Relapsing polychondritis: a clinical review

An Unusual Coexistence of Progressive Pseudorheumatoid Dysplasia and Relapsing Polychondritis

Progressive pseudorheumatoid dysplasia is a rare hereditary skeletal disease characterized by bone and cartilage dysplasia, progressive arthropathy without sign of systemic or synovial inflammation. Relapsing polychondritis (RP) is a rare autoimmune disease associated with inflammation in cartilaginous and other proteoglycan rich structures. An associated autoimmune and/or hematologic disorder is seen in over 30% of patients with RP. To our knowledge, coexistence of progressive pseudorheumatoid dysplasia and RP has not been previously reported. In this article, we describe an unusual case of coexisting progressive pseudorheumatoid dysplasia with RP. Physicians should be aware of this possible association.

A Case of Relapsing Polychondritis Initiating with Unexplained Fever

Relapsing polychondritis (RP) is a rare autoimmune disease affecting the multiple organ system. Here, we describe a case of RP initially presenting with high fever. The patient was referred to our hospital for further examination of fever of unknown origin (FUO). On admission, the patient reported dry cough in addition to fever. On physical examination, her red, swollen ears were noted, attributed on histology to inflammation with auricular perichondritis. She was diagnosed with RP and treated with oral prednisone (50 mg/day); her fever and auricular inflammation resolved. The patient no longer reported cough and body temperature returned to normal and the elevated levels of C-reactive protein (CRP) were normalized. In this case, identification of the origin of fever was a challenge because of unspecific symptoms; however, awareness of the systemic manifestations of RP may lead to the prompt diagnosis and therapeutic intervention.

Relapsing polychondritis

Relapsing polychondritis (RPC) is a unique and rarely observed autoimmune condition regarded as recurrent extensive chondritis of the auricular, nasal, and tracheal cartilages. Moreover, heart, main arteries, skin, and eyes may be involved. Several forms of clinical manifestations may be seen, and the pathogenesis still remains anonymous. A concomitant disease, particularly myelodysplasia or other systemic autoimmune disease can be detected in one-third of the patients with RPC. The treatment of RPC should be considered on personal basis and classified according to disease activity and severity. This study reviews the available data on clinical manifestations, pathogenesis, diagnosis, and therapeutics of the RPC.

Granulomatous disease in the head and neck: developing a differential diagnosis

Granulomatous diseases have a varied etiology that includes autoimmune, infectious, idiopathic, and hereditary causes. The unifying factor in these diseases is the formation of granulomas, which histologically are mononuclear inflammatory cells or macrophages surrounded by lymphocytes. Granulomatous diseases often have systemic manifestations that affect organs throughout the body. Granulomatous diseases with head and neck manifestations include granulomatosis with polyangiitis, Churg-Strauss syndrome, Behçet disease, chronic granulomatous disease, and sarcoidosis. Infectious causes include tuberculosis, cat-scratch disease, syphilis, leprosy, actinomycosis, rhinoscleroma, and fungal infections. In the head and neck, granulomatous disease may affect the orbits, sinonasal cavities, salivary glands, aerodigestive tract, temporal bone, or skull base. Imaging findings include sinonasal opacification, ocular and other soft-tissue masses, osseous erosion, airway narrowing, lymphadenopathy, and salivary gland infiltration. Vascular involvement may also be evident, with displacement, narrowing, or occlusion of arteries and veins. Some radiologic findings of granulomatous processes have a considerable overlap with findings of malignancy, and a radiologic differential diagnosis inclusive of both is critical to avoid incorrect clinical treatment. Without the benefit of a prior clinical diagnosis, laboratory findings, or suggestive clinical signs and symptoms, granulomatous diseases may be difficult to differentiate radiologically. Although individual granulomatous diseases may have overlapping findings at imaging, certain radiologic findings should prompt the inclusion of granulomatous diseases in the differential diagnosis, thus facilitating appropriate clinical management.

Fatal relapsing tracheobronchial polychondritis diagnosed at autopsy

A 31-year-old woman was referred to chest clinic with an 18-month history of cough, breathlessness and weight loss. She had previously been treated unsuccessfully with bronchodilators. In clinic she was found to have vocal hoarseness and harsh, monophonic inspiratory breath sounds. A bronchoscopy was arranged, but the patient was found dead before it could be performed. A postmortem examination with histology found evidence of active and chronic inflammation as well as destruction of cartilage, in keeping with a diagnosis of relapsing tracheobronchial polychonditis.

[A case of bilateral auricular chondritis with anti-glutamate receptor (GluRε2) antibody-positive non-herpetic acute limbic encephalitis]

A 62-year-old man experienced pain and swelling in both of his auricles. One and a half months later, he was referred to us because of a memory disturbance. A neurological examination revealed disorientation and recent memory impairment. Diffusion-weighted and fluid-attenuated inversion recovery magnetic resonance images showed high intensity and swelling lesions in the bilateral medial temporal regions. In cerebrospinal fluid, mononuclear cell counts and total protein concentration were increased, but a herpes polymerase chain reaction was negative. Thus, he was suspected to have non-herpetic acute limbic encephalitis (NHALE). In addition, relapsing polychondritis (RP) was suspected because of the bilateral auricular chondritis and type-II collagen antibody positivity in the serum. He was treated with high-dose steroid therapy (two cycles of intravenous methylprednisolone, 500 mg per day for 3 days), which was followed by oral steroid therapy. With these treatments, his symptoms, including the painful auricular swelling and memory disturbance, gradually improved. This case exhibited anti-glutamate receptor (GluRε2) antibody positivity in both serum and cerebrospinal fluid, but anti-N-methyl-D-aspartate glutamate receptor antibody (NR1 + NR2) by cell-based assay negative in cerebrospinal fluid. Although a vascular mechanism of NHALE that is associated with RP has been suggested in the literature, this autoantibody might have induced NHALE as the mechanism of neuronal damage to target neuron in our case. More studies on the pathogenesis of NHALE that is associated with RP are needed.

New onset of immunoglobulin G4-related disease in a patient with relapsing polychondritis

Relapsing polychondritis (RP) is a rare systemic autoimmune disorder characterized by the episodic and progressive deterioration of cartilage inflammation. Approximately 30% patients with RP have concurrent disease. However, there have been no previous reports of RP complicated by immunoglobulin G4-related disease (IgG4-RD). Here we report the case of a 67-year-old male who developed IgG4-RD approximately 20 years after RP diagnosis. The association between IgG4-RD and RP remains unclear.

Airway involvement of relapsing polychondritis revealed by 18F-fluoride PET/CT

A 48-year-old man with progressive respiratory symptoms was suspected of having relapsing polychondritis (RPC). A 99mTc-MDP bone scintigraphy showed only mild activity in the bilateral costal cartilage. In contrast, 18F-fluoride PET/CT revealed intense radioactivity accumulation in the tracheal cartilages. Biopsy results from tracheal cartilage were consistent with a diagnosis of RPC. The patient received therapy toward RPC, and his symptoms was gradually alleviated.

Relapsing polychondritis: inflamed joints and ears

BACKGROUND

Relapsing polychondritis (RP) is an episodic and progressive inflammatory disease of the cartilaginous structures, including elastic cartilage of the ear and nose, hyaline cartilage of the peripheral joints, fibrocartilage at axial sites, and cartilage of the tracheo-bronchial tree. The spectrum of its presentations may vary from intermittent mild episodes of chondritis to occasional organ involvement or even life-threatening manifestations.

CASE REPORT

We presented a 64 year-old male patient with bilaterally knee arthritis and discoloration of pinna.

CONCLUSION

There is lack of awareness about this disease due to its rarity. With this case presentation, our goal was to draw attention to this disease, which could be delayed for the diagnosis.

Critical airway involvement in relapsing polychondritis

Relapsing polychondritis (RP) is a rare multisystem disease characterised by progressive inflammation and destruction of cartilaginous structures. Airway involvement in RP occurs in approximately 50% of cases. We present a 70-year-old woman with a diagnosis of early adult onset asthma. She required multiple hospital admissions for recurrent episodes of acute severe dyspnoea for 1 year. These were treated as asthma. Months later she developed saddle nose deformity and hoarseness of voice. CT revealed tracheal/bronchial wall thickening and luminal narrowing. Based on these findings, RP was diagnosed. Insertion of a tracheobronchial stent was necessary due to severe tracheobronchomalacia. This intervention improved the patient's dyspnoea immediately. This case is reported to raise awareness of airway involvement in RP and discuss its current management. Early diagnosis of RP is essential to allow prompt treatment and to decrease the risk of life-threatening airway collapse.

Orbital inflammatory disease in relapsing polychondritis

We present a 73-year-old Chinese male with bilateral relapsing, remitting orbital inflammatory disease associated with relapsing polychondritis. He first presented with right orbital inflammation that did not improve despite antibiotic treatment. Computer tomography (CT) of the orbits showed a soft tissue mass along the roof of the orbit, which was biopsied, revealing acute on chronic inflammation. There was complete resolution of his orbital inflammation within 2 weeks of initiating systemic steroid treatment. He subsequently developed recurrent bouts of left orbital inflammation. One year later, he was diagnosed with relapsing polychondritis and subsequently developed multiple myeloma seven years later. Comanagement with a rheumatologist will be helpful to achieve control of the disease with judicious use of immunosuppression. Long-term follow-up of the patient will be necessary to monitor for malignant transformation of the orbital lesion, as well as the development of other hematologic malignancies.

Diagnosis and classification of relapsing polychondritis

Relapsing polychondritis is a rare and potentially fatal autoimmune disease of unknown etiology, characterized by inflammation and destruction of different cartilaginous structures, including the ear, nose, larynx, trachea, bronchi, peripheral joints, eye, heart and skin, with high risk of misdiagnosis. The spectrum of clinical presentations is protean and may vary from intermittent episodes of painful and disfiguring auricular and nasal chondritis or polyarthritis to severe progressive multi-organ damage. A laryngotracheobronchial involvement appears in nearly half of patients and is complicated by local obstructions, which may be life-threatening. A highly medical specialized approach is required for diagnosis of relapsing polychondritis. This review comprehensively examines the literature related to the clinical sceneries of the disease and focuses on both diagnostic tools used in clinical studies and recent findings related to its etiopathogenesis.

Respiratory insufficiency and dynamic hyperinflation after rigid bronchoscopy in a patient with relapsing polychondritis -a case report-

Relapsing polychondritis (RP) is an uncommon disease that is characterized by inflammation and destruction of cartilaginous structures. When tracheobronchial tree is involved, respiratory obstructive symptoms can occur. A 35-year-old man, with a previous diagnosis of RP, was scheduled for rigid bronchoscopy to relieve dyspnea, caused by subglottic stenosis. After laser splitting of the subglottic web, the spontaneous respiration of the patient was insufficient, and hypercarbia developed progressively even with assisted ventilation. After 20 minutes of aggressive hyperventilation to reduce end-tidal CO₂ level, sudden extreme tachycardia and hypotension developed. Ventilation rate was reduced and prolonged expiration time was allowed to alleviate a near-tampon status from dynamic hyperinflation. After the hemodynamic status was stabilized, the patient was transferred to the ICU for mechanical ventilation. He received ICU care for 30 days, and now, he was on supportive care on a ward, considering Y stent insertion to prevent luminal collapse from tracheobronchomalacia.

A unique case of relapsing polychondritis presenting with acute pericarditis

Relapsing polychondritis (RP) is an inflammatory disease of the cartilaginous tissue primarily affecting the cartilaginous structures of the ear, nose, joints, and the respiratory system. Cardiovascular complications of RP are associated with high morbidity and mortality and occur most commonly as valvular disease. Pericarditis is a less common complication, occurring in 4% of patients with RP and has not previously been described at presentation. We describe a case of relapsing polychondritis with acute pericarditis at presentation.

MR findings in the arthropathy of relapsing polychondritis

We report a case of relapsing polychondritis involving three synovial joints in a child. Initial presentation was at 5 years of age with periorbital edema and chemosis of the conjunctiva with a definite diagnosis established at 9 years of age following an acute monoarticular arthropathy of the knee. The role of MRI in suggesting the diagnosis of relapsing polychondritis is emphasized by demonstrating a unique pattern of inflammation and enhancement that preferentially involves the perichondrium and chondroepiphysis.

Mounier-Kuhn syndrome and bilateral vocal cord paralysis

Mounier-Kuhn syndrome is a rare disorder of unknown cause that is characterized by atrophy of the elastic and smooth muscle of the tracheobronchial tree leading to tracheobronchomegaly and bronchiectasis. The syndrome is likely underdiagnosed, because the patients usually present with common respiratory symptoms such as productive cough and usually labeled as chronic obstructive pulmonary disease. Diagnosis is established on the basis of radiologic findings. Association with bilateral vocal cord paralysis has not been described. Treatment is mainly supportive. Symptomatic patients may require endobronchial stenting if airway collapse is encountered. Here, we described a patient who presented with hoarseness and pneumonia. Further studies confirmed the diagnosis of Mounier-Kuhn syndrome with bilateral vocal cord paralysis.

Clinical characteristics and treatment outcomes of patients with relapsing polychondritis with airway involvement

We investigated the clinical characteristics, management modalities, and outcomes in patients with relapsing polychondritis (RP) with airway involvement. The medical records of RP patients with airway involvement seen at Samsung Medical Center from August 2004 to December 2011 were collected. The clinical manifestations were investigated retrospectively, including rheumatologic record, diagnostic tests, treatment modalities, and clinical outcomes. Twelve patients (five females, seven males) with a median age of 48(interquartile range (IQR) 44-60) years were included. All patients had airway involvement, including the trachea (100 %), main bronchi (83 %), and larynx (25 %). Rheumatological manifestations were frequent, including inflammatory arthritis (50 %), auricular chondritis (42 %), keratoconjunctivitis (42 %), nasal chondritis (42 %), saddle nose (25 %), and sensorineural hearing loss (17 %). All patients who had acute exacerbations were treated with high-dose corticosteroids (1,000 mg per day) and were maintained on oral prednisolone (5-40 mg per day), with weekly methotrexate (2.5-15 mg per week) during follow up. One out of 12 patients required mechanical ventilation. Nine patients have survived without ventilator support and eight patients without a tracheostomy. Two patients underwent a tracheostomy with endobronchial stenting. During follow-up (median 24[IQR 7-50] months), the clinical outcome was favorable in nine patients, while three patients died of pneumonia and respiratory failure. High-doses of corticosteroids during an acute exacerbation followed by maintenance prednisolone with methotrexate could be recommended as a therapeutic option in RP patients with airway involvement. Airway intervention by an experienced clinician is sometimes required.

Anti-neutrophil cytoplasmic antibodies in rheumatoid arthritis: two case reports and review of literature

Background

Anti-neutrophil cytoplasmic antibodies are typically detected in anti-neutrophil cytoplasmic antibody associated vasculitis, but are also present in a number of chronic inflammatory non-vasculitic conditions like rheumatoid arthritis. Rare cases of granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis, a vasculitic disorder frequently associated with the presence of anti-neutrophil cytoplasmic antibodies) in patients with rheumatoid arthritis have been described in literature.

Case presentation

We report two middle-aged female patients with rheumatoid arthritis who developed anti-neutrophil cytoplasmic antibodies and symptoms reminiscent of granulomatosis with polyangiitis. Despite the lack of antibodies specific for proteinase 3 and the absence of a classical histology, we report a probable case of granulomatosis with polyangiitis in the first patient, and consider rheumatoid vasculitis in the second patient.

Conclusion

Taken together with previous reports, these cases highlight that anti-neutrophil cytoplasmic antibodies have to be evaluated very carefully in patients with rheumatoid arthritis. In this context, anti-neutrophil cytoplasmic antibodies detected by indirect immunofluorescence appear to have a low diagnostic value for granulomatosis with polyangiitis. Instead they may have prognostic value for assessing the course of rheumatoid arthritis.

Chronic non-granulomatous supraglottitis: a rare and difficult disease

OBJECTIVES

To examine chronic non-granulomatous supraglottitis, a rare disorder of uncertain aetiology with few reported cases in the literature.

CASE REPORTS

We describe two cases of chronic non-granulomatous supraglottitis that led to persistent respiratory compromise. Patients underwent extensive investigation that failed to reveal a definitive diagnosis.

CONCLUSION

In patients suffering from chronic inflammation of the supraglottic larynx without evidence of infection, neoplasm or granulomatous disease, many disorders must be ruled out in order to diagnose chronic non-granulomatous supraglottitis, which is a diagnosis of exclusion. We review the literature on this rare entity, discuss current management strategies, and suggest an algorithm for diagnostic investigation.

Updated assessment of the prevalence, spectrum and case definition of autoimmune disease

Autoimmune diseases are heterogeneous with regard to prevalence, manifestations, and pathogenesis. The classification of autoimmune diseases has varied over time. Here, we have compiled a comprehensive up-to-date list of the autoimmune diseases, and have reviewed published literature to estimate their prevalence. We identified 81 autoimmune diseases. The overall estimated prevalence is 4.5%, with 2.7% for males and 6.4% for females. For specific diseases, prevalence ranges from 1% to <1/10(6). Considering all diseases in the class, the most common mean age-of-onset was 40-50 years. This list of autoimmune diseases has also yielded information about autoantigens. Forty-five autoimmune diseases have been associated with well-defined autoantigens. Of the diseases with known autoantigens, 33.3% had highly repetitive sequences, 35.6% had coiled-coil arrangements and 57.8% were associated with cellular membranes, which means that based on these structural motifs alone, autoantigens do not appear to be a random sample of the human proteome. Finally, we identified 19 autoimmune diseases that phenocopy diseases arising from germline mutations in the corresponding autoantigen. Collectively, our findings lead to a tentative proposal for criteria for assigning autoimmune pathogenesis to a particular disease.

Steroid Responsive Parenchymal Lung Involvement and Acute Renal Failure in a Patient with Relapsing Polychondritis

Relapsing polychondritis is a multisystem disorder affecting cartilaginous structures like ear, nose, laryngotracheal tree and proteogylcan rich structures like eyes. Kidney involvement has also been reported in the absence of associated conditions like SLE and vasculitides but parenchymal lung involvement has not been reported in the English literature. One such case of relapsing polychondritis who had parenchymal lung involvement with respiratory failure, renal failue and pancytopenia is described. All these complications recovered with institution of corticosteroids.

How to cite this article

Sharma A, Kumar S, Goyal P, Law AD, Lal A, Singh S. Steroid Responsive Parenchymal Lung Involvement and Acute Renal Failure in a Patient with Relapsing Polychondritis. J Postgrad Med Edu Res 2012;46(4):198-201.

Relapsing polychondritis associated with hepatitis C virus infection

This article is aimed to review of relapsing polychondritis (RP) and its association to hepatitis C virus (HCV) infection. A case of RP associated with HCV infection in a 59-year-old male is reported. The English medical literature was reviewed for RP and its association with HCV infection. RP is a rare autoimmune and multisystem disorder of unknown etiology in which the cartilaginous and related tissues are the primary targets of inflammation. HCV infection is a more common systemic illness with known hepatic and extra-hepatic manifestations. Although RP is associated with other diseases in about 35% of cases, only one case of RP, HCV, and mixed cryoglobulinemia has been reported. We report a case of RP associated with HCV infection. Treatment with pegylated interferon and ribavirin resulted in sustained virologic response and remission of treatment-resistant RP with azathioprine. We report a case of RP and associated HCV infection. Although treatment of HCV infection resulted in remission of RP, it is unknown if there is a causal relationship between HCV infection and RP.

Papular and annular fixed urticarial eruption: a characteristic skin manifestation in patients with relapsing polychondritis

BACKGROUND

Skin manifestations of relapsing polychondritis (RP) are usually nonspecific.

OBJECTIVE

We report a series of patients with RP who presented with annular skin lesions.

METHODS

The clinical and histologic features and follow-up data of patients with RP and an annular urticarial eruption were retrospectively reviewed.

RESULTS

Ten patients (9 male, 1 female) (mean age 63.7 years) were included. All patients had tense, fixed, urticarial papules with an annular configuration predominantly located on the upper part of the trunk. Skin lesions occurred before the chondritis in 7 of 10 cases with a mean delay of 23 ± 13 months. Histologic examination consistently showed a lymphocytic vasculitis with no leukocytoclastic vasculitis, even when biopsies were repeated during the evolution (n = 7). Hematologic abnormalities were found in all cases. A myelodysplastic syndrome was found in 4 patients. Oral corticosteroids were effective in all cases, although skin lesions recurred during the decrease of corticosteroid doses in 4 cases. Five patients died during the evolution.

LIMITATION

Retrospective case series design is a limitation.

CONCLUSION

Annular and papular fixed urticarial eruption may represent a characteristic skin manifestation of RP. It is frequently associated with hematologic abnormalities and may auger a poor prognosis.

Relapsing polychondritis: a description of a case and review article

Relapsing polychondritis (RPC) is a rare autoimmune disease in which the cartilaginous tissues are the target for inflammation and destruction, the associated immune reaction causes inflammation in non-cartilaginous tissues like kidney and blood vessels. This article provides a description of a case of RPC and a review article about the disease.

Cartilage destruction is partly induced by the internal proteolytic enzymes and apoptotic phenomenon of chondrocytes in relapsing polychondritis

OBJECTIVE

We analyzed 9 cases by immunohistochemical studies in order to elucidate the mechanisms of cartilage destruction in relapsing polychondritis (RP), which often involves the external auricle and respiratory tract through immunological disorder.

METHODS

Cartilage tissues were obtained during surgical operations. Cell species in the granulation tissues, especially near the cartilage, were identified by cell-surface markers [CD3, CD4, CD8, CD20, CD45 (LCA), and CD68]. The proteolytic enzymes expressed in the cells in the perichondral granulation and in chondrocytes themselves were analyzed by immunohistochemical studies using anti-matrix metalloproteinase (MMP) -1, -3, -8, -9, and -13, and cathepsin D, K, L, and elastase antibodies. Apoptosis and nitric oxide (NO), an apoptosis-related factor, were also examined using ApopTag and antinitrotyrosine antibody, respectively.

RESULTS

Among cell species that infiltrated in perichondral granulation, LCA, CD68 (monocytes/macrophages), and CD4 cells were dominant in number; MMP-8, MMP-9, and elastase were expressed only in the perichondral granulation; whereas MMP-3 and cathepsin K and L were detected in both chondrocytes and granulations. Out of 9 cases examined, 6 revealed apoptotic cells in excess of 50% of chondrocytes. There was a strong correlation between the number of apoptotic cells and the number of MMP-3-positive (r = 0.83) and cathepsin K-positive cells (r = 0.92). Abundant NO-expressing cells were observed in the chondrocytes in degenerated cartilage, similar to apoptosis.

CONCLUSION

Cartilage destruction in polychondritis is induced not only by perichondral inflammation, but also by intrinsic factors expressed in chondrocytes themselves, including certain kinds of proteolytic enzymes and apoptosis.

Relapsing polychondritis: new therapeutic strategies with biological agents

Relapsing polychondritis (RP) is a rare disease of unknown etiology characterized by recurrent episodes of inflammation resulting in the destruction of cartilaginous tissues. We describe a young girl with RP unresponsive to conventional therapy.