for patients with HBV markers has combined 2 weeks of CS followed by an antiviral agent (successively, vidarabine, interferon-alpha, and lamivudine) combined with plasma exchanges (PE).Ninety-three (80.9%) patients entered remission during this period and 9 (9.7%) of them relapsed; 41 (35.7%) patients died. For the 80 patients given the antiviral strategy as intention-to-treat, 4 (5%) relapsed and 24 (30%) died vs 5 (14.3%) relapses (not significant [NS]) and 17 (48.6%) deaths (NS) among the 35 patients treated with CS alone or with CY or PE. HBe-anti-HBe seroconversion rates for the 2 groups, respectively, were: 49.3% vs 14.7% (p < 0.001). Patients who seroconverted obtained complete remission and did not relapse.Thus, HBV-PAN, a typical form of classic PAN, can be characterized as follows: when renal involvement is present, so is renal vasculitis; glomerulonephritis due to vasculitis is never found; antineutrophil cytoplasmic antibodies (ANCA) are not detected; relapses are rare, and never occur once viral replication has stopped and seroconversion has been obtained. Combining an antiviral drug with PE facilitates seroconversion and prevents the development of long-term hepatic complications of HBV infection. The major cause of death is gastrointestinal tract involvement. Importantly, the frequency of HBV-PAN has decreased in relation to improved blood safety and vaccination campaigns.

Pathogénie des vascularites systémiques primitives (II): vascularites ANCA-négatives

The pathogenesis of different types of systemic vasculitis negative for antineutrophil cytoplasm antibodies (ANCA) and involving small or medium-sized vessels is not very well documented. During polyarteritis nodosa (PAN), which is related to hepatitis B virus (HBV) infection, as well as during cryoglobulinemic vasculitides, associated with hepatitis C virus (HCV), and probably during Henoch Schönlein purpura, histological lesions may result from the deposition of immune complexes formed from viral antigens and from antibodies responsible for the activation of the classic complement pathway and for recruitment of polymorphonuclear neutrophils. Two other mechanisms are discussed for other types of ANCA-negative systemic vasculitis: immune complex deposition and sheer stress at arterial bifurcation points. A bacterial superantigen is suspected in Kawasaki disease but remains unproved.

Postirradiation morphea and subcutaneous polyarteritis nodosa: Case report and literature review

OBJECTIVE

To describe a case of postirradiation morphea and subcutaneous polyarteritis nodosa occurring simultaneously in a patient and to review the literature on postirradiation autoimmune phenomenon and the potential pathogenesis of such changes.

METHODS

A 75-year-old woman with breast cancer treated with chemotherapy and radiation who developed postirradiation morphea and subcutaneous polyarteritis nodosa, both inside and outside of the field of radiation, is described. Literature searches were performed on postirradiation morphea and other radiation-related inflammatory cutaneous conditions and the potential pathogenic mechanisms involved.

RESULTS

Twenty-five cases of postirradiation morphea and 8 cases of postirradiation panniculitis were reported in the literature. Only 3 cases of morphea with distant vasculitis occurring in the same patient have been reported and each of these patients had features suggestive of an underlying connective tissue disease. This is the first case of morphea and subcutaneous polyarteritis nodosa occurring in the same location both inside and outside the field of radiation.

CONCLUSIONS

Postirradiation morphea is an uncommon condition but is being increasingly recognized. Related phenomena following radiation include postirradiation panniculitis and now postirradiation subcutaneous polyarteritis nodosa. Radiation may be responsible for inducing some of the pathogenic changes seen in scleroderma and other autoimmune diseases. Rheumatologists should be aware of these potential complications of radiation treatment.

Virus-induced systemic vasculitides: new therapeutic approaches

The best therapeutic strategy in virus-induced vasculitides should take into account the etiology of the disease and be adapted to the pathogenesis. The combination of antiviral treatments and plasma exchanges has been proven effective in polyarteritis nodosa (PAN). In human immunodeficiency virus (HIV)-related vasculitis this strategy is also effective and does not jeopardize, like cytotoxic agents, the outcome of AIDS. In vasculitis related to HCV-associated cryoglobulinemia, plasma exchanges improve the outcome but the poor effectiveness of antiviral drugs is not able to favor, usually, a definite recovery of the patients and relapses are frequent.

Polyarteritis nodosa reports to the vaccine adverse event reporting system (VAERS): implications for assessment of suspected vaccine-provoked vasculitis

OBJECTIVE

To examine polyarteritis nodosa (PAN) reports to the Vaccine Adverse Event Reporting System (VAERS) as the initial stage in investigating the hypothesis that vaccination can very rarely cause PAN.

METHODS

We reviewed PAN reports submitted from 1990 through 2001 using a causal inference framework to evaluate the consistency of the reports' clinical details with this hypothesis. We also reviewed published literature relating to the hypothesized association's biological plausibility.

RESULTS

VAERS received 25 PAN reports. Ten met our case definition for definite or possible PAN and had no alternative etiology for PAN identified. Nine of these 10 followed hepatitis B vaccine with a modal peak (4 definite cases) in time to symptom onset 2 weeks after vaccination. However, all potential triggering infections were not excluded, and identification of vaccine antigens in clinical specimens was not attempted. Also, 14 of 25 reports were European, with 11 from France. All 9 French reports with a known diagnosis date began during 1994-97, when autoimmune and rheumatologic events following hepatitis B vaccine were a focus of public concern in France.

CONCLUSION

While we identified some supportive evidence, overall, current adverse event reports do not support a causal link between vaccination and PAN. Appropriate prospective evaluation of future post-vaccination PAN cases could add to current knowledge with rigorous confirmation of diagnosis, appropriate testing for possible triggering infections including polymerase chain reaction testing for latent hepatitis B infection, and an attempt to link the vaccine antigen to pathology such as by immunohistochemical staining or immune complex identification.

Microscopic polyangiitis sparing the kidneys in a long-term survivor after allogeneic bone marrow transplantation and graft-versus-host disease

We report an unusual case of microscopic polyangiitis sparing the kidneys in a long-term survivor of allogeneic bone marrow transplantation. Clinical and pathologic studies revealed cutaneous leukocytoclastic vasculitis and isolated pulmonary capillaritis. Serological studies revealed "double positive": perinuclear antineutrophil cytoplasmic (P-ANCA) antibody testing with anti-myeloperoxidase (MPO) activity and anti-glomerular basement membrane (anti-GBM) antibody. The vasculitis has been successfully controlled with prednisone and cyclophosphamide.

Complete molecular remission of chronic eosinophilic leukemia complicated by CNS disease after targeted therapy with imatinib

Many cases of hypereosinophilia, formerly classified as hypereosinophilic syndrome, can now be characterized as chronic eosinophilic leukemia (CEL) based on the demonstration of characteristic genetic markers indicating clonality of hematopoiesis. Here we report on a 33-year-old male patient with central nervous system manifestations of CEL and an excellent response to low-dose imatinib (Glivec). Molecular analysis demonstrated a constitutive activation of the platelet-derived growth factor receptor-alpha (PDGFR-A) as the mechanism of responsiveness to imatinib.

Variable expression of vasculitis in siblings with familial Mediterranean fever

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by recurrent and self-limited attacks of serosal inflammation with abdominal pain, chest pain, and arthritis usually accompanied by fever. Different vasculitides such as polyarteritis nodosa (PAN) and Henoch-Schönlein syndrome (HSS) may be associated with FMF. We report two sisters of a Turkish family with FMF who developed distinct vasculitides. The younger sister developed severe PAN with perirenal hematoma at the age of 13 years, the older sister presented with severe HSS and acute renal failure at the age of 19 years. Neither sister developed amyloidosis until the age of 30 years. This observation suggests that early events in the pathogenesis of PAN and HSS are generally quite similar.

Polyarteritis nodosa in a case of familial Mediterranean fever

We describe a 7-year-old boy with familial Mediterranean fever (FMF) complicated by polyarteritis nodosa (PAN) with distinct angiographic findings. On admission, he had abdominal pain, arthralgia, and severe fibromyalgia. During hospitalization, he displayed maculopapular eruptions, high blood pressure, gastrointestinal bleeding, and persistent constitutional symptoms mimicking a vasculitic process, most probably PAN. Renal angiography showed a perfusion defect compatible with a renal infarction secondary to a vasculitic process. He responded well to pulse methylprednisolone therapy with colchicine. We emphasize the rare association of FMF and PAN and the non-aneurysmal angiographic signs of PAN.

Microscopic polyangiitis and polyarteritis nodosa: How and when do they start?

OBJECTIVE

To describe initial clinical symptoms attributable to microscopic polyangiitis (MPA) or polyarteritis nodosa (PAN).

METHODS

We retrospectively reviewed the medical files of 72 patients (mean followup 6.7 years) with biopsy-proven MPA (n = 36) or PAN (n = 36).

RESULTS

Initial manifestations were similar in both entities except for peripheral neuropathy (P = 0.02) and gastrointestinal tract involvement (P = 0.006), which were significantly more frequent in PAN, and general signs alone in MPA (8%; P = 0.02). The mean time to diagnosis was 9.8 +/- 19.4 months; 35% of the patients died and 26% relapsed; significantly more MPA than PAN patients relapsed (P = 0.03). Time to diagnosis >/=90 days was associated with a trend toward more patients relapsing (P = 0.12), but not with an increased risk of mortality.

CONCLUSION

Initial symptoms of MPA and PAN are usually nonspecific and last for several months before the diagnosis is made. A longer time to diagnosis is associated with a tendency to a higher relapse rate.

[Case of vascular Behçet's disease initially presented with Bürger's disease-like vasculitides]

The patient was a 24-year-old man. Bürger's disease was diagnosed initially based on the finding of bilateral radial artery obstruction, and the patient underwent vascular reconstructive surgery. After the operation, however, formation of false aneurysms was observed frequently in the left brachial artery at the elbow, which necessitated performance of vascular reconstructive surgery up to five times in total, including of the right common femoral artery, which had been punctured several times for investigational procedures. During the clinical course, fever, oral aphthoid ulcers, genital ulcers, and nodular erythema appeared, and incomplete Behçet's disease was diagnosed. Histopathological examination suggested that the vascular lesion was consistent with necrotizing angiitis. The systemic inflammatory findings and angiitis improved following steroid administration. Vascular Behçet's disease is known as a special type of Behçet's disease, but usually develops in the patients with a long history of the disease. Our patient was believed to be very instructive because, when Behçet's disease occurs with angiitis and the epidemiological characteristics agree with those of Bürger's disease like in our patient, differentiation may be difficult.

Vasculitis with digital gangrene in a patient with HIV infection

A case of polyarteritis nodosa (PAN) like systemic necrotizing vasculitis in an HIV infected individual, who presented with digital ischaemia is reported. The pathogenesis of PAN in HIV infected patients is not well understood and whether HIV or other agents are directly involved in the vascular injury remains to be established.

Polyarteritis associated with hypopharyngeal carcinoma

A rare case of polyarteritis associated with a solid tumor is presented. A 66-year-old man was referred to our hospital, because of gangrene in the bilateral fingers and toes, right pleural effusion, and an abnormal sensation in the throat. A diagnosis of polyarteritis was made based on pleuritis, digital gangrene and the arteriography findings. He also had a hypopharyngeal carcinoma. After being treated with intermittent intravenous cyclophosphamide, oral corticosteroid, alprostadil and aspirin, the pleural effusion rapidly disappeared, while the digital gangrene gradually improved. For the treatment of hypopharyngeal carcinoma, radiation therapy was initiated and resulted in complete disappearance.

The role of the thymus in development of necrotizing arteritis in transgenic rats carrying the env-pX gene of human T-cell leukemia virus type-I

Necrotizing arteritis mimicking polyarteritis nodosa occurred in transgenic rats carrying the env-pX gene of human T-cell leukemia virus type I. To investigate the pathogenesis of necrotizing arteritis in these rats (env-pX rats), adoptive transfers of spleen cells and bone marrow cells were done from env-pX rats before they developed arteritis to nontransgenic rats. Necrotizing arteritis occurred in lethally irradiated nontransgenic rats reconstituted by env-pX spleen cells, thus indicating that the env-pX transgene in affected vessels may not be essential for the development of arteritis. In contrast, arteritis was not induced in nontransgenic recipients by adoptive transfers of env-pX bone marrow cells, which suggested that T cells derived from the env-pX thymus may play a role in the development of arteritis. To clarify if the process of differentiation of T cells in the env-pX thymus is crucial to develop necrotizing arteritis, reciprocal exchange of thymus frameworks was done between env-pX and nontransgenic rats. Necrotizing arteritis occurred in nontransgenic rats with an env-pX thymus framework, whereas development of arteritis was suppressed in env-pX rats in which the thymus framework was replaced with a nontransgenic one. This collective evidence shows that the thymus is directly associated with the development of necrotizing arteritis in env-pX rats.

The spectrum of vasculitis in children

The common vasculitides of childhood are more self-limited than those in adults. Clinical evidence suggests that infectious agents may have a significant role in the aetiology of these diseases although exact pathogenic mechanisms are not known. One of the most frequent of such diseases in childhood is Henoch-Schönlein purpura. The controversies regarding the management of gastrointestinal and renal disease and suggested treatments are reviewed. The limitations of current definitions for polyarteritis nodosa are discussed and a new classification tree for this disease is introduced. The definitions and classification criteria for the other major vasculitides encountered in children are also presented. Current treatment protocols for polyartertis nodosa, Wegener's granulomatosis and Behcet's disease are summarized.

Hepatitis B associated fulminant polyarteritis nodosa: successful treatment with pulse cyclophosphamide, prednisolone and lamivudine following emergency surgery

For hepatitis B virus associated polyarteritis nodosa, alpha interferon and plasma exchanges have been proposed to be the first-line treatment. We report a case of hepatitis B surface antigen (HBsAg)-positive fulminant polyarteritis nodosa with predominant gastrointestinal involvement who showed good response to pulse cyclophosphamide, prednisolone, and lamivudine therapy. The patient, a 22-year-old man, presented with a short history of epigastric pain. Initial upper gastrointestinal endoscopy revealed gastritis and duodenal erosions. His pain did not respond to H2-receptor antagonists. He had slightly impaired liver function tests, and was HBsAg and hepatitis B e antigen (HBeAg) positive. Around 3 weeks after initial presentation, he developed massive gastrointestinal haemorrhage requiring resuscitation and emergency laparotomy. Microscopic examination of the resection specimens revealed necrotizing vasculitis of small and medium-sized arteries in the submucosa compatible with polyarteritis nodosa. The patient was treated with pulse cyclophosphamide and prednisolone, with lamivudine being added when he showed an acute rise in liver enzymes. He subsequently developed HBeAg seroconversion, and remained well 18 months after cessation of all immunosuppressives. We believe that the efficacy of pulse cyclophosphamide, prednisolone, and lamivudine in the treatment of hepatitis B virus associated polyarteritis nodosa, especially in comparison with interferon and plasma exchanges, deserves further evaluation.

Catastrophic visceral involvement secondary to de novo systemic vasculitis in a renal transplant recipient

De novo systemic vasculitis after renal transplant is a rare complication. We report a patient who developed rapid, catastrophic necrotizing vasculitis of the gastrointestinal tract 11 months after renal transplant. A 60-year-old man was admitted for persistent pain in the right abdomen and mild intestinal hemorrhage. After some days the patient presented partial intestinal occlusion, severe hypoproteinemia and acute renal insufficiency. The patient was urgently operated with resection of a tract of the jejunum where there was a venous infarct. Laboratory tests were not significant and the search for hepatitis B, C viruses and ANCA was negative. After some days of irrepressible intestinal hemorrhage, total gastrectomy, splenectomy and resection of the duodenum and pancreas were performed. Histological pictures showed vascular lesions pathognomonic of systemic polyarteritis nodosa (PAN). After thirty days the patient died. The autopsy confirmed atypical systemic PAN with involvement of the pulmonary arteries besides the gastrointestinal tract and pancreas. Gastrointestinal (GI) complications are not frequent in renal transplant recipients, but 30% of patients with such lesions die as a direct consequence of visceral vascular damage. To the best of our knowledge, de novo PAN has been reported as the cause of catastrophic gastrointestinal involvement in only one renal transplant recipient. This case therefore raises the number of reports of PAN in kidney transplantation recipients who had no history of underlying connective tissue disease.

Polyarteritis nodosa developing after discoid lupus erythematosus

We describe a patient with discoid lupus erythematosus whose pattern of disease evolved into a systemic vasculitis polyarteritis nodosa.

Polyarteritis nodosa and mixed cryoglobulinaemia related to hepatitis B and C virus coinfection

OBJECTIVE

To determine the responsibility of hepatitis B virus (HBV) and hepatitis C virus (HCV) and therapeutic implications in a patient who developed systemic vasculitis.

CASE REPORT

The case of a 38 year old woman who had a past history of addiction to intravenous drugs and developed systemic vasculitis after infection by HBV and HCV is described. The clinical and laboratory findings substantiated not only the diagnosis of polyarteritis nodosa (PAN) but also that of mixed cryoglobulinaemia with a monoclonal IgMkappa component.

CONCLUSION

Because cryoglobulins are rarely found in HBV related PAN but often associated with HCV infection, and in light of the histological findings, cryoglobulinaemia was interpreted as being secondary to HCV infection. This example of a highly complex situation emphasises the need to gather all relevant clinical, biological, histological, and complementary data so that the best treatment for overlapping of distinct vasculitides can be selected.