101
|
Qureshi HA, Bandhlish A, DeConde RP, Humphreys IM, Abuzeid WM, Jafari A. Initial Presentation of Granulomatosis with Polyangiitis as Progressive Skull Base Osteomyelitis. ORL J Otorhinolaryngol Relat Spec 2021; 84:342-346. [PMID: 34592738 DOI: 10.1159/000518971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022]
Abstract
A healthy man in his 30s presented with a 2-week history of severe bitemporal pain and pressure. He was initially treated for presumed acute rhinosinusitis, but his symptoms continued to worsen and underwent endoscopic sinus surgery at an outside community facility. He developed left abducens nerve palsy postoperatively, and magnetic resonance imaging (MRI) demonstrated evidence of extensive skull base osteomyelitis. He was initiated on intravenous (IV) broad-spectrum antibiotics but was subsequently found to have prostatic and submandibular sterile fluid collections. The patient subsequently developed new right abducens and left vagal nerve palsies and underwent revision endoscopic sinus surgery. Pathology revealed extensive inflammation, necrotizing granulomas, and evidence of small and medium vessel vasculitis. Extensive laboratory workup was negative, except for anti-PR-3 antibody positivity. Given the characteristic findings on pathology and laboratory findings, the patient was diagnosed with granulomatosis with polyangiitis (GPA). High-dose glucocorticoid therapy as well as rituximab infusion were promptly initiated. He had marked improvement in his symptoms and resolution of his right CN VI palsy but left-sided CN VI and CN X palsies persisted. This patient presented without the typical rhinologic manifestations of GPA, and rather presented with progressive sinusitis, skull base osteomyelitis with associated cranial neuropathies, and aseptic systemic abscesses. Prompt diagnosis of GPA is particularly important in those with otorhinolaryngological manifestations, as early initial immunosuppressive therapy has been linked to lower relapse and mortality rates. Vigilance and early differentiation between GPA and other forms of sinusitis is of critical importance, particularly when symptoms are refractory to standard rhinosinusitis therapies.
Collapse
Affiliation(s)
- Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Anshu Bandhlish
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Robert P DeConde
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| |
Collapse
|
102
|
Coattrenec Y, Muller YD, Spoerl D, Lobrinus JA, Seebach JD. Prevalence of large vessel vasculitis in ANCA-associated vasculitis: a retrospective cohort study. Rheumatol Int 2021; 41:2147-56. [PMID: 34559277 DOI: 10.1007/s00296-021-04993-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/11/2021] [Indexed: 11/23/2022]
Abstract
ANCA-associated vasculitis (AAV) in general involves small blood vessels and includes granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA). Although reported in a few studies, the prevalence of large vessel vasculitis (LVV) in patients with AAV remains to be further explored. The goal of the present study was to assess the prevalence of LVV in a cohort of patients with AAV and to characterize this population. We conducted a ten-year retrospective study of a single-center cohort of AAV, including 101 patients with GPA (n = 58), EGPA (n = 28), MPA (n = 15), and compared the groups with or without associated LVV. LVV was diagnosed in five patients, two with aortitis and three with temporal arteritis, corresponding to a total prevalence of 5.0% [95% CI 1.6–11.2%]. This value was significantly higher than the estimated prevalence of LVV in the normal Swiss population (OR 234.9 95% CI 91.18–605.2, p < 0.001). All five patients had GPA, whereas no cases with EGPA or MPA were identified. Anti-PR3 antibodies were detected in four out of five patients, anti-MPO in one patient. Since LVV can occur in a significant proportion of patients with GPA, evaluation for LVV may be considered systematically in the diagnostic workup of AAV.
Collapse
|
103
|
Neerhut T, Neerhut G, Magree C. Rapidly recurrent prostatic obstruction due to granulomatosis with polyangiitis. Urol Case Rep 2021; 39:101771. [PMID: 34552860 PMCID: PMC8441620 DOI: 10.1016/j.eucr.2021.101771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare cause of prostatitis. Our case illustrates a case of granulomatous prostatitis secondary to unrecognised GPA requiring multiple surgical interventions. The patient presented with lower urinary tract symptoms. They underwent two endoscopic prostatic resections for recurrent urinary obstruction due to granulomatous prostatitis before a diagnosis of GPA was made. The rarity of this pathology, challenges in making a diagnosis and the systemic nature of this disease are emphasised.
Collapse
Affiliation(s)
- Thomas Neerhut
- Princess Alexandra Hospital, Metro South Health Brisbane, Unit 5/28 Carl Street, Woolloongabba, QLD, 4102, Australia
| | - Gregory Neerhut
- St John of God Geelong Hospital, Barwon Urology Geelong, 59 Myers St, Geelong, VIC, 3220, Australia
| | - Cleve Magree
- Anatpath, 120 Gardenvale Road, Gardenvale, VIC, 3185, Australia
| |
Collapse
|
104
|
Iudici M, Pagnoux C, Courvoisier DS, Cohen P, Néel A, Aouba A, Lifermann F, Ruivard M, Aumaître O, Bonnotte B, Maurier F, Le Gallou T, Hachulla E, Karras A, Khouatra C, Jourde-Chiche N, Viallard JF, Blanchard-Delaunay C, Godmer P, Le Quellec A, Quéméneur T, de Moreuil C, Régent A, Terrier B, Mouthon L, Guillevin L, Puéchal X. Localised Versus Systemic Granulomatosis with Polyangiitis: Data from the French Vasculitis Study Group Registry. Rheumatology (Oxford) 2021; 61:2464-2471. [PMID: 34542599 DOI: 10.1093/rheumatology/keab719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/08/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To describe the main features at diagnosis and evolution over time of patients with localised granulomatosis with polyangiitis (L-GPA) compared to those of systemic GPA (S-GPA). METHODS EULAR definitions of L-GPA, i.e., upper and/or lower respiratory tract involvement, and S-GPA were applied to patients from the French Vasculitis Study Group Registry. L-GPA and S-GPA patients' characteristics at diagnosis and long-term outcomes were analyzed and compared. RESULTS Among the 795 Registry patients, 79 (10%) had L-GPA. Their main clinical manifestations were rhinitis, lung nodules, sinusitis and otitis. L-GPA versus S-GPA patients at diagnosis, respectively, were younger, more frequently had saddle nose deformity or subglottic stenosis and were less often PR3-ANCA-positive. L-GPA versus S-GPA induction therapy less frequently included cyclophosphamide but more often a combination of methotrexate and glucocorticoids; 64% of methotrexate-treated patients experienced disease progression within 18 months post-diagnosis. L- and S-GPA patients' estimated relapse-free-survival probabilities, relapse rates and refractory disease rates at each time point were comparable, but L-GPA patients had more frequent ENT and lung relapses, and higher overall survival rates (P <0.02). Over a median follow-up of 3.5 years, 18 (22.8%) L-GPA progressed to S-GPA, either as a relapse after a period in remission or more frequently in the context of refractory disease. L-GPA patients experienced more ENT-related damage. CONCLUSIONS The relapse risks of L-GPA and S-GPA were similar, but relapse patterns differed and L-GPA overall survival rate was higher. About one-quarter of L-GPA patients developed S-GPA over time, but without end-stage organ involvement.
Collapse
Affiliation(s)
- Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Delphine S Courvoisier
- Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Antoine Néel
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Hôtel-Dieu, Nantes, France
| | - Achille Aouba
- Department of Internal Medicine, CHU Côte-de-Nacre, Caen, France
| | | | - Marc Ruivard
- Department of Internal Medicine, CHU Estaing, Clermont-Ferrand, France
| | - Olivier Aumaître
- Department of Internal Medicine, CHU Estaing, Clermont-Ferrand, France
| | - Bernard Bonnotte
- Department of Internal Medicine, CHU François Mitterrand, Dijon, France
| | - François Maurier
- Service of Internal Medicine, Groupe Hospitalier UNEOS, Metz-Vantoux, France
| | - Thomas Le Gallou
- Department of Internal Medicine and Immunology, CHU, Rennes, France
| | - Eric Hachulla
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine and Clinical Immunology, CHU Claude Huriez, Lille, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Chahéra Khouatra
- Department of Respiratory Medicine, CHU Louis-Pradel and UMR754, Université Claude-Bernard Lyon 1, Lyon, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Univ, C2VN, INSERM 1263, INRAE 1260, APHM, Department of Nephrology, CHU de la Conception, Marseille, France
| | | | | | - Pascal Godmer
- Department of Internal Medicine, CH Bretagne-Atlantique, Vannes, France
| | - Alain Le Quellec
- Department of Internal Medicine, CHU Saint-Eloi, Montpellier, France
| | - Thomas Quéméneur
- Department of Nephrology and Internal Medicine, CH, Valenciennes, France
| | - Claire de Moreuil
- Department of Internal Medicine, CHU La Cavale Blanche, Brest, France
| | - Alexis Régent
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | | |
Collapse
|
105
|
Rostami Z, Cegolon L, Jafari NJ, Gholami N, Mousavi SV, Allahyari F, Azami A, Javanbakht M. A rare case of coexistence of Wegener's granulomatosis and pulmonary tuberculosis with subsequent development of thrombosis of the cerebral veins. BMC Infect Dis 2021; 21:948. [PMID: 34521368 PMCID: PMC8442395 DOI: 10.1186/s12879-021-06583-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis, is an idiopathic systemic disease typically affecting the lungs, although other organs may also be involved. CASE PRESENTATION A 28-year-old male was admitted to Baqiyatallah university hospital in Teheran (Iran) after a 3-week history of fever and productive cough. The patient gradually developed fatigue, arthralgia, hematuria, nausea, vomiting, dyspnea, hemoptysis, weight loss, oliguria and then anuria. Chest-X-ray (CXR) and computerized tomography scan revealed cavitating nodular opacities in the right lung lobe. Furthermore, plasma creatinine increased from 2.2 to 4 mg/dl in a few days. Histopathological examination of kidney biopsy revealed peri-glomerular and peri-vascular inflammation, degeneration and necrosis of the tubular epithelial lining, red blood cell casts, distorted glomerular structure, fibrin thrombi, segmental breaks of the glomerular basal membrane, disruption of Bowman's capsular membrane and crescent formation of the affected glomeruli. An abnormal CXR, an abnormal urinary sediment and a typical kidney histology were used as criteria to diagnose glomerulonefritis with poliangiitis (GPA). Bronchoalveolar lavage smear and PCR turned out positive for mycobacterium tuberculosis. After 3 months of treatment for (GPA) and tuberculosis the patient developed headache and seizure. Cerebral Magnetic Resonance Venography revealed cerebral venous thrombosis of the sinus transverse and sigmoid. CONCLUSIONS Tuberculosis may coexist with GPA, as it occurred in our patient. Since a crescentic glomerulonephritis can progress to renal failure, clinicians should always be aware of potential multiple conditions when considering differential diagnoses.
Collapse
Affiliation(s)
- Zohreh Rostami
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Luca Cegolon
- Public Health Department, Local Health Unit N. 2 "Marca Trevigiana", Treviso, Italy
| | - Nematollah Jonaidi Jafari
- Health Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Nasrin Gholami
- Hematology Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Vahid Mousavi
- Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Fakhri Allahyari
- Neuroscience Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Atena Azami
- Department of Pathology, School of Medicine, Alborz University of Medical Sciences, Alborz, Iran
| | - Mohammad Javanbakht
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
106
|
Akiyama M, Takanashi S, Takeuchi T, Kaneko Y. Salivary gland involvement in ANCA-associated vasculitis. Autoimmun Rev 2021; 20:102940. [PMID: 34509652 DOI: 10.1016/j.autrev.2021.102940] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/13/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Salivary gland involvement in anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is rare, but can lead to the misdiagnosis of other diseases. The objective of this study was to clarify the characteristics of patients with salivary gland involvement. METHODS We conducted a systematic literature review of articles reporting salivary gland involvement in ANCA-associated vasculitis from the inception dates until May 2, 2021. RESULTS We identified 58 patients with salivary gland involvement. The mean age was 52 years, and men were predominantly affected (59%). Half of the patients presented with fever. Swelling of the salivary gland was the initial manifestation in 88% of the patients, unilaterally affected in 53%, and painful in 47%. The affected salivary glands were as follows: parotid gland alone (53%), submandibular gland alone (33%), and both parotid and submandibular glands (14%). Additionally, two patients had sublingual gland involvement. The most frequent clinical diagnosis was granulomatosis with polyangiitis (83%), followed by eosinophilic granulomatosis with polyangiitis (17%), while no patient was diagnosed with microscopic polyangiitis. PR3-ANCA positivity (72%) was predominant to MPO-ANCA positivity (6%), and ANCA was negative in 22% of the patients. Among 37 ANCA-positive patients, 6 patients (16%) were initially ANCA-negative, but subsequently became positive during the clinical course. The serum C-reactive protein levels were elevated in all the examined patients. On contrast-enhanced computed tomography, a finding suggestive of necrosis, which was heterogeneous enhancement with low-density areas, was found in 33% of the patients. Vasculitis, granulomatous inflammation, necrosis, or the presence of multinucleated giant cells was found in 83% of the biopsy samples of the affected salivary gland. Glucocorticoids with or without other immunosuppressive agents, such as cyclophosphamide were effective in most patients, but twelve patients (21%) experienced a relapse of the disease and nine patients (16%) died during the clinical course. CONCLUSION Salivary gland involvement can be an initial manifestation of ANCA-associated vasculitis. The recognition of this unusual atypical presentation is important for the early and accurate diagnosis and treatment.
Collapse
Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Satoshi Takanashi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan.
| |
Collapse
|
107
|
Lakhani DA, Balar AB, Adelanwa A, Gross A, Mohamed R, Smith KT, Kim C. Granulomatosis with polyangiitis: A case report and brief review of literature. Radiol Case Rep 2021; 16:3445-3450. [PMID: 34527120 PMCID: PMC8429614 DOI: 10.1016/j.radcr.2021.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/11/2021] [Indexed: 02/08/2023] Open
Abstract
Granulomatosis with polyangiitis formerly known as Wegener's granulomatosis was first described by German pathologist Friedrich Wegener in 1936. It is a multi-system necrotizing noncaseating granulomatous vasculitis which affects small to medium-sized vessels. It can involve any organ system, most commonly the lungs and kidneys. American College of Rheumatology requires 2 of 4 criteria for diagnosis: Positive biopsy for granulomatous vasculitis, urinary sediment with red blood cells, abnormal chest radiograph and oral/nasal inflammation. Here we present a case of Granulomatosis with polyangiitis with brief review of literature.
Collapse
Affiliation(s)
- Dhairya A Lakhani
- Department of Radiology, Diagnostic Radiology Residency Program, Morgantown, WV 26506, USA,Corresponding author.
| | - Aneri B Balar
- Department of Radiology, Diagnostic Radiology Residency Program, Morgantown, WV 26506, USA
| | - Ayodele Adelanwa
- Department of Pathology, Anatomy and Laboratory Medicine; West Virginia University, Morgantown, WV 26506, USA
| | - Alexander Gross
- Department of Pathology, Anatomy and Laboratory Medicine; West Virginia University, Morgantown, WV 26506, USA
| | - Rehab Mohamed
- Department of Pathology, Anatomy and Laboratory Medicine; West Virginia University, Morgantown, WV 26506, USA
| | - Kelly T Smith
- Department of Radiology, Diagnostic Radiology Residency Program, Morgantown, WV 26506, USA
| | - Cathy Kim
- Department of Radiology, Diagnostic Radiology Residency Program, Morgantown, WV 26506, USA
| |
Collapse
|
108
|
Borowiec A, Kowalik I, Chwyczko T, Jankowski J, Kandyba P, Życińska K. Predictors of cardiovascular events in patients with primary systemic vasculitis: A 5 years prospective observational study. Eur J Intern Med 2021; 91:70-74. [PMID: 34074580 DOI: 10.1016/j.ejim.2021.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) - associated systemic vasculitis and is characterised by inflammation of blood vessels. Systemic vasculitis exhibits an enhanced cardiovascular morbidity and cardiovascular disease (CVD) has become a leading cause of death in this group of patients. OBJECTIVES The aim of the present study was to assess the prevalence of clinical manifestation of atherosclerosis and its relation with classic risk factors for atherosclerosis, echocardiographic parameters and laboratory findings in GPA patients. PATIENTS AND METHODS The group of consecutive patients with GPA were followed in the study. RESULTS One hundred six patients with GPA (mean age 50.4 ± 14.9 yrs, 67 female) were prospectively followed for 5.1 ± 1.6 yrs. In 19 patients (18%) cardiovascular disease (9 acute coronary syndromes, 4 symptomatic peripheral vascular diseases and 6 strokes) occurred in association with GPA. In a multivariate model, only age was predictive of cardiovascular events in this group of patients (OR=1.078, 95% CI: 1.025-1.134, p = 0.003). During observation in patients without CVD the level of hs-CRP and D-dimer were significantly reduced on the follow-up visit (p = 0.041, p = 0.0002). On the other hand, in patients with CV events there was no significant differences in both markers' concentrations despite clinical remission. CONCLUSIONS The age was the only independent predictor of cardiovascular events. Persistent elevation of inflammatory and prothrombotic markers despite clinical remission of the disease could be an indicator of premature atherosclerosis development in patients with systemic vasculitis.
Collapse
Affiliation(s)
- Anna Borowiec
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland; National Institute of Oncology, Warsaw, Poland.
| | | | | | - Jan Jankowski
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland
| | - Piotr Kandyba
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland
| | - Katarzyna Życińska
- Medical University of Warsaw, Stepinska str 19/25, Warsaw, Poland; Central Clinical Hospital of Ministry of MSWiA, Warsaw, Poland
| |
Collapse
|
109
|
Alesaeidi S, Piri SM, Tavakolpour S. The Paradoxical Reaction to Rituximab in Six Granulomatosis with Polyangiitis Patients: How Could it be Explained and Managed? Curr Rheumatol Rev 2021; 17:327-330. [PMID: 33605863 DOI: 10.2174/1573397117666210219121659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/07/2020] [Accepted: 10/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Granulomatosis with polyangiitis is a systemic anti-neutrophil cytoplasmic antibody-associated vasculitides (AAVs), mainly involving the respiratory tract and renal system. Treatment by Rituximab as a next-generation therapy in ANCA-associated vasculitis is associated with promising outcomes in GPA patients. Despite symptoms improvements, disease recurrence and drug reaction are a challenging topic nowadays. OBJECTIVES In this study, we examined six GPA patients who were confirmed to have paradoxical reactions to rituximab and then described how to control their symptoms. METHODS In this study, all the systemic GPA patients (diagnosed based on ACR/EULAR criteria) who received RTX in Amir-Allam hospital were monitored for any sign of disease exacerbation up to 3 months after RTX exposure. RESULTS From 78 GPA-diagnosed patients, six, including one man and five women with the mean age of 37.3 ± 13.8, were identified for exacerbation after RTX administration. CONCLUSION According to our observation, it could be recommended not to deprive the patient of the benefits of RTX treatment due to the early patient's possible complications.
Collapse
Affiliation(s)
- Samira Alesaeidi
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Piri
- Rheumatology and Internal Medicine, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Genomic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
110
|
Rivera M, Villafranca A, Khamooshi P, Reyes V, Sanchez J, Manadan A. Reasons for hospitalization and in-hospital mortality for anti-neutrophil cytoplasmic antibody vasculitides: analysis of the National Inpatient Sample. Clin Rheumatol 2021; 41:159-166. [PMID: 34453230 DOI: 10.1007/s10067-021-05880-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/08/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a heterogeneous group of conditions resulting in frequent hospitalizations and high in-hospital mortality (IHM). Our study aimed to use the National Inpatient Sample (NIS) to determine and categorize the main reasons for hospital admission and IHM in patients with AAV. METHODS We performed a retrospective study of adult AAV hospitalizations in 2016, 2017, and 2018 in acute care hospitals across the USA conducted using the NIS database. We classified the main reasons for hospital admission and IHM into 19 different categories using the principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis. RESULTS A total of 41,155 hospitalizations had either a principal or secondary ICD-10 code for AAV (GPA or MPA). Rheumatologic and respiratory diagnoses were the most common reasons for hospitalization, while infectious and respiratory diagnoses were the most common reasons for IHM. Sepsis, unspecified organism A41.9, was the most common specific principal diagnosis for hospitalized and deceased AAV patients. CONCLUSIONS Our results show that the leading reasons for hospitalization and mortality for AAV patients were rheumatologic, respiratory, and infectious diagnoses. This data suggests that careful monitoring and management of infectious and pulmonary complications in AAV may improve hospital outcomes. Key points • AAV is a heterogeneous group of conditions resulting in frequent hospitalizations and high IHM. In our study, AAV hospitalizations ended in IHM 4.5% of the time, substantially greater than non-ANCA patients. • The leading reasons for hospital admission for AAV patients were rheumatologic and respiratory diagnoses, but the main reason for IHM were infectious and respiratory diagnoses. • Sepsis was the most common principal diagnosis for hospitalized and deceased AAV patients. • Our results highlight the importance of close monitoring and timely management of infectious and respiratory complications to improve hospitalization outcomes.
Collapse
Affiliation(s)
- Mavi Rivera
- Cook County Hospital, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - A Villafranca
- MacNeal Hospital, 3249 South Oakpark Avenue, Berwyn, IL, 60402, USA
| | - P Khamooshi
- Cook County Hospital, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - V Reyes
- Cook County Hospital, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - J Sanchez
- Cook County Hospital, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - A Manadan
- Cook County Hospital, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| |
Collapse
|
111
|
Verma A, Rajbhar S, Thakur P, Agrawal S, Pradhan S. Favorable Pregnancy Outcome in a Granulomatosis With Polyangiitis Patient With Renal Insufficiency. J Med Cases 2021; 12:27-31. [PMID: 34434424 PMCID: PMC8383638 DOI: 10.14740/jmc3610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/04/2020] [Indexed: 12/02/2022] Open
Abstract
To present a case of successful pregnancy outcome in a granulomatosis with polyangiitis (GPA) patient with renal insufficiency. GPA, formerly known as Wegener’s granulomatosis, is a rare necrotizing systemic vasculitis, presenting with classical clinical triad of manifestations involving upper and lower airway and glomerulonephritis. An association of Antineutrophil cytoplasmic antibodies with GPA has been established and the antibodies are present in most patients with active disease. Pregnancy with GPA is burdened with the risk of possible maternal and fetal complications, further leading to higher morbidity and mortality rate. Due to sparsity of studies of GPA in pregnancy, management needs to be individualised. Diagnostic workup should include serological markers, radiological and histopathological examination. Cyclophosphamide combined with prednisolone is the standard induction regimen. A 22-year-old woman, multigravida at 35 weeks of gestation was referred to our department owing to 1-year diagnosis of GPA. During active phase, the disease manifested as pneumonia and acute kidney injury and perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCAs) were positive. She received pulse therapy of injection cyclophosphamide and methylprednisolone as induction regimen, followed by tapering doses of oral prednisolone and azathioprine for maintenance therapy. The disease was in remission at the onset of pregnancy but had flare up at 34 - 35 weeks of gestation and she presented with renal dysfunction. Neither the disease nor the treatment adversely affected the pregnancy and she delivered a healthy baby at 37 weeks. The unpredictable disease course and complications at unexpected gestation appears to be a major variable to take into account when assessing the risk of pregnancy with GPA. Early diagnosis, monitoring and timely intervention resulted in favourable pregnancy outcome in our patient.
Collapse
Affiliation(s)
- Arpana Verma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sarita Rajbhar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Pushpawati Thakur
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sarita Agrawal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sangeeta Pradhan
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| |
Collapse
|
112
|
Juche A, Leo F, Grohé C, Wormanns D, Krause A. [Arthritis and pulmonary cavities]. Z Rheumatol 2021; 81:686-691. [PMID: 34427736 DOI: 10.1007/s00393-021-01064-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
This case report describes the very rare simultaneous occurrence of rheumatoid arthritis and granulomatosis with polyangiitis with the only organ manifestation of life-threatening bilateral pulmonary cavities. Due to the acuteness of the vasculitis, treatment was primarily with cyclophosphamide infusions and high-dose glucocorticoids, and in the further course with high-dose methotrexate. Routine thoracic imaging also seems to be useful when conventional basic rheumatologic treatment is newly initiated, as treatment-decisive changes are seen with a relevant frequency. The occurrence of both autoimmune diseases might be due to common genetic predispositions.
Collapse
Affiliation(s)
- Aaron Juche
- Abteilung für Rheumatologie, Klinische Immunologie und Osteologie, Immanuel Krankenhaus Berlin, Lindenberger Weg 19, 13125, Berlin, Deutschland.
| | - Fabian Leo
- Klinik für Pneumologie, Evangelische Lungenklinik, Berlin, Deutschland
| | - Christian Grohé
- Klinik für Pneumologie, Evangelische Lungenklinik, Berlin, Deutschland
| | - Dag Wormanns
- Radiologisches Institut, Evangelische Lungenklinik, Berlin, Deutschland
| | - Andreas Krause
- Abteilung für Rheumatologie, Klinische Immunologie und Osteologie, Immanuel Krankenhaus Berlin, Lindenberger Weg 19, 13125, Berlin, Deutschland
| |
Collapse
|
113
|
Cho LK, Carette S, Pagnoux C. ANCA status and renal parameters at month 12 post-diagnosis can help predict subsequent relapses in patients with granulomatosis with polyangiitis. Semin Arthritis Rheum 2021; 51:1011-1015. [PMID: 34416622 DOI: 10.1016/j.semarthrit.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the predictive value of disease characteristics at 12-month follow-up after the diagnosis of GPA for subsequent relapses in a cohort of patients followed at a tertiary vasculitis clinic. METHODS Demographic, clinical, and biological data at diagnosis and during follow-up from patients with GPA followed for at least 24 months at the Mount Sinai Hospital Vasculitis Clinic in Toronto, Canada were extracted from the Canadian Vasculitis Research Network (CanVasc) database and analyzed. The association between ANCA status and type (PR3- or MPO-ANCA), presence of microscopic hematuria, or serum creatinine level at follow-up month 12 ± 3 (M12) and relapses after M12 were assessed using Cox proportional hazard models. RESULTS A total of 113 GPA patients were included in this study (50 ANCA positive, 63 ANCA negative at M12). Patient demographics and disease characteristics were similar at diagnosis, including the treatments used for induction and at M12. The global 5-year relapse rate was 55.8%, without any difference in the relapse rates after M12 between those ANCA-positive or negative at M12. However, in multivariate analyses, MPO-ANCA positivity at M12 was predictive of increased relapses after M12 (hazard ratio [HR] 3.54, P=0.01), as was the presence of microhematuria at M12 (HR 1.91, P=0.04). In contrast, higher serum creatinine levels at M12 were associated with a decreased risk of subsequent relapse (HR 0.99, P=0.04). CONCLUSION In this cohort of patients with GPA, MPO-ANCA positivity and persistent microscopic hematuria at M12 were associated with increased risk of subsequent relapse, and could thus have value to predict disease outcome during follow-up.
Collapse
Affiliation(s)
- Lindsay K Cho
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada.
| | - Simon Carette
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, Department of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
114
|
Rezac J, Honsova E, Masek M, Rysava R, Neprasova M, Jancova E, Hruskova Z, Tesar V. Granulomatosis with polyangiitis mimicking cancer: a diagnostic dilemma. J Nephrol 2021; 35:675-678. [PMID: 34406622 DOI: 10.1007/s40620-021-01128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jakub Rezac
- Department of Urology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic. .,Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
| | - Eva Honsova
- Institute of Pathology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Masek
- Department of Radiodiagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Romana Rysava
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michaela Neprasova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Jancova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| |
Collapse
|
115
|
Domínguez-Quintana M, Alba MA, Hinojosa-Azaola A. Classification of ANCA-associated vasculitis: differences based on ANCA specificity and clinicopathologic phenotype. Rheumatol Int 2021; 41:1717-28. [PMID: 34383129 DOI: 10.1007/s00296-021-04966-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/03/2021] [Indexed: 01/24/2023]
Abstract
The classification of vasculitis according to a schema with universal acceptance is challenging, given the heterogeneous and protean nature of these diseases. Formal nomenclature and classification criteria for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have suffered several changes since their first description; none provides comprehensive diagnostic and classification criteria. Different factors account for the difficulties in the classification of vasculitis, including the incomplete understanding of the pathogenesis, the multisystemic nature of the disease, the non-specific patterns of vascular involvement, the overlap between entities, and the presence of various classification systems. The present article reviews the classification of AAV considering different points of view, including clinical, serologic, pathogenetic, organ predilection, therapeutic, and prognostic factors, and provides perspectives on future challenges in the understanding of AAV. There is an unmet need for a unifying view of the disease spectrum that considers the constantly evolving paradigms.
Collapse
|
116
|
Puchala M, Rydzewski A, Kowalik I, Wisłowska M. Comparison of granulomatosis with polyangiitis clinical features in patients depending of involvement or absence of kidney involvement. Curr Rheumatol Rev 2021; 17:379-389. [PMID: 34313202 DOI: 10.2174/1573397117666210726143757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND GPA is a necrotizing inflammation of the small vessels with granulomas. Kidney involvement deteriorated its prognosis. OBJECTIVE Comparison of GPA patients with kidney (KI) and without kidney involvement (nKI). MATERIAL AND METHODS We conducted a cross-sectional study of 50 consecutive adult GPA patients, 25 KI from Nephrology and 25 nKI from Rheumatology Department of Central Clinical Hospital Ministry of Interior in Warsaw. We analyzed clinical features, organ involvement, laboratory, serological, imaging, histopathological data, BVAS, treatment. RESULTS The mean age of KI patients was statistically older then nKI (67.3±9.5 vs 55.1±15.9, p=0.002). Generalized, severe, resistance disease was observed respectively in 92% vs 44%, p<0.001. The number of red blood cells (3.47 vs 4.41T/l, p<0.001), hemoglobin (10.0 vs 12.9g/dl, p<0.001) was lower in KI, higher mean serum creatinine (3.95 vs. 0.89mg/dl, p<0.001), lower GFR (20.1 vs. 79.3, p<0.001), higher CRP (median: 43.4 vs 2.0mg/l, p<0.001), BVAS (16.6±4.4 vs 10.1±6.2, p<0.001), c-ANCA (median: 119.0 vs 15.2CU, p=0.017). Nodules in 28% KI, in 4% nKI (p=0.048) in chest X-ray, infiltration in 43.5% KI, in 15% nKI (p=0.042) in HRCT were observed. Skin granulomas were found in 61.5% nKI vs 18.2% KI, (p=0.047). Renal biopsy revealed in KI patients focal segmental glomerulonephritis in 11.8%, crescentic glomerulonephritis in 17.6%, pauci-immune crescentic glomerulonephritis in 70.6%. CONCLUSIONS In patients with KI more frequently we found generalized, severe, resistant GPA, higher BVAS in comparison in patients without KI. The results of laboratory parameters, were worse in patients with KI. Aggressive immunosuppressive treatment is often used in KI group.
Collapse
Affiliation(s)
- Mateusz Puchala
- Rheumatology and Internal Disease Department, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Andrzej Rydzewski
- Nephrology, Transplantology and Internal Disease Department, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | | | - Małgorzata Wisłowska
- Rheumatology and Internal Disease Department, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| |
Collapse
|
117
|
Abstract
Granulomatous diseases are chronic inflammatory disorders whose pathogenesis is triggered by an array of infectious and noninfectious agents, and may be localized or a manifestation of systemic, disseminated disease. As in the skin, oral manifestations of granulomatous inflammation are often nonspecific in their clinical appearance. Thus, in the absence of overt foreign material or a recognizable infectious agent, identifying the underlying cause of the inflammation can be challenging. This article highlights various conditions known to induce granulomatous inflammation within the oral soft tissues.
Collapse
|
118
|
Gravos A, Katsifa K, Tselioti P, Grammatikopoulou V, Sakellaridis K, Kanakaki S, Tsapas C, Destounis A, Moschouris H, Athanasiadou I, Chatzivasiloglou F, Ivanova E, Prekates A. Ruptured arterial aneurysm in Wegener's granulomatosis: a case report. J Med Case Rep 2021; 15:343. [PMID: 34247654 PMCID: PMC8274053 DOI: 10.1186/s13256-021-02955-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/14/2021] [Indexed: 12/24/2022] Open
Abstract
Background Aneurysm formation is a possible, but rare, complication of granulomatosis with polyangiitis, known as Wegener’s granulomatosis. Urgent diagnosis and therapy is very important because a ruptured aneurysm could be life threatening. Case presentation We, therefore, present the case of a 63-year-old Greek man who was diagnosed with granulomatosis with polyangiitis and retroperitoneal hematoma due to ruptured aneurysm in renal artery and upper pancreaticoduodenal artery. His clinical course was complicated by acute renal failure and acute respiratory failure due to alveolar hemorrhage. Emergency coil embolization was performed. Postembolization recovery was uneventful; no bleeding occurred. The patient underwent mechanical ventilation and continuous veno-venous hemofiltration and received combined immunosuppression and supportive therapy, but eventually died 30 days after admission to hospital from severe septic shock and multiple organ failure. Conclusion Endovascular treatment is the therapy of choice, especially for patients with ruptured aneurysms that are hemodynamically stable. Early diagnosis is very important, as urgent embolization and early initiation of immunosuppression therapy are the treatment of choice.
Collapse
Affiliation(s)
- A Gravos
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece.
| | - K Katsifa
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - P Tselioti
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - V Grammatikopoulou
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - K Sakellaridis
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - S Kanakaki
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - C Tsapas
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - A Destounis
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - H Moschouris
- Radiology Department, Tzaneio General Hospital of Piraeus, Kamatero, Greece
| | - I Athanasiadou
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - F Chatzivasiloglou
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - E Ivanova
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| | - A Prekates
- Intensive Care Unit (ICU), Tzaneio General Hospital of Piraeus, Dodonis 26, Kamatero, PC: 13451, Greece
| |
Collapse
|
119
|
König D, Sauvigny T, Brekenfeld C, Friedrich RE, Gosau M, Assaf AT. Massive Transoral Bleeding from the Internal Carotid Artery in a Patient With Granulomatosis With Polyangiitis (Wegener). Anticancer Res 2021; 41:3667-3672. [PMID: 34230165 DOI: 10.21873/anticanres.15157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND In the oral and maxillofacial area, granulomatosis with polyangiitis (GPA) can lead to extended tissue destruction. CASE REPORT This is a case report of a life-threatening local complication resulting from a large osseous defect in the cranial base with consecutive massive bleeding from the right internal carotid artery. Intraoperative examination and diagnostic imaging led to neuroradiological interventional treatment by embolization, and in neurosurgical and further reconstructive surgical treatment by the oral and maxillofacial surgeons. The purpose of this case report was to draw attention to the possibly life-threatening local complications of GPA and to discuss the importance of early intervention. CONCLUSION As a prevention strategy, regular examinations including three-dimensional radiographic diagnostic imaging are important for the early detection of complications and the possible involvement of important structures.
Collapse
Affiliation(s)
- Daniela König
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Reinhard E Friedrich
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Martin Gosau
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Alexandre T Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg Eppendorf, University of Hamburg, Hamburg, Germany;
| |
Collapse
|
120
|
Iudici M, Puéchal X, Pagnoux C, Courvoisier DS, Hamidou M, Blanchard-Delaunay C, Maurier F, Ruivard M, Quemeneur T, Aumaitre O, Guillevin L, Terrier B. Significance of eosinophilia in granulomatosis with polyangiitis: data from the French Vasculitis Study Group Registry. Rheumatology (Oxford) 2021; 61:1211-1216. [PMID: 34142135 DOI: 10.1093/rheumatology/keab495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/03/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe disease presentation and long-term outcome of granulomatosis with polyangiitis (GPA) patients according to blood eosinophils count (Eos) at vasculitis diagnosis. METHODS Data from newly diagnosed GPA patients registered in the French Vasculitis Study Group database with available eosinophil count at diagnosis were reviewed. Disease characteristics, rate and type of relapses and overall survival were analyzed according to Eos, categorized as normal (<500/mm3), mild-to-moderate hypereosinophilia (HE) between 500 and 1500/mm3 and severe HE > 1500/mm3. RESULTS Three hundred and fifty-four patients were included. At diagnosis, 90 (25.4%) patients had HE ≥ 500/mm3; they were more likely male (73% vs 56%, p= 0.006) and had more frequent cutaneous manifestations (49% vs 33%, p= 0.01), peripheral neuropathy (32% vs 17%, p= 0.004) and higher BVAS (21 vs 18, p= 0.01), compared with those with Eos <500/mm3. Patients with severe HE (n = 28; median Eos 2355, range 1500-9114) had more frequent renal function worsening at presentation (p= 0.008). After a median follow-up of 3.95 (IQR 1.95-6.76) years, no difference was found in overall relapse rates according to baseline Eos, but those with HE experienced more neurologic (p= 0.013) and skin (p= 0.024) relapses and had more frequently peripheral neuropathy as damage at last follow-up (p= 0.02). Overall survival difference was not significantly different in patients with normal Eos or HE at diagnosis. (p= 0.08). CONCLUSIONS Blood HE at diagnosis, observed in about one quarter of GPA patients, identifies a subgroup of patients with a more severe disease and higher rate of skin and neurological involvement both at presentation and during follow-up.
Collapse
Affiliation(s)
- Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Rheumatology Unit, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Delphine S Courvoisier
- Rheumatology Unit, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | | | - François Maurier
- Service de médecine interne, Groupe Hospitalier UNEOS, Metz-Vantoux, France
| | - Marc Ruivard
- Service de médecine interne, CHU, Clermont-Ferrand, France
| | - Thomas Quemeneur
- Département de médecine interne, Centre Hospitalier, Valenciennes, France
| | | | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Université de Paris, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Université de Paris, Paris, France
| | | |
Collapse
|
121
|
Rodriguez-Pla A, Vikram HR, Khalid V, Wesselius LJ. COVID-19 pneumonia in a patient with granulomatosis with polyangiitis on rituximab: case-based review. Rheumatol Int 2021; 41:1509-1514. [PMID: 34091704 PMCID: PMC8180184 DOI: 10.1007/s00296-021-04905-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022]
Abstract
A 77-year-old man with past medical history of granulomatosis with polyangiitis (GPA) on rituximab and prednisone, presented to the hospital with worsening cough and shortness of breath. He had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by nasal swab polymerase chain reaction (PCR) while asymptomatic, 6 weeks earlier. He started with cough and shortness of breath 2 weeks after his initial positive test. After developing symptoms, he tested negative twice by nasal swab PCR, but the PCR of his bronchioloalveolar lavage was positive for SARS-CoV-2. He did not develop antibodies against coronavirus. Prednisone 15 mg daily was continued, and he received remdesivir, and convalescent plasma with quick recovery. We reviewed the literature to search for similar cases. Our case suggests that SARS-CoV-2 infection in patients on rituximab may have an atypical presentation and the diagnosis may be delayed due to negative PCR testing in the nasal swab. Patients may benefit from treatment with convalescent plasma.
Collapse
Affiliation(s)
| | | | - Vanood Khalid
- Division of Hospital Internal Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Lewis J Wesselius
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
122
|
Singh S, Selva D. Non-infectious Dacryoadenitis. Surv Ophthalmol 2021; 67:353-368. [PMID: 34081929 DOI: 10.1016/j.survophthal.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Dacryoadenitis is an inflammation of the lacrimal gland that may have various etiologies with similar presentations. Despite more recent elucidation of specific causes, the management has remained largely unchanged. Hence, the condition remains under biopsied with the rationale that empirical treatment with corticosteroids is effective for many of the causes. Dacryoadenitis, however, dacryoadenitis can be the presenting sign of an undiagnosed systemic disease and a mimick for lymphoma; hence, tissue diagnosis and systemic investigations play a vital role. A significant proportion of dacryoadenitis has a specific etiology, and IgG4-related dacryoadenitis is more frequently identified as a cause. We summarize the different types of immune-mediated dacryoadenitis, their clinical findings, histopathology, management, and prognosis. We have also highlighted and formulated practice guidelines for diagnosis and effective treatment based on the underlying systemic disease.
Collapse
Affiliation(s)
- Swati Singh
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Telangana, Hyderabad, India.
| | - Dinesh Selva
- Department of Ophthalmology, Royal Adelaide Hospital, South Australia, Adelaide, Australia
| |
Collapse
|
123
|
Sato H, Shirai T, Fujii H, Ishii T, Harigae H. Cyclophosphamide-associated enteritis presenting with severe protein-losing enteropathy in granulomatosis with polyangiitis: A case report. World J Gastroenterol 2021; 27:2657-2663. [PMID: 34092982 PMCID: PMC8160622 DOI: 10.3748/wjg.v27.i20.2657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/09/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although cyclophosphamide (CPA) is the key drug for the treatment of autoimmune diseases including vasculitides, it has some well-known adverse effects, such as myelosuppression, hemorrhagic cystitis, infertility, and infection. However, CPA-associated severe enteritis is a rare adverse effect, and only one case with a lethal clinical course has been reported. Therefore, the appropriate management of patients with CPA-associated severe enteritis is unclear.
CASE SUMMARY We present the case of a 61-year-old woman diagnosed with granulomatosis with polyangiitis based on the presence of symptoms in ear, lung, and, kidney with positive myeloperoxidase-antineutrophil cytoplasmic antibody. She received pulsed methylprednisolone followed by prednisolone 55 mg/d and intravenous CPA at a dose of 500 mg/mo. Ten days after the second course of intravenous CPA, she developed nausea, vomiting, and diarrhea, and was admitted to the hospital. Laboratory testing revealed hypoalbuminemia, suggesting protein-losing enteropathy. Computed tomography revealed wall thickening of the stomach, small intestine, and colon with contrast enhancement on the lumen side. Antibiotics and immunosuppressive therapy were not effective, and the patient’s enteritis did not improve for > 4 mo. Because her condition became seriously exhausted, corticosteroids were tapered and supportive therapies including intravenous hyperalimentation, replenishment of albumin and gamma globulin, plasma exchange, and infection control were continued. These supportive therapies improved her condition, and her enteritis gradually regressed. She was finally discharged 7 mo later.
CONCLUSION Immediate discontinuation of CPA and intensive supportive therapy are crucial for the survival of patients with CPA-associated severe enteritis.
Collapse
Affiliation(s)
- Hiroko Sato
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai 9808574, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai 9808574, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai 9808574, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai 9808574, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai 9808574, Japan
| |
Collapse
|
124
|
Murthy SI, Shah S, Bagga B, Dudam R. Rituximab therapy combined with methotrexate for severe necrotizing scleritis in a case of granulomatosis with polyangiitis. Indian J Ophthalmol 2021; 68:1981-1983. [PMID: 32823449 PMCID: PMC7690469 DOI: 10.4103/ijo.ijo_2249_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 19-year-old girl presented with severe pain and redness in her right eye and also with nasal congestion and epistaxis since the past 5 months. The patient was systemically investigated and tested positive for proteinase 3 anti-neutrophil cytoplasmic antibody (PR-3 ANCA) with raised erythrocyte sedimentation rate (ESR). The provisional diagnosis of granulomatosis with polyangiitis (GPA) was made, and she was started on systemic steroids and azathioprine after consultation with the rheumatologist. However on steroid taper, she developed severe reactivation of the scleritis and the corneal involvement was noted in the form of peripheral ulcerative keratitis. Instead of starting another course of high dose oral cortico-steroids or pulse cyclophosphomide, she was started on rituximab infusion (two doses), and oral methotrexate was added, leading to the successful remission of the disease.
Collapse
Affiliation(s)
- Somasheila I Murthy
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Sahil Shah
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Bhupesh Bagga
- Department of Cornea, The Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, L.V. Prasad Marg, Banjara Hills, Hyderabad, India
| | - Rajkiran Dudam
- Department of Rheumatology, Hyderabad Rheumatology Center, Prakash Nagar, Begumpet, Hyderabad, India
| |
Collapse
|
125
|
Orazbekov L, Issergepova B, Assainova M, Ruslanuly K. Granulomatosis with Polyangiitis with Ocular Manifestations. Case Rep Ophthalmol 2021; 12:98-104. [PMID: 33976664 PMCID: PMC8077634 DOI: 10.1159/000510959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/18/2020] [Indexed: 12/03/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a granulomatous-necrotic systemic vasculitis with a lesion of predominantly the upper and lower respiratory tracts at the onset of the disease (vasculitis, accompanied by granulomatous inflammation), and subsequently renal (glomerulonephritis). In addition, GPA may manifest as inflammation of small arteries and veins. Despite many years of study of this disease, the etiology of GPA remains unknown. The present case is about a 47-year-old female, who had been suffering from necrotizing scleritis, corneal ulcer, and secondary glaucoma in both eyes for 3 months, and she was treated with anti-inflammatory and antimicrobial therapy that showed no effect; the patient's general condition became worse. In the second week of treatment, multiple abscess ruptures exposed the sclera. Sampling of the affected conjunctival tissue and positive HLA B8 haplotype and ANCA (PR3-ANCA) testings make it clear that GPA was the main reason of necrotizing scleritis with inflammation. The targeted treatment of the underlying disease allows to stabilize an inflammation of corneal and scleral lesions.
Collapse
Affiliation(s)
- Lukpan Orazbekov
- First Ophthalmology Department, Kazakh Eye Research Institute, Almaty, Kazakhstan
| | - Botagoz Issergepova
- Postgraduate Education Department, Kazakh Eye Research Institute, Almaty, Kazakhstan
| | - Makpal Assainova
- Fourth Ophthalmology Department, Kazakh Eye Research Institute, Almaty, Kazakhstan
| | - Kairat Ruslanuly
- Postgraduate Education Department, Kazakh Eye Research Institute, Almaty, Kazakhstan
| |
Collapse
|
126
|
Abstract
PURPOSE OF REVIEW There is ongoing debate concerning the classification of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. That is, whether classification should be based on the serotype (proteinase 3 (PR3)- or myeloperoxidase (MPO)-ANCA) or on the clinical phenotype (granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)). To add clarity, this review focused on integration of the most recent literature. RECENT FINDINGS Large clinical trials have provided evidence that a serology-based risk assessment for relapses is more predictive than distinction based on the phenotype. Research conducted in the past decade indicated that a serology-based approach more closely resembles the genetic associations, the clinical presentation (i.e., lung involvement), biomarker biology, treatment response, and is also predicting comorbidities (such as cardiovascular death). Our review highlights that a serology-based approach could replace a phenotype-based approach to classify ANCA-associated vasculitides. In future, clinical trials and observational studies will presumably focus on this distinction and, as such, translate into a "personalized medicine."
Collapse
Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstrasse 42, 4600, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Erica L Bettac
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Avenue, Vancouver, WA, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| |
Collapse
|
127
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the most recent evidence on the treatment innovations and future prospective in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). RECENT FINDINGS In AAV, a growing body of research is available on novel treatment options for remission induction and to clarify some uncertainties concerning the optimal use of available drugs. Efforts are being made to reduce the toxicity associated with high-dose, prolonged glucocorticoids (GC) regimens. Despite major advances in the prognosis of AAV, relapses are still common and the intensity and duration of remission treatment constitute a great challenge in the management of these chronic conditions. A paradigm shift in practice in the management of AAV is being supported by recent evidence suggesting the comparable efficacy and improved safety profile of schemes with a reduced dose of GC for the induction and maintenance of remission in patients with severe granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Moreover, recent appraisal of pathogenetic mechanisms, including complement activation pathways, has introduced the revolutionary concept of an alternative to GC, such as avacopan. Plasma exchange failed to prevent end-stage renal disease and mortality in patients with severe renal involvement or pulmonary haemorrhage according to a large multicentre randomised trial. Intensified immunosuppressive strategies for patients with life-threatening manifestations, including the combination of rituximab (RTX) with cyclophosphamide (CYC) have revealed promising preliminary data. New evidence for the use of alternative immunosuppressive agents (e.g. mycophenolate mofetil or abatacept) for the induction of remission in patients with non-severe disease is emerging. Several studies have been recently published, or are ongoing, to assess the optimal strategy and duration of maintenance of remission with the available treatment options (GC, azathioprine, and RTX). Preliminary evidence supports the superiority of a more prolonged course of maintenance treatment. The management of refractory or relapsing eosinophilic granulomatosis with polyangiitis (EGPA) has been improved by the recent demonstration of efficacy and safety of an interleukin-5 inhibitor, mepolizumab. Ongoing randomised studies will clarify the role of RTX in patients with severe manifestations of EGPA.
Collapse
Affiliation(s)
- Sara Monti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - Fabio Brandolino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Alessandra Milanesi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Blerina Xoxi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| |
Collapse
|
128
|
Zimba O, Doskaliuk B, Yatsyshyn R, Bahrii M, Hrytsevych M. Challenges in diagnosis of limited granulomatosis with polyangiitis. Rheumatol Int 2021; 41:1337-45. [PMID: 33939014 DOI: 10.1007/s00296-021-04858-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/01/2021] [Indexed: 01/06/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is an orphan disease with multifaceted clinical presentations and delayed diagnosis. Given the risks of delayed diagnosis and treatment, improving clinicians' awareness of atypical course of this disease is critically important. The aim of this report is to analyze a case of delayed diagnosis of GPA in view of similar publications. We analyzed articles retrieved from Scopus and MEDLINE/PubMed. The following keywords were used: "granulomatosis with polyangiitis", "Wegener granulomatosis", and "diagnostic errors". All case studies that fulfilled the Chapel Hill Consensus Conference and the American College of Rheumatology GPA criteria were retrieved. We report a 71-year-old female patient with a facial defect in the nasal region, nasal congestion, and serosanguineous discharge. Her final diagnosis of GPA was reached after a series of incorrect diagnoses in the past 40 years. A deforming facial lesion developed during this period of uncertainty and absence of appropriate treatment. This patient presented with atypical features of laboratory and instrumental examinations. Anti-neutrophil cytoplasmic antibodies (ANCA) were negative, while rheumatoid factor (RF; 46.3 IU/mL) and anti-citrullinated protein antibody (ACPA; 25.6 IU/mL) were elevated. The histological analysis of the nasal mucous membrane specimen did not indicate definite signs of vasculitis. However, it revealed a granuloma with aggregation of macrophages and massive infiltration of lymphocytes, ruling out previous diagnosis of carcinoma. We analyzed delayed diagnosis of GPA in our patient in the context of 12 previously reported similar cases of limited form of GPA. We emphasize the importance of histological examination for differential diagnosis of GPA.
Collapse
|
129
|
Torp CK, Brüner M, Keller KK, Brouwer E, Hauge EM, McGonagle D, Kragstrup TW. Vasculitis therapy refines vasculitis mechanistic classification. Autoimmun Rev 2021; 20:102829. [PMID: 33872767 DOI: 10.1016/j.autrev.2021.102829] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/19/2021] [Indexed: 12/18/2022]
Abstract
The primary vasculitides constitute a heterogeneous group of immune mediated diseases of incompletely understood pathogenesis currently classified by the size of blood vessels affected (Chapel Hill classification). In recent years, several drugs with well-characterized immunological targets have been tested in clinical trials in large vessel vasculitis and small vessel vasculitis. Such trials provide "reverse translational" or bedside to bench information about underlying pathogenic mechanisms. Therefore, the aim of this systematic literature review was to examine the evidence base for a more refined mechanistic immunological classification of vasculitis. A total of 40 studies (20 randomized controlled trials (RCTs), 16 prospective studies, 1 retrospective cohort study and 3 case series) were included for full qualitative assessment. RCTs concerning biologic therapy for large vessel vasculitis mainly supports interleukin 6 receptor inhibition (tocilizumab). RCTs concerning biologic therapy for granulomatosis with polyangiitis and microscopic polyangiitis mainly support anti-CD20 treatment (rituximab) and complement inhibition with a small molecule C5a receptor antagonist (avacopan) is an emerging treatment option. The biologic treatment of eosinophilic granulomatosis with polyangiitis is centered around interleukin 5 inhibition (mepolizumab). Studies on tumor necrosis factor alpha inhibition (adalimumab, infliximab, and etanercept) showed negative results in giant cell arteritis but some effect in Takayasu arteritis. Taken together, clinical studies with cytokine and cell specific drugs are dissecting the heterogeneous immunopathogenic mechanisms of vasculitis and support a mechanistic immunological classification. Especially, cytokine antagonism is pointing towards immunological distinctions between eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis/microscopic polyangiitis and differences between giant cell arteritis and Takayasu arteritis.
Collapse
Affiliation(s)
| | - Mads Brüner
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.
| | - Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Elisabeth Brouwer
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark; Department of Rheumatology, Silkeborg Regional Hospital, Silkeborg, Denmark.
| |
Collapse
|
130
|
Piper K, Beldick SR, Karsy M, Allawh T, Shirodkar M, Miller J, Kiriakidou M, Curtis M, Evans JJ. Granulomatosis with polyangiitis masquerading as pituitary adenoma with apoplexy. Mod Rheumatol Case Rep 2021; 5:342-346. [PMID: 33784948 DOI: 10.1080/24725625.2021.1909222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a small- and medium-vessel autoimmune vasculitis. Rare presentations of GPA can manifest as ophthalmologic and endocrinological deficits with sellar enhancement on imaging. While GPA typically presents distinct in appearance from other sellar pathologies, such as pituitary adenoma, we report the case of a 41-year-old woman with GPA of the pituitary that was initially diagnosed as pituitary macroadenoma with apoplexy and treated with two surgical resections without improvement of clinical symptoms. Pathology analysis of the second resection specimen revealed an inflammatory process consistent with GPA. After the pathologic and clinical diagnosis of GPA was established, treatment with steroid and steroid-sparing immunosuppressants resulted in improvements both on imaging and symptomatically. We discuss important aspects of the diagnosis and treatment of this rare presentation of GPA.
Collapse
Affiliation(s)
- Keenan Piper
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stephanie R Beldick
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael Karsy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tanya Allawh
- Department of Rheumatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Monika Shirodkar
- Department of Endocrinology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey Miller
- Department of Endocrinology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marianthi Kiriakidou
- Department of Rheumatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Curtis
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| |
Collapse
|
131
|
Ledó N, Pethő ÁG. Gastrointestinal symptoms as first remarkable signs of ANCA-associated granulomatosis with polyangiitis: a case report and reviews. BMC Gastroenterol 2021; 21:158. [PMID: 33832425 PMCID: PMC8028736 DOI: 10.1186/s12876-021-01730-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Systemic vasculitis associated with antineutrophil cytoplasmic autoantibodies (ANCA) have an extremely wide variety of symptoms, therefore the fast and proper diagnosis is difficult to establish even for experienced physicians. Gastrointestinal manifestations in ANCA-associated granulomatosis with polyangiitis (GPA) may be present, however, severe, life-threatening complications (such as perforations) are rare.
Case presentation A case of an 18-year-old male patient is presented, where gastrointestinal symptoms (abdominal pain, vomiting, diarrhoea) were the first remarkable signs of GPA. The initial diagnosis of inflammatory bowel disease delayed the administration of proper immunosuppressive therapy, which might have contributed to the rare and life-threatening complication of arterial duodenal bleeding with perforation. Our systematic review of the literature found only a few case reports where gastrointestinal symptoms were the first signs of GPA, however, this entity might be more frequent if physicians would think of this possibility more often. Conclusions Gastrointestinal bleeding is a rare but potential lethal complication of vasculitis. Consequently, we recommend investigating the patients diagnosed with GPA for gastrointestinal bleeding during the treatment.
Collapse
Affiliation(s)
- Nóra Ledó
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
| | - Ákos Géza Pethő
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| |
Collapse
|
132
|
Li XJ, Yang L, Yan XF, Zhan CT, Liu JH. Granulomatosis with polyangiitis presenting as high fever with diffuse alveolar hemorrhage and otitis media: A case report. World J Clin Cases 2021; 9:2344-2351. [PMID: 33869612 PMCID: PMC8026843 DOI: 10.12998/wjcc.v9.i10.2344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/03/2020] [Accepted: 02/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis is a necrotizing inflammation of small and medium-sized vessels accompanied by formation of granuloma, involvement of primary granulomatous upper and lower respiratory tracts, glomerulonephritis, and vasculitis of small vessels.
CASE SUMMARY Herein, we described a case of a 52-year-old man admitted with pulmonary nodules and high fever. Autoantibody workup revealed that the patient was positive for c-anti-neutrophil cytoplasmic antibodies and proteinase-3 anti-neutrophil cytoplasmic antibodies. Pulmonary biopsies revealed a local granulomatous structure. The patient received therapy with methylprednisolone and intravenous immunoglobulin, and his clinical symptoms improved.
CONCLUSION Intravenous immunoglobulin may act on granulomatosis with polyangiitis similar to immunosuppressants.
Collapse
Affiliation(s)
- Xiao-Jie Li
- Department of General Practice, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Liu Yang
- Department of General Practice, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Feng Yan
- Department of General Practice, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Chu-Ting Zhan
- Department of General Practice, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| | - Jiang-Hua Liu
- Department of General Practice, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
- Department of General Practice, General Practice School of Guangxi Medical University, Nanning 530007, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
133
|
Al-Mehisen R, Alnemri K, Al-Mohaissen M. Cardiac imaging of a patient with unusual presentation of granulomatosis with polyangiitis: A case report and review of the literature. J Nucl Cardiol 2021; 28:441-455. [PMID: 31350714 DOI: 10.1007/s12350-019-01809-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent evidence suggests that cardiac involvement in patients with granulomatosis with polyangiitis (GPA) occurs more frequently than previously reported. Multimodality cardiac imaging is gaining attention in the diagnosis, prognostication, and follow-up of such patients; however, the data remain scarce. RESULTS 2D-TTE was useful for initial screening; while both cardiac magnetic resonance imaging and 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) metabolic imaging with rubidium-82 PET perfusion imaging were useful for characterization of myocardial disease. 18FDG-PET/CT was very useful for the follow-up of cardiac disease activity following treatment. CONCLUSION 18FDG-PET/CT is sensitive for the detection of cardiac involvement by GPA and is useful for the tissue characterization and follow-up of disease activity following treatment.
Collapse
Affiliation(s)
- Rabah Al-Mehisen
- Department of Cardiology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Khalid Alnemri
- Department of Cardiology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Maha Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, PO Box 48247, Riyadh, 11511, Kingdom of Saudi Arabia.
- Princess Nourah Bint Abdulrahman University Cardiovascular Disease in Women Research Chair, Riyadh, Kingdom of Saudi Arabia.
| |
Collapse
|
134
|
Tomczyk B, Janeczko Z, Kruczkowska A, Maciążek-Chyra B, Tański W, Chabowski M. Thoracic Manifestation of Granulomatosis with Polyangiitis: A Case Report. Adv Exp Med Biol 2021; 1324:35-40. [PMID: 33346903 DOI: 10.1007/5584_2020_600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated disorder with necrotic vasculitis of small- and medium-size arteries and veins. In the literature, there are many case reports of patients with GPA of different, sometimes unusual, clinical manifestations. In this paper, we present difficulties that accompanied the process of diagnosing GPA in a 54-year-old symptomatic patient who was. Computer tomography scans showed numerous tumor-like lesions of various and irregular sizes in both lungs. Positron emission tomography scans suggested a lymphoproliferative disease, otherwise failing to provide a clue concerning its nature or localization. After a series of diagnostic twists and turns, inclusive of bronchoalveolar lavage, cervical mediastinoscopy, paratracheal lymph biopsy, and histopathologic examinations, and other tests, the diagnosis of GPA was established as the most probable. The patient was acutely treated with loading doses of methylprednisolone and cyclophosphamide, gradually tapered off during the long-term follow-up. He was discharged from the hospital in a good condition. We conclude that GPA is an uncommon disease with indistinctive signs, which raises the risk of its being overlooked. A diagnostic algorithm is required for patients with suspected GPA. A timely diagnosis is essential as the disease may quickly progress into renal or multiorgan dysfunction, and ultimately lead to death if untreated. Pulmonary involvement may also suggest neoplastic changes.
Collapse
|
135
|
Pendolino AL, Kaura A, Navaratnam AV, Pendolino M, Bianchi G, Unadkat S, Ottaviano G, Randhawa PS, Andrews PJ. Olfactory dysfunction in antineutrophil cytoplasmic antibody-associated vasculitides: A review of the literature. World J Methodol 2021; 11:15-22. [PMID: 33777721 PMCID: PMC7970017 DOI: 10.5662/wjm.v11.i2.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/02/2021] [Accepted: 02/21/2021] [Indexed: 02/06/2023] Open
Abstract
Olfactory dysfunction (OD) has been described in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but the underlying mechanisms are not completely understood. The causes of altered smell function can generally be divided into conductive, sensorineural or others. To date no specific treatment is available for AAV-related OD and the efficacy of currently available options has not been explored. The aim of this review is to provide an overview of the causes that may lead to OD in patients with AAV. Current available treatments for OD and possible options in patients with AAV presenting with smell impairment are also mentioned.
Collapse
Affiliation(s)
- Alfonso Luca Pendolino
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
- Ear Institute, University College London, London WC1X 8EE, United Kingdom
| | - Anika Kaura
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
- Ear Institute, University College London, London WC1X 8EE, United Kingdom
| | - Annakan V Navaratnam
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
| | - Monica Pendolino
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa 16121, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa 16121, Italy
| | - Samit Unadkat
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
| | - Giancarlo Ottaviano
- Department of Neurosciences DNS, Otolaryngology Section, University of Padua, Padua 35128, Italy
| | - Premjit S Randhawa
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
| | - Peter J Andrews
- Department of Ear, Nose and Throat, Royal National ENT and Eastman Dental Hospitals, London WC1E 6DG, United Kingdom
- Ear Institute, University College London, London WC1X 8EE, United Kingdom
| |
Collapse
|
136
|
Arfaoui H, Elkihal H, Jabri H, Elkhattabi W, Afif H. Adolescent with severe granulomatosis with polyangiitis: a case report. Pan Afr Med J 2021; 38:285. [PMID: 34122712 PMCID: PMC8179993 DOI: 10.11604/pamj.2021.38.285.26893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/07/2021] [Indexed: 12/04/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare vasculitis among adolescents. Its pulmonary manifestations may mimic tuberculosis. We report the case of a 16-years-old female patient with multiple excavated lung nodules revealed by a chronic cough, hemoptysis, epistaxis and weight loss. The diagnosis of GPA was achieved due to systemic pulmonary, ENT and renal involvement, the positivity of anti-neutrophil cytoplasmic antibody directed against proteinase 3 (C-ANCA) and bronchial and nasal biopsies showing granulomatous inflammation with a dense perivascular infiltrate destroying the vessel wall. Bolus of glucocorticoids and immunosuppressants reversed her symptoms. Although GPA is a rare disease in teenagers, it should be considered as one of the differential diagnosis in adolescents presenting with excavated pulmonary nodules.
Collapse
Affiliation(s)
- Hajar Arfaoui
- Department of Respiratory Diseases, Hospital 20 Août 1953, University of Hassan II, University Hospital Center Ibn Rochd, Casablanca, Morocco
| | - Hamza Elkihal
- Department of Respiratory Diseases, Hospital 20 Août 1953, University of Hassan II, University Hospital Center Ibn Rochd, Casablanca, Morocco
| | - Hasna Jabri
- Department of Respiratory Diseases, Hospital 20 Août 1953, University of Hassan II, University Hospital Center Ibn Rochd, Casablanca, Morocco
| | - Wiam Elkhattabi
- Department of Respiratory Diseases, Hospital 20 Août 1953, University of Hassan II, University Hospital Center Ibn Rochd, Casablanca, Morocco
| | - Hicham Afif
- Department of Respiratory Diseases, Hospital 20 Août 1953, University of Hassan II, University Hospital Center Ibn Rochd, Casablanca, Morocco
| |
Collapse
|
137
|
Thompson LDR. Algorithmic Approach to Fibroinflammatory Sinonasal Tract Lesions. Head Neck Pathol 2021; 15:120-9. [PMID: 33723762 DOI: 10.1007/s12105-020-01272-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/21/2022]
Abstract
Fibroinflammatory lesions of the sinonasal tract are one of the most common head and neck lesions submitted to surgical pathology. When the fibroinflammatory pattern represents the lesion (i.e., not surface reactive ulceration), an algorithmic approach can be useful. Separated into reactive, infectious, and neoplastic, and then further divided based on common to rare, this logical progression through a series of differential considerations allows for many of these lesions to be correctly diagnosed. The reactive lesions include chronic rhinosinusitis and polyps, granulomatosis with polyangiitis, and eosinophilic angiocentric fibrosis. Infectious etiologies include acute invasive fungal rhinosinusitis, rhinoscleroma, and mycobacterial infections. The neoplastic category includes lobular capillary hemangioma, inflammatory myofibroblastic tumor, and NK/T-cell lymphoma, nasal type. Utilizing patterns of growth, dominant cell types, and additional histologic features, selected ancillary studies help to confirm the diagnosis, guiding further clinical management.
Collapse
|
138
|
Yamamoto T, Tkahata K, Kamei S, Ishikawa M, Matsumoto D, Suzuki K. Granulomatosis with polyangiitis presenting as a solitary renal mass: A case report with imaging and literature review. Radiol Case Rep 2021; 16:736-741. [PMID: 33510827 PMCID: PMC7815982 DOI: 10.1016/j.radcr.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/02/2021] [Accepted: 01/02/2021] [Indexed: 11/24/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) manifests as necrotizing granulomatous inflammatory masses in the nasal cavity, paranasal sinuses, and lungs. However, a mass in the kidney is extremely rare. We herein report a case of GPA that presented as a solitary mass in the left kidney. The patient was a man in his 60s. A 2.5-cm solitary mass was incidentally discovered in the left kidney at another hospital and was followed-up. Eight months later, the mass had enlarged, and the patient visited our hospital for further examination and treatment. The mass was hypovascular, with unclear margins on contrast-enhanced computed tomography (CT). The signal of the mass was nonuniform and iso- to slightly hypo-intense on T2-weighted and diffusion-weighted magnetic resonance imaging (MRI). Enlarged para-aortic lymph nodes were also detected on the CT and MRI. Based on imaging, malignant tumors were suspected, and nephrectomy was performed. The pathological diagnosis was GPA. We performed a literature review of this rare renal manifestation and present a summary of reported imaging findings. If a hypovascular renal mass with an unclear margin can be found in those with GPA, unnecessary operations may be avoided by actively promoting renal biopsy.
Collapse
Affiliation(s)
- Takahiro Yamamoto
- Department of Radiology, Aichi Medical University, 1-1 Yazako Karimata, Yatomi City, Aichi 480-1195, Japan
- Department of Radiology, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Yatomi City, Aichi, Japan
- Corresponding author.
| | - Kyohei Tkahata
- Department of Radiology, Aichi Medical University, 1-1 Yazako Karimata, Yatomi City, Aichi 480-1195, Japan
- Department of Radiology, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Yatomi City, Aichi, Japan
| | - Seiji Kamei
- Department of Radiology, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Yatomi City, Aichi, Japan
| | - Misawo Ishikawa
- Department of Pathology, Aichi Prefectural Welfare Federation of Agricultural Cooperatives Kainan Hospital, Yatomi City, Aichi, Japan
| | - Daisuke Matsumoto
- Department of Nephro-Urology, Graduate School of Medical Sciences, Nagoya City University, Nagoya City, Aichi, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, 1-1 Yazako Karimata, Yatomi City, Aichi 480-1195, Japan
| |
Collapse
|
139
|
Tiong BK, Singh AS, Sarantopoulos GP, Kermani TA. Kaposi sarcoma in anti-neutrophil cytoplasmic antibody-associated vasculitis: a case-based review. Rheumatol Int 2021; 41:1357-1367. [PMID: 33620515 PMCID: PMC8164621 DOI: 10.1007/s00296-021-04810-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/06/2021] [Indexed: 12/19/2022]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) are systemic necrotizing vasculitides associated with significant morbidity and mortality. Given the immunosuppression used to manage these conditions, it is important for clinicians to recognize complications, especially infectious ones, which may arise during treatment. Kaposi sarcoma (KS) is a lymphoangioproliferative neoplasm caused by human herpes virus 8 (HHV-8). Its cutaneous manifestations can mimic vasculitis. We describe a 77-year-old man with microscopic polyangiitis with pulmonary-renal syndrome treated with prednisone and intravenous cyclophosphamide who developed KS (HHV-8 positive) after 2 months of treatment. Cyclophosphamide was discontinued and prednisone gradually lowered with improvement and clinical stabilization of KS lesions. This comprehensive review includes all published cases of KS in patients with AAV, with a goal to summarize potential risk factors including the clinical characteristics of vasculitis, treatment and outcomes of patients with this rare complication of immunosuppressive therapy. We also expanded our literature review to KS in other forms of systemic vasculitis. Our case-based review emphasizes the importance of considering infectious complications of immunosuppressive therapy, especially glucocorticoids, and highlights the rare association of KS in systemic vasculitis.
Collapse
Affiliation(s)
- Benedict K Tiong
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
| | - Arun S Singh
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - G Peter Sarantopoulos
- Department of Pathology and Laboratory Medicine, UCLA Medical Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA
| |
Collapse
|
140
|
Kwon HC, Song JJ, Park YB, Lee SW. Fibrosis-5 predicts end-stage renal disease in patients with microscopic polyangiitis and granulomatosis with polyangiitis without substantial liver diseases. Clin Exp Med 2021; 21:399-406. [PMID: 33611672 PMCID: PMC8266773 DOI: 10.1007/s10238-021-00691-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
We previously reported that fibrosis-4 (FIB-4) was associated with poor outcomes of microscopic polyangiitis (MPA) and granuloma with polyangiitis (GPA). We also investigated the potential of FIB-5, a novel index, in predicting all-cause mortality and end-stage renal disease (ESRD) during follow-up in patients with MPA and GPA without substantial liver diseases. Clinical and laboratory data at diagnosis were collected by reviewing the medical records of 180 patients with MPA and GPA. FIB-5 was obtained by a following equation: FIB-5 = (serum albumin (g/L) × 0.3 + platelet count (109/L) × 0.05) − (alkaline phosphatase (IU/L) × 0.014 + aspartate aminotransferase/alanine aminotransferase ratio × 6 + 14). The median age of the patients at diagnosis was 61.0 years. FIB-5 at diagnosis could not reflect the cross-sectional vasculitis activity. The cutoffs of FIB-5 for poor outcomes was set as 0.82 (the lowest tertile) and -0.42 (the lowest quartile) at diagnosis. In Kaplan–Meier survival analysis, patients with FIB-5 < 0.82 and those with FIB-5 < -0.42 exhibited lower ESRD-free survival rates than those without. However, it could not predict all-cause mortality. In multivariable Cox hazards analysis, both FFS (Hazard ratio (HR) 1.554) and FIB-5 < 0.82 (HR 2.096) as well as both FFS (HR 1.534) and FIB-5 < -0.42 (HR 2.073) at diagnosis independently predicted ESRD during follow-up. In conclusion, FIB-5 < 0.82 and FIB-5 < -0.42 at diagnosis could predict the occurrence of ESRD, but not all-cause mortality, during follow-up in patients with MPA and GPA without substantial liver diseases.
Collapse
Affiliation(s)
- Hyeok Chan Kwon
- Department of Rheumatology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
141
|
Iudici M, Pagnoux C, Courvoisier DS, Cohen P, Hamidou M, Aouba A, Lifermann F, Ruivard M, Aumaître O, Bonnotte B, Maurier F, Decaux O, Hachulla E, Karras A, Khouatra C, Jourde-Chiche N, Viallard JF, Blanchard-Delaunay C, Godmer P, Quellec AL, Quéméneur T, de Moreuil C, Régent A, Terrier B, Mouthon L, Guillevin L, Puéchal X. Granulomatosis with polyangiitis: Study of 795 patients from the French Vasculitis Study Group registry. Semin Arthritis Rheum 2021; 51:339-346. [PMID: 33601189 DOI: 10.1016/j.semarthrit.2021.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 02/06/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe the characteristics and long-term outcomes of patients with granulomatosis with polyangiitis (GPA) from the French Vasculitis Study Group database. METHODS Patients' clinical and laboratory characteristics, Birmingham Vasculitis Activity Score (BVAS)-assessed disease activity, malignancies, opportunistic infections, and vital status were collected at diagnosis and each visit. Estimated probabilities and predictors of overall (OS) and relapse-free survival (RFS) were analyzed by Cox regression. RESULTS We enrolled 795 newly diagnosed patients, followed for a median of 3.5 years. Initial clinical manifestations involved ear, nose & throat (ENT; 80%), lungs (68%) and kidneys (56%). Among the 728 available ELISA results, 75.0% were PR3-ANCA-positive, 16.5% MPO-ANCA-positive and 62 (8.5%) ANCA-negative. Relapses occurred in 394 (50%) patients, involving ≥1 organ(s) affected at onset in 179 (46%), mainly ENT, lungs and kidneys, with mean BVAS 10.2 points below that at diagnosis (p<0.001). Five- and 10-year RFS rates were 37% and 17%, respectively. PR3-ANCA-positivity independently predicted relapse (p = 0.05) and prolonged survival (p = 0.038). OS-but not RFS-improved significantly over time (p<0.001); 10-year OS reached 88.2% (95% CI 83.9 to 92.7) for the 660 patients diagnosed after 2000. Infections were the main causes of death. Malignancy or opportunistic infection each occurred in ≤5% of the patients. CONCLUSION Survival has improved dramatically over the last decades but the high relapse rate remains a major concern for GPA patients, once again stressing the need for therapeutic strategy optimization to lower it. PR3-ANCA-positivity was associated with increased probability of relapse and survival.
Collapse
Affiliation(s)
- Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France; Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France; Present address: Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Delphine S Courvoisier
- Division of Rheumatology, Department of Internal Medicine Specialties, Geneva University Hospitals, Switzerland
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Hôtel-Dieu, Nantes, France
| | - Achille Aouba
- Department of Internal Medicine, CHU Côte-de-Nacre, Caen, France
| | | | - Marc Ruivard
- Department of Internal Medicine, CHU, Clermont-Ferrand, France
| | | | | | | | - Olivier Decaux
- Department of Internal Medicine, CHU Sud, Rennes, France
| | - Eric Hachulla
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine and Clinical Immunology, Claude-Huriez Hospital, University of Lille, Lille, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Chahéra Khouatra
- Department of Respiratory Medicine, CHU Louis-Pradel and UMR754, Université Claude-Bernard Lyon 1, Lyon, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Univ, C2VN, INSERM 1263, INRAE 1260, AP-HM, Department of Nephrology, CHU de la Conception, Marseille, France
| | | | | | - Pascal Godmer
- Department of Internal Medicine, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Alain Le Quellec
- Department of Internal Medicine, CHU Saint-Eloi, Montpellier, France
| | - Thomas Quéméneur
- Department of Nephrology and Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Claire de Moreuil
- Department of Internal Medicine, CHU La Cavale Blanche, Brest, France
| | - Alexis Régent
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), 27, rue du faubourg Saint-Jacques, Paris, Cedex 14 75679, France.
| | | |
Collapse
|
142
|
Ince B, Kamali S, Bektaş M, Ögret YD, Savran FO, Yalçinkaya Y, Artim-Esen B, Inanç M, Öcal L, Gül A. A shared motif of hla-dpb1 affecting the susceptibility to pr3-anca positive granulomatosis with polyangiitis: comparative analysis of a Turkish cohort with matched healthy controls. Rheumatol Int 2021; 41:1667-72. [PMID: 33544216 DOI: 10.1007/s00296-021-04789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
We aimed to analyse the distribution of HLA Class 2 genotypes which were reported among the genetic risk factors for ANCA-associated vasculitis (AAV) among Turkish patients in comparison with healthy subjects and previously reported data of AAV cohorts. Ninety-eight patients (F/M: 47/51 and mean age: 49 ± 1.14) were enrolled in the study and records of gender and birthplace-matched 196 healthy kidney donors were used as the control group. Patients were classified according to the clinical subgroups and ANCA serotypes (MPO-AAV, PR3-AAV). DNA was isolated from venous blood from all patients, and high-resolution HLA Class 2 genotyping was carried out by using NGS-Omixon Holotype HLA Kit. The frequencies of HLA-DQB1*03:03, - *06:04, and -DPB1*13:01, -*16:01 and -*66:01:00 alleles were significantly higher, and the frequencies of HLA-DQB1*02:02, -DPB1*02:01 and -*04:01 alleles were lower in the PR3-AAV subgroup (n = 53) compared to the controls. Comparison of amino acid sequences of the associated HLA-DPB1 alleles revealed the sequence of D-E-A-V in risk alleles replaced with the G-G-P-M sequence in protective alleles between 84 and 87th positions. Structural analysis of the HLA-DPB1*02:01 showed that this shared position is in the contact area between HLA-DP α and β chains and within pocket 1 of the antigen-binding groove. First HLA genotyping analysis in Turkish AAV patients revealed a negative correlation between PR3-ANCA positivity and certain HLA-DPB1 alleles contradictory to the results reported from European cohorts. Known functional effects of D-E-A-V sequence on HLA-DPB1 support the importance of our finding, but further studies are needed to reveal its pathogenic mechanisms.
Collapse
|
143
|
Guimarães F, Santos-Faria D, Azevedo S, Ramos Rodrigues J, Leite Silva J, Esperança-Almeida D, Ribeiro B, Vaz R, Teixeira F, Tavares-Costa J, Afonso C, Peixoto D. ANCA-associated vasculitis in a patient with enteropathic spondylarthritis: a case report and literature review. Clin Rheumatol 2021; 40:3351-3355. [PMID: 33517484 DOI: 10.1007/s10067-021-05612-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
Coexistence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and inflammatory bowel disease (IBD) is rare (Sy et al. in Semin Arthritis Rheum 45:475-482, 2016). Nevertheless, we present a case of an AAV in a 53-year-old female with enteropathic spondylarthritis previously treated with tumor necrosis factor α inhibitors (TNFi). Management of vasculitis in a patient with IBD may be problematic due to the difficulty in distinguishing if the vasculitis is an extraintestinal manifestation of the IBD or a new coexistent entity. Moreover, in our report, the previous treatment with TNFi is a possible confounding factor due to the paradoxical effects induced by TNFi, including vasculitis (Ramos-Casals et al. in Curr Rheumatol Rep 10:442-448, 2008). The reported case alerts to the complexity in the management of patients with enteropathic spondylarthritis and vasculitis, as well as discusses the diversity of differential diagnosis in this particular clinical scenario.
Collapse
Affiliation(s)
- Francisca Guimarães
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal.
| | - Daniela Santos-Faria
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - Soraia Azevedo
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - Joana Ramos Rodrigues
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - Joana Leite Silva
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | | | | | - Raquel Vaz
- Nephrology Department, Hospital de Braga, Braga, Portugal
| | - Filipa Teixeira
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - José Tavares-Costa
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - Carmo Afonso
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| | - Daniela Peixoto
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Largo Conde Bertiandos, 4990-041, Ponte de Lima, Portugal
| |
Collapse
|
144
|
Furlam PL, Perez MO, Franco AS, Caparbo VF, Shinjo SK, Pereira RMR. Visceral adipose tissue in granulomatosis with polyangiitis: association with disease activity parameters. Clin Rheumatol 2021; 40:2835-41. [PMID: 33483919 DOI: 10.1007/s10067-021-05592-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/21/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the body composition (BC) of patients with granulomatosis with polyangiitis (GPA) compared to healthy controls, emphasizing visceral adipose tissue (VAT) and associated BC parameters with disease activity, the damage index, and inflammatory parameters in patients with GPA. METHODS This study was conducted in 43 patients with GPA and 43 healthy controls matched by sex, age, and body mass index (BMI). BC was analyzed using dual-energy X-ray absorptiometry (DXA). The fat mass parameters evaluated were total fat mass (FM), adiposity (%), the fat mass index (FMI: fat mass/ht2), and VAT (g, cm2, cm3). Disease activity was assessed by the Birmingham Vasculitis Activity Score (BVAS). Damage was assessed by the Vasculitis Damage Index (VDI). C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured. RESULTS Comparing patients with GPA with healthy controls, patients had a significantly greater VAT (VAT in g: 685.81 ± 306.10 vs. 581.21 ± 235.57, p = 0.04; VAT in cm2: 142.23 ± 63.48 vs. 119.84 ± 49.54, p = 0.03; VAT in cm3: 741.33 ± 330.97 vs. 628.44 ± 254.66, p = 0.04). Patients with higher VAT (≥ 768 g) had an increased value of ESR (22.77 ± 26.79 vs. 11.57 ± 11.30 mm/1st hour, p = 0.04) and an increased value of BVAS (3.18 ± 4.15 vs. 0.90 ± 1.70, p = 0.01) when compared to patients with less VAT (< 768 g). CONCLUSION Patients with GPA have altered BC compared to healthy controls. Moreover, higher VAT was associated with disease activity and higher inflammatory markers, suggesting a relationship between GPA activity and adiposity parameters. Key points • Granulomatosis with polyangiitis patients have increased visceral adipose tissue when compared to health controls; • Granulomatosis with polyangiitis patients with higher values of visceral adipose tissue have worse disease activity and higher inflammatory markers; • This paper represents important contribution to the well-studied association between vasculitis and inflammatory markers, adding the role of adipose visceral tissue in the disease physiopathology.
Collapse
|
145
|
Yamada Y, Harada M, Hara Y, Iwabuchi R, Hashimoto K, Yamamoto S, Kamijo Y. Efficacy of plasma exchange for antineutrophil cytoplasmic antibody-associated systemic vasculitis: a systematic review and meta-analysis. Arthritis Res Ther 2021; 23:28. [PMID: 33446268 PMCID: PMC7809754 DOI: 10.1186/s13075-021-02415-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/04/2021] [Indexed: 02/08/2023] Open
Abstract
Objective To assess through systematic review and meta-analysis whether plasma exchange (PE) is associated with prognosis in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. Methods A systematic search of PubMed, MEDLINE, Embase, and CENTRAL databases from inception to 17 June 2020 was conducted. Ongoing or unpublished trials were also searched in ClinicalTrials.gov and the World Health Organization trials portal. Randomised controlled trials (RCTs) comparing PE vs. non-PE in AAV patients (microscopic polyangiitis [MPA], granulomatosis with polyangiitis [GPA], or eosinophilic granulomatosis with polyangiitis [EGPA]) were included. The combined risk ratio (RR) was calculated by the random-effects model using the Mantel-Haenszel method. Heterogeneity was measured using the I2 statistic. Primary outcomes were mortality, clinical remission (CR), and adverse events (AEs). Results Four RCTs comparing PE vs. no PE (N = 827) and 1 RCT comparing PE vs. pulse steroid treatment (N = 137) were included. All participants were MPA or GPA patients (no EGPA patients). PE was not associated with main primary outcomes compared with no PE (mortality RR 0.93 [95% confidence interval {CI} 0.70–1.24], I2 = 0%; CR RR 1.02 [95% CI 0.91–1.15], I2 = 0%; and AE RR 1.10 [95% CI 0.73–1.68], I2 = 37%) or pulse steroid (mortality RR 0.99 [95% CI 0.71–1.37]; CR [the Birmingham Vasculitis Activity score] mean difference − 0.53 [95% CI − 1.40–0.34]; and AE RR 1.05 [95% CI 0.74–1.48]). Focusing on the early treatment phases, PE was associated with a reduction in end-stage renal disease incidence compared with both no PE (PE 1/43 vs. no PE 10/41; RR 0.14 [0.03–0.77] at 3 months) and pulse steroid (PE 11/70 vs. pulse steroid 23/67; RR 0.46 [0.24–0.86] at 3 months). Conclusion We carried out a systematic review and meta-analysis targeting all AAV patients, including MPA, GPA, and EGPA. In AAV patients, performing PE was not associated with the risk of mortality, CR, and AE. No RCT exists evaluating the efficacy of PE for EGPA; hence, this is required in the future. The results may affect the development of guidelines for AAV and may indicate the direction of future clinical research on AAV. Trial registration UMIN R000045239, PROSPERO CRD42020182566. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02415-z.
Collapse
Affiliation(s)
- Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuuta Hara
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Ryohei Iwabuchi
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| |
Collapse
|
146
|
Kyurkchiev D, Yoneva T, Yordanova A, Kurteva E, Vasilev G, Zdravkova Y, Sheytanov I, Rashkov R, Ivanova-Todorova E. Alterations of serum levels of plasminogen, TNF-α, and IDO in granulomatosis with polyangiitis patients. Vascular 2021; 29:874-882. [PMID: 33427113 DOI: 10.1177/1708538120986305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is a representative of vasculitides associated with anti-neutrophil cytoplasmic autoantibodies. "Classical" antibodies directed against proteinase 3 are involved in the pathogenesis and are part of the GPA diagnosis at the same time. Along with them, however, antibodies against Lysosomal-Associated Membrane Protein-2 (LAMP-2) and antibodies directed against plasminogen have been described in GPA.Objectives and methodology: We performed a cross-sectional study enrolling 34 patients diagnosed with GPA. Our study was aimed at looking for correlations between serum levels of LAMP-2 and plasminogen and the clinical manifestations of the GPA. Furthermore, we examined serum levels of tumor necrosis factor-alpha (TNF-α) and its associated indoleamine-pyrrole 2,3-dioxygenase (IDO), as well as we looked for a correlation between these cytokines and the clinical manifestations of GPA. RESULTS The results showed that in GPA, serum plasminogen levels were negatively associated with renal involvement (receiver operating characteristic (ROC) area under the curve (AUC) of 0.78) (95% CI 0.53-0.91), p = 0.035, and the extent of proteinuria, Spearman's Rho = -0.4, p = 0.015. Increased levels of TNF-α and IDO correlated with disease activity, Spearman's Rho =0.62, p = 0.001 and Spearman's Rho = 0.4, p = 0.022, respectively, whereas only TNF-α was increased in severe forms of GPA with lung involvement (ROC AUC of 0.8) (95% CI 0.66-0.94), p = 0.005. CONCLUSIONS In this study, we demonstrate the alteration of soluble factors, which play an important role in the pathogenesis of GPA and their relationship with the clinical manifestations of the disease. Our main results confirm the associations of increased secretory TNF-α and some clinical manifestations, and we describe for the first time decreased serum plasminogen levels and their association with renal involvement.
Collapse
Affiliation(s)
- Dobroslav Kyurkchiev
- Laboratory of Clinical immunology, University Hospital St. Ivan Rilski, Department of Clinical Immunology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetelina Yoneva
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Adelina Yordanova
- Laboratory of Clinical immunology, University Hospital St. Ivan Rilski, Department of Clinical Immunology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Ekaterina Kurteva
- Laboratory of Clinical immunology, University Hospital St. Ivan Rilski, Department of Clinical Immunology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Georgi Vasilev
- Laboratory of Clinical immunology, University Hospital St. Ivan Rilski, Department of Clinical Immunology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Yana Zdravkova
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Ivan Sheytanov
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Rasho Rashkov
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Ekaterina Ivanova-Todorova
- Laboratory of Clinical immunology, University Hospital St. Ivan Rilski, Department of Clinical Immunology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| |
Collapse
|
147
|
Holme SS, Kilian K, Eggesbø HB, Moen JM, Molberg Ø. Impact of baseline clinical and radiological features on outcome of chronic rhinosinusitis in granulomatosis with polyangiitis. Arthritis Res Ther 2021; 23:18. [PMID: 33430923 PMCID: PMC7802308 DOI: 10.1186/s13075-020-02401-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) causes a recurring inflammation in nose and paranasal sinuses that clinically resembles chronic rhinosinusitis (CRS) of other aetiologies. While sinonasal inflammation is not among the life-threatening features of GPA, patients report it to have major negative impact on quality of life. A relatively large proportion of GPA patients have severe CRS with extensive damage to nose and sinus structures evident by CT, but risk factors for severe CRS development remain largely unknown. In this study, we aimed to identify clinical and radiological predictors of CRS-related damage in GPA. METHODS We included GPA patients who had clinical data sets from time of diagnosis, and two or more paranasal sinus CT scans obtained ≥12 months apart available for analysis. We defined time from first to last CT as the study observation period, and evaluated CRS development across this period using CT scores for inflammatory sinus bone thickening (osteitis), bone destructions, and sinus opacifications (here defined as mucosal disease). In logistic regression, we applied osteitis as main outcome measure for CRS-related damage. RESULTS We evaluated 697 CT scans obtained over median 5 years observation from 116 GPA patients. We found that 39% (45/116) of the GPA patients remained free from CRS damage across the study observation period, while 33% (38/116) had progressive damage. By end of observation, 32% (37/116) of the GPA patients had developed severe osteitis. We identified mucosal disease at baseline as a predictor for osteitis (odds ratio 1.33), and we found that renal involvement at baseline was less common in patients with severe osteitis at last CT (41%, 15/37) than in patients with no osteitis (60%, 27/45). CONCLUSIONS In this largely unselected GPA patient cohort, baseline sinus mucosal disease associated with CRS-related damage, as measured by osteitis at the end of follow-up. We found no significant association with clinical factors, but the data set indicated an inverse relationship between renal involvement and severe sinonasal affliction.
Collapse
Affiliation(s)
- Sigrun Skaar Holme
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, PB 4950 Nydalen, Oslo, 0424, Norway.,Institute of Clincal Medicine, University of Oslo, PB 1072 Blindern, Oslo, 0316, Norway
| | - Karin Kilian
- Institute of Clincal Medicine, University of Oslo, PB 1072 Blindern, Oslo, 0316, Norway.,Department of Rheumatology, Oslo University Hospital, PB 4950 Nydalen, Oslo, 0424, Norway
| | - Heidi B Eggesbø
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, PB 4950 Nydalen, Oslo, 0424, Norway.,Institute of Clincal Medicine, University of Oslo, PB 1072 Blindern, Oslo, 0316, Norway
| | - Jon Magnus Moen
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, PB 4950 Nydalen, Oslo, 0424, Norway
| | - Øyvind Molberg
- Institute of Clincal Medicine, University of Oslo, PB 1072 Blindern, Oslo, 0316, Norway. .,Department of Rheumatology, Oslo University Hospital, PB 4950 Nydalen, Oslo, 0424, Norway.
| |
Collapse
|
148
|
Ota H, Sato C, Igarashi A, Inoue S, Masuda S, Ishizu A, Watanabe M. Spontaneously regressed granulomatosis with polyangiitis: A case report. Respir Investig 2021; 59:372-376. [PMID: 33431355 DOI: 10.1016/j.resinv.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/19/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
A 71-year-old woman presented with chest pain, cough, and back pain. A chest roentgenogram showed multiple nodular shadows in both lungs. She was diagnosed with granulomatosis with polyangiitis (GPA). The multiple nodular shadows in both lungs regressed spontaneously in a few months. There are few reports of spontaneous regression of GPA, and the underlying mechanism is unclear. Neutrophil extracellular traps (NETs) have been recently shown to be involved in GPA. NETs may also be related to the natural regression of GPA.
Collapse
Affiliation(s)
- Hiroki Ota
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
| | - Chisa Sato
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
| | - Akira Igarashi
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
| | - Sumito Inoue
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
| | - Sakiko Masuda
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo 060-0812, Japan.
| | - Akihiro Ishizu
- Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, Sapporo 060-0812, Japan.
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
| |
Collapse
|
149
|
Murai Y, Kurimoto T, Mori S, Ueda K, Sakamoto M, Akashi K, Yamada-Nakanishi Y, Nakamura M. Granulomatosis with Polyangiitis Presenting with Bilateral Orbital Apex Syndrome. Case Rep Ophthalmol 2021; 12:32-40. [PMID: 33613248 PMCID: PMC7879294 DOI: 10.1159/000510329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
We report a rare case of granulomatosis with polyangiitis (GPA) presenting with bilateral orbital apex syndrome (OAS). A 73-year-old woman with a history of endoscopic sinus surgery for ethmoidal sinusitis experienced a sudden decrease in visual acuity (VA) of both eyes. At the initial examination, her VA had decreased to 0.01 in the right eye and 0.03 in the left eye, and eye movement in both eyes was mildly limited in all directions. Visual field tests of both eyes showed a large central scotoma. Laboratory tests revealed an elevation of myeloperoxidase-anti-neutrophil cytoplasmic antibody. Facial computed tomography demonstrated a thickened mucosal membrane in the entire ethmoidal sinus, and the posterosuperior walls of Onodi cells filled with infiltrative lesions had thinned. Orbital magnetic resonance imaging showed severe inflammation in the orbital apex. From these clinical findings, the patient was diagnosed with GPA presenting with OAS associated with ethmoid sinusitis. Emergent endoscopic sinus surgery was performed for biopsy and debridement of the ethmoidal and sphenoid sinusitis to decompress the optic nerve. One day after endoscopic sinus surgery, the patient's VA and visual field were improved, and steroid pulse therapy was commenced postoperatively. Four days later, VA had recovered to 1.0 in both eyes, and eye movement and visual field had were improved. Although OAS is a rare manifestation, early surgical treatment should be considered when the orbital lesion presents as risk of rapid deterioration of visual function in patients with GPA.
Collapse
Affiliation(s)
- Yusuke Murai
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takuji Kurimoto
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sotaro Mori
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kaori Ueda
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mari Sakamoto
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kengo Akashi
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuko Yamada-Nakanishi
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Makoto Nakamura
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
150
|
Atas DB, Atas H, İzgi TN, Velioglu A, Arikan H, Oner FA, Direskeneli H, Tuglular S, Asicioglu E. The prevalence of metabolic syndrome is increased in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. Int Urol Nephrol 2021; 53:1427-1434. [PMID: 33387219 DOI: 10.1007/s11255-020-02736-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/02/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Cardiovascular disease is one of the major causes of mortality in anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). Metabolic syndrome (MetS) is associated with increased cardiovascular risk in the normal population. However, MetS in AAV has not been adequately investigated. We aimed to determine MetS prevalence and associated factors in AAV patients. METHODS Thirty-seven AAV patients and 42 healthy controls were enrolled. MetS was determined by International Diabetes Federation (IDF) and National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. The relationship between clinical features of AAV and MetS was also investigated. RESULTS MetS was significantly higher in AAV patients than controls by NCEP-ATPIII (51.4% vs. 26.2%, p 0.022) and IDF (62.2% vs. 35.7%, p 0.020). When AAV patients with MetS were compared to those without, there were significant differences in age, CRP, GFR and NT-pro-BNP. Age [58 (13) vs. 50 (8) years p: 0.028], CRP [4.0 (3.6) vs. 3.2 (1.0) mg/l, p 0.021] and NT-pro-BNP [173.5 (343.7) vs. 106.0 (103.0) pg/ml, p 0.013] were significantly higher in AAV patients with MetS than those without; GFR was significantly lower [38 (46) vs. 83 (51) ml/min/1.73 m2, p 0.004]. ROC curve analysis showed NT-pro-BNP > 58.0 ng/ml predicted MetS with 87.1% sensitivity and 46.7% specificity (Area under curve: 0.71, CI 0.536-0.902, p 0.041). Multivariate analysis revealed age [OR (95% CI): 1.180 (1.010-1.370), p 0.039] and NT-pro-BNP > 58 pg/ml [OR (95% CI): 5.5 (1.02-30.1) p 0.047] were independent predictors of MetS in AAV patients. CONCLUSION MetS is significantly higher in AAV patients than controls and is associated with age and NT-pro-BNP. Screening and treating MetS may improve prognosis in AAV patients.
Collapse
Affiliation(s)
- Dilek Barutcu Atas
- School of Medicine, Department of Internal Medicine, Division of Nephrology, Marmara University, Istanbul, Turkey
| | - Halil Atas
- School of Medicine, Department of Cardiology, Marmara University, Istanbul, Turkey
| | - Tuba Nur İzgi
- School of Medicine, Department of Internal Medicine, Marmara University, Istanbul, Turkey
| | - Arzu Velioglu
- School of Medicine, Department of Internal Medicine, Division of Nephrology, Marmara University, Istanbul, Turkey
| | - Hakki Arikan
- School of Medicine, Department of Internal Medicine, Division of Nephrology, Marmara University, Istanbul, Turkey
| | - Fatma Alibaz Oner
- School of Medicine, Department of Internal Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Haner Direskeneli
- School of Medicine, Department of Internal Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Serhan Tuglular
- School of Medicine, Department of Internal Medicine, Division of Nephrology, Marmara University, Istanbul, Turkey
| | - Ebru Asicioglu
- School of Medicine, Department of Internal Medicine, Division of Nephrology, Marmara University, Istanbul, Turkey. .,Pendik Teaching and Training Hospital, Marmara University, Fevzi Cakmak Mah. MuhsinYazicioglu Cad. No: 10 Ust Kaynarca-Pendik, Istanbul, Turkey.
| |
Collapse
|