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Drynda A, Padjas A, Wójcik K, Dziedzic R, Biedroń G, Wawrzycka-Adamczyk K, Włudarczyk A, Wilańska J, Musiał J, Zdrojewski Z, Czuszyńska Z, Masiak A, Majdan M, Jeleniewicz R, Augustyniak-Bartosik H, Jakuszko K, Krajewska M, Dębska-Ślizień A, Storoniak H, Bułło-Piontecka B, Tłustochowicz W, Kur-Zalewska J, Wisłowska M, Głuszko P, Madej M, Jassem E, Damps-Konstańska I, Kucharz E, Brzosko M, Milchert M, Hawrot-Kawecka A, Miłkowska-Dymanowska J, Górski P, Lewandowska-Polak A, Makowska J, Zalewska J, Zaręba L, Bazan-Socha S. Clinical Characteristics of EGPA Patients in Comparison to GPA Subgroup with Increased Blood Eosinophilia from POLVAS Registry. J Immunol Res 2024; 2024:4283928. [PMID: 38699219 PMCID: PMC11065486 DOI: 10.1155/2024/4283928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/26/2024] [Accepted: 04/06/2024] [Indexed: 05/05/2024] Open
Abstract
Objective To characterize the eosinophilic granulomatosis with polyangiitis (EGPA) population from the POLVAS registry depending on ANCA status and diagnosis onset, including their comparison with the granulomatosis with polyangiitis (GPA) subset with elevated blood eosinophilia (min. 400/μl) (GPA HE) to develop a differentiating strategy. Methods A retrospective analysis of the POLVAS registry. Results The EGPA group comprised 111 patients. The ANCA-positive subset (n = 45 [40.54%]) did not differ from the ANCA-negative one in clinics. Nevertheless, cardiovascular manifestations were more common in ANCA-negative patients than in those with anti-myeloperoxidase (MPO) antibodies (46.97% vs. 26.92%, p = 0.045). Patients diagnosed before 2012 (n = 70 [63.06%]) were younger (median 41 vs. 49 years, p < 0.01), had higher blood eosinophilia at diagnosis (median 4,946 vs. 3,200/μl, p < 0.01), and more often ear/nose/throat (ENT) and cardiovascular involvement. GPA HE comprised 42 (13.00%) out of 323 GPA cases with reported blood eosinophil count. Both GPA subsets had a lower prevalence of respiratory, cardiovascular, and neurologic manifestations but more often renal and ocular involvement than EGPA. EGPA also had cutaneous and gastrointestinal signs more often than GPA with normal blood eosinophilia (GPA NE) but not GPA HE. The model differentiating EGPA from GPA HE, using ANCA status and clinical manifestations, had an AUC of 0.92, sensitivity of 96%, and specificity of 95%. Conclusion Cardiovascular symptoms were more prevalent in the ANCA-negative subset than in the MPO-ANCA-positive one. Since EGPA and GPE HE share similarities in clinics, diagnostic misleading may result in an inappropriate therapeutic approach. Further studies are needed to optimize their differentiation and tailored therapy, including biologics.
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Affiliation(s)
- Anna Drynda
- Students' Scientific Group of Immune Diseases and Hypercoagulation, Jagiellonian University Medical College, Cracow, Poland
| | - Agnieszka Padjas
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Krzysztof Wójcik
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Radosław Dziedzic
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Grzegorz Biedroń
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | | | - Anna Włudarczyk
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Wilańska
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek Musiał
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Zbigniew Zdrojewski
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, Gdansk, Poland
| | - Zenobia Czuszyńska
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, Gdansk, Poland
| | - Anna Masiak
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, Gdansk, Poland
| | - Maria Majdan
- Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Lublin, Poland
| | - Radosław Jeleniewicz
- Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Lublin, Poland
| | | | - Katarzyna Jakuszko
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Hanna Storoniak
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Barbara Bułło-Piontecka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Witold Tłustochowicz
- Department of Internal Medicine and Rheumatology, Military Medical Institute, Warsaw, Poland
| | - Joanna Kur-Zalewska
- Department of Internal Medicine and Rheumatology, Military Medical Institute, Warsaw, Poland
| | - Małgorzata Wisłowska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Piotr Głuszko
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marta Madej
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Ewa Jassem
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | | | - Eugeniusz Kucharz
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Marek Brzosko
- Department of Rheumatology, Internal Medicine, Diabetology, Geriatrics and Clinical Immunology with the Gastroenterology Unit, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Marcin Milchert
- Department of Rheumatology, Internal Medicine, Diabetology, Geriatrics and Clinical Immunology with the Gastroenterology Unit, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Anna Hawrot-Kawecka
- Department of Internal Medicine and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Paweł Górski
- Department of Pneumology, Chair of Internal Medicine, Medical University of Lodz, Lodz, Poland
| | | | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Lodz, Poland
| | - Joanna Zalewska
- Department of Rheumatology and Connective Tissue Diseases, Ludwik Rydygier Collegium Medicum in Bydgoszcz of the Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Lech Zaręba
- Institute of Computer Science, College of Natural Sciences, University of Rzeszow, Rzeszow, Poland
| | - Stanisława Bazan-Socha
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
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Walker BS, Peterson LK, Koening C, White SK, Schmidt RL, Tebo AE. Performance of MPO-ANCA and PR3-ANCA immunoassays for the stratification of specific ANCA-associated vasculitis: A systematic review and meta-analysis. Autoimmun Rev 2022; 21:103100. [PMID: 35452854 DOI: 10.1016/j.autrev.2022.103100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the impact of myeloperoxidase (MPO) and proteinase 3 (PR3) antigen-specific immunoassays in the stratification of patients at-risk for anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) at diagnosis. METHODS A Medline search was conducted to identify diagnostic accuracy studies using PR3-ANCA or MPO-ANCA for the evaluation of granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Studies estimates were pooled using the bivariate method. RESULTS Diagnostic accuracy varied by analyte and AAV subtype. PR3-ANCA had greater sensitivity than MPO-ANCA for GPA (74% vs 11%, p < 0.001) and MPO-ANCA greater sensitivity for MPA (73% vs 7%, p < 0.001). Specificities of both MPO-ANCA and PR3-ANCA were consistently high (mean 97%, range: 93-99%) for both AAV subtypes. There was insufficient data to perform meta-analysis for the diagnostic accuracy of EPGA. CONCLUSION These results validate the use of high quality MPO-ANCA and PR3-ANCA immunoassays to screen patients at-risk for AAV as well as to categorize disease as GPA or MPA subtype. However, caution must be exercised in doing so, since some assays may not have optimal performance. Each laboratory should validate appropriate algorithms based on the tests used and testing population.
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Affiliation(s)
| | - Lisa K Peterson
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Curry Koening
- Department of Internal Medicine, Division of Rheumatology, University of Utah, Salt Lake City, UT, United States of America
| | - Sandra K White
- Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Robert L Schmidt
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America
| | - Anne E Tebo
- ARUP Laboratories, Salt Lake City, UT, United States of America; Department of Pathology, University of Utah, Salt Lake City, UT, United States of America.
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Moiseev S, Bossuyt X, Arimura Y, Blockmans D, Csernok E, Damoiseaux J, Emmi G, Flores-Suárez LF, Hellmich B, Jayne D, Jennette JC, Little MA, Mohammad AJ, Moosig F, Novikov P, Pagnoux C, Radice A, Sada KE, Segelmark M, Shoenfeld Y, Sinico RA, Specks U, Terrier B, Tzioufas AG, Vaglio A, Zhao MH, Cohen Tervaert JW. International Consensus on ANCA Testing in Eosinophilic Granulomatosis with Polyangiitis. Am J Respir Crit Care Med 2020; 202:1360-1372. [PMID: 32584187 DOI: 10.1164/rccm.202005-1628so] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
An international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in eosinophilic granulomatosis with polyangiitis (EGPA) is presented. ANCA, specific for myeloperoxidase (MPO), can be detected in 30-35% of EGPA patients. MPO-ANCA should be tested with antigen-specific immunoassays in any patient with eosinophilic asthma and clinical features suggesting EGPA, including constitutional symptoms, purpura, polyneuropathy, unexplained heart, gastrointestinal or kidney disease, and/or pulmonary infiltrates or hemorrhage. A positive MPO-ANCA result contributes to the diagnostic work‑up for EGPA. Patients with MPO-ANCA associated EGPA have more frequently vasculitis features, such as glomerulonephritis, neuropathy, and skin manifestations than patients with ANCA negative EGPA. However, the presence of MPO-ANCA is neither sensitive nor specific enough to identify whether a patient should be subclassified as having "vasculitic" or "eosinophilic" EGPA. At present, ANCA status cannot guide treatment decisions, that is, whether cyclophosphamide, rituximab or mepolizumab should be added to conventional glucocorticoid treatment. In EGPA, monitoring of ANCA is only useful when MPO-ANCA was tested positive at disease onset.
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Affiliation(s)
- Sergey Moiseev
- Sechenov First Moscow State Medical University, Tareev Clinic of Internal Diseases, Moscow, Russian Federation;
| | - Xavier Bossuyt
- KU Leuven University Hospitals Leuven, 60182, Leuven, Belgium
| | | | | | | | - Jan Damoiseaux
- Maastricht University Medical Centre+, 199236, Maastricht, Netherlands
| | - Giacomo Emmi
- University of Florence, 9300, Department of Experimental and Clinical Medicine, Firenze, Italy
| | | | - Bernhard Hellmich
- Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim-unter-Teck, Germany
| | - David Jayne
- University of Cambridge, 2152, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - J Charles Jennette
- University of North Carolina at Chapel Hill, 2331, Chapel Hill, North Carolina, United States
| | - Mark A Little
- Trinity Translational Medicine Institute, Dublin, Ireland
| | | | | | - Pavel Novikov
- Sechenov First Moscow State Medical University, Tareev Clinic of Internal Diseases, Moscow, Russian Federation
| | | | | | - Ken-Ei Sada
- Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 199491, Okayama, Japan
| | | | | | - Renato A Sinico
- Università degli Studi di Milano-Bicocca, 9305, Milano, Italy
| | | | | | | | | | - Ming-Hui Zhao
- Peking University First Hospital, 26447, Beijing, China
| | - Jan Willem Cohen Tervaert
- University of Alberta, Medicine, Edmonton, Alberta, Canada
- Maastricht University, MHeNS, Maastricht, Netherlands
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Trimethoprim-sulfamethoxazole and antineutrophil cytoplasmic antibodies-associated vasculitis. Curr Opin Rheumatol 2018; 30:388-394. [DOI: 10.1097/bor.0000000000000508] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sowa M, Hiemann R, Schierack P, Reinhold D, Conrad K, Roggenbuck D. Next-Generation Autoantibody Testing by Combination of Screening and Confirmation-the CytoBead® Technology. Clin Rev Allergy Immunol 2017; 53:87-104. [PMID: 27368807 PMCID: PMC5502073 DOI: 10.1007/s12016-016-8574-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Occurrence of autoantibodies (autoAbs) is a hallmark of autoimmune diseases, and the analysis thereof is an essential part in the diagnosis of organ-specific autoimmune and systemic autoimmune rheumatic diseases (SARD), especially connective tissue diseases (CTDs). Due to the appearance of autoAb profiles in SARD patients and the complexity of the corresponding serological diagnosis, different diagnostic strategies have been suggested for appropriate autoAb testing. Thus, evolving assay techniques and the continuous discovery of novel autoantigens have greatly influenced the development of these strategies. Antinuclear antibody (ANA) analysis by indirect immunofluorescence (IIF) on tissue and later cellular substrates was one of the first tests introduced into clinical routine and is still an indispensable tool for CTD serology. Thus, screening for ANA by IIF is recommended to be followed by confirmatory testing of positive findings employing different assay techniques. Given the continuous growth in the demand for autoAb testing, IIF has been challenged as the standard method for ANA and other autoAb analyses due to lacking automation, standardization, modern data management, and human bias in IIF pattern interpretation. To address these limitations of autoAb testing, the CytoBead® technique has been introduced recently which enables automated interpretation of cell-based IIF and quantitative autoAb multiplexing by addressable microbead immunoassays in one reaction environment. Thus, autoAb screening and confirmatory testing can be combined for the first time. The present review discusses the history of autoAb assay techniques in this context and gives an overview and outlook of the recent progress in emerging technologies.
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Affiliation(s)
- Mandy Sowa
- GA Generic Assays GmbH, Dahlewitz, Berlin, Germany
| | - Rico Hiemann
- Institute of Biotechnology, Faculty of Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Peter Schierack
- Institute of Biotechnology, Faculty of Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Dirk Reinhold
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Karsten Conrad
- Institute of Immunology, Medical Faculty, Technical University Dresden, Dresden, Germany
| | - Dirk Roggenbuck
- GA Generic Assays GmbH, Dahlewitz, Berlin, Germany.
- Institute of Biotechnology, Faculty of Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany.
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Kemna MJ, van Paassen P, Damoiseaux JG, Cohen Tervaert JW. Maintaining remission in patients with granulomatosis with polyangiitis or microscopic polyangiitis: the role of ANCA. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1281123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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7
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Abstract
Interstitial Lung Disease Program, National Jewish Medical and Research Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA The diagnosis and management of SVV remains one of the most challenging clinical scenarios encountered by a clinician. Careful attention to detail and a thorough knowledge of the specific disorders, their therapies, and complications thereof is required to optimally care for these patients. The recent completion of a number of randomized, controlled, multicenter clinical trials has greatly improved our knowledge base and ability to care for vasculitis patient. The next decade holds even more promise.
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Affiliation(s)
- S K Frankel
- Interstitial Lung Disease Program, National Jewish Medical and Research Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, Colorado 80206, USA
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Bahmer T, Romagnoli M, Girelli F, Claussen M, Rabe KF. The use of auto-antibody testing in the evaluation of interstitial lung disease (ILD) – A practical approach for the pulmonologist. Respir Med 2016; 113:80-92. [DOI: 10.1016/j.rmed.2016.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/27/2015] [Accepted: 01/28/2016] [Indexed: 11/29/2022]
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9
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Renauer P, Coit P, Sawalha AH. Epigenetics and Vasculitis: a Comprehensive Review. Clin Rev Allergy Immunol 2015; 50:357-66. [DOI: 10.1007/s12016-015-8495-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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10
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Hilhorst M, van Paassen P, Tervaert JWC. Proteinase 3-ANCA Vasculitis versus Myeloperoxidase-ANCA Vasculitis. J Am Soc Nephrol 2015; 26:2314-27. [PMID: 25956510 DOI: 10.1681/asn.2014090903] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In patients with GN or vasculitis, ANCAs are directed against proteinase 3 (PR3) or myeloperoxidase (MPO). The differences between PR3-ANCA-associated vasculitis (AAV) and MPO-AAV described in the past have been supplemented during the last decade. In this review, we discuss the differences between these two small-vessel vasculitides, focusing especially on possible etiologic and pathophysiologic differences. PR3-AAV is more common in northern parts of the world, whereas MPO-AAV is more common in southern regions of Europe, Asia, and the Pacific, with the exception of New Zealand and Australia. A genetic contribution has been extensively studied, and there is a high prevalence of the HLA-DPB1*04:01 allele in patients with PR3-AAV as opposed to patients with MPO-AAV and/or healthy controls. Histologically, MPO-AAV and PR3-AAV are similar but show qualitative differences when analyzed carefully. Clinically, both serotypes are difficult to distinguish, but quantitative differences are present. More organs are affected in PR3-AAV, whereas renal limited vasculitis occurs more often in patients with MPO-AAV. For future clinical trials, we advocate classifying patients by ANCA serotype as opposed to the traditional disease type classification.
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Affiliation(s)
- Marc Hilhorst
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Pieter van Paassen
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Jan Willem Cohen Tervaert
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands jw.cohentervaert@maastrichtuniversity
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11
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Antineutrophil cytoplasmic autoantibodies: how are they detected and what is their use for diagnosis, classification and follow-up? Clin Rev Allergy Immunol 2013; 43:211-9. [PMID: 22669754 DOI: 10.1007/s12016-012-8320-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antineutrophil cytoplasmic antibodies (ANCA) are traditionally detected by an indirect immunofluorescence technique. According to the international consensus on ANCA testing, ANCA should also be tested by antigen-specific tests for myeloperoxidase-ANCA and proteinase 3-ANCA. The direct noncompetitive enzyme-linked immunosorbent assay (ELISA) used to be the method of choice. Nowadays, these assays are called "first-generation" assays. Second-generation tests (capture ELISA) or third-generation tests (anchor ELISA) are more sensitive and specific for ANCA testing. We postulate that ANCA as detected by these newer ANCA tests may replace the need to perform indirect immunofluorescence-based assays. For classification of patients, ANCA serotype seems more important than classifying patients according to their clinical subtype, since genetics, clinical manifestations and response to therapy are more related to ANCA serotype than to clinical subtype. Detection of ANCA to monitor disease activity is still a controversial issue. Treatment based on ANCA levels is at present only experimentally performed in those patients who are treated with B-cell depletion therapy with rituximab. Future studies are needed to establish whether this way of monitoring patients is warranted.
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12
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Wilde B, Thewissen M, Damoiseaux J, Hilhorst M, van Paassen P, Witzke O, Cohen Tervaert JW. Th17 expansion in granulomatosis with polyangiitis (Wegener's): the role of disease activity, immune regulation and therapy. Arthritis Res Ther 2012; 14:R227. [PMID: 23079279 PMCID: PMC3580538 DOI: 10.1186/ar4066] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 08/28/2012] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In autoimmune diseases, IL-17 producing T-cells (Th17), a pro-inflammatory subset of T-cells, are pathophysiologically involved. There is little knowledge on the role of Th17 cells in granulomatosis with polyangiitis (GPA). In the present study, we investigated Th17 cells, Tregs and subsets of circulating Th17 cells in GPA and related results to disease activity. METHODS 42 GPA patients in remission, 18 with active disease and 14 healthy controls (HC) were enrolled. Th17 cells, their subsets and regulatory T-cells were determined by intracellular fluorescence activated cell sorter (FACS). Data are given as mean percentage ±SD of total T-helper-cells. RESULTS Th17 cells are expanded in active and quiescent GPA as compared to HC (1.7±1.4% vs. 0.7 ±0.3%, P = 0.006 and 1.9 ±1.5% vs. 0.7 ±0.3%, P<0.0001). Th17 expansion is stable over time and does not decline when remission is achieved. However, a negative association of Th17 cells and steroid dosage is observed (r=-0.46, P = 0.002). The Th17 expansion was not balanced by Tregs as indicated by skewed Th17/Treg ratios in active and quiescent GPA. Th17 subsets co-producing IFNγ or IL-10 are significantly increased in GPA. GPA patients in remission not receiving maintenance therapy have significantly more IL-10/IL-17A double positive T-cells than HC (0.0501 ±0.031% vs. 0.0282 ±0.016%, P = 0.007). CONCLUSIONS We provide evidence for a persistent, unbalanced expansion of Th17 cells and Th17 subsets which seems to be independent of disease activity. Maintenance therapy reduces -but does not normalize- Th17 expansion.
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Yunt ZX, Frankel SK, Brown KK. Diagnosis and management of pulmonary vasculitis. Ther Adv Respir Dis 2012; 6:375-90. [DOI: 10.1177/1753465812454693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The pulmonary vasculitides are a heterogeneous group of disorders characterized pathologically by vascular destruction with cellular inflammation and necrosis. These disorders can affect small, medium, and large vessels and may be primary or occur secondary to a variety of conditions. Vasculitis involving the lungs is most commonly due to primary, idiopathic, small-vessel antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, which includes granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), Churg–Strauss syndrome, and microscopic polyangiitis. From a clinical perspective these remain among the most challenging of diseases both in terms of diagnosis and treatment. This review will focus on diagnosis and management of ANCA-associated vasculitides.
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Affiliation(s)
- Zulma X. Yunt
- National Jewish Health, A542, 1400 Jackson Street, Denver, CO 80206, USA
| | - Stephen K. Frankel
- Division of Pulmonary Medicine, Department of Medicine, National Jewish Health, and Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, CO, USA
| | - Kevin K. Brown
- Division of Pulmonary Medicine, Department of Medicine, National Jewish Health, and Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, CO, USA
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14
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Abstract
The pulmonary vasculitides are a rare group of heterogeneous disorders unified by the histopathologic finding of inflammation and destruction of the blood vessel wall. Diagnosis of these disorders is exceptionally challenging, given their highly variable clinical presentation, their relative rarity, and the overlap of the signs and symptoms of vasculitis with much more common entities. However, advances in the management of vasculitis allow for accurate diagnosis, risk stratification in the individual patient, and the implementation of evidence-based, effective pharmacologic therapies. This concise clinical review addresses the diagnosis and management of the patient with pulmonary vasculitis and provides an up-to-date review of the state of the field.
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Affiliation(s)
- Stephen K Frankel
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.
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Wiik A. Clinical and pathophysiological significance of anti-neutrophil cytoplasmic autoantibodies in vasculitis syndromes. Mod Rheumatol 2010; 19:590-9. [PMID: 19730973 DOI: 10.1007/s10165-009-0219-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 07/28/2009] [Indexed: 11/28/2022]
Abstract
Necrotizing vasculitis of small blood vessels is a rare condition, but when it affects important organs it can lead to life-threatening organ damage and death. Thus, recognizing these conditions at an early stage before they spread to become systemic is a constant challenge to clinical medicine. The objectives of this review are: to give advice on clinical indications for ANCA diagnostics and laboratory procedures for highly specifically detecting the most important ANCA; to provide some data on the autoantigens involved in ANCA reactivity in small vessel vasculitides; and to discuss at the occurrence of ANCA in different vasculitic populations and at different stages of disease. One important task for the near future will be to standardize the assays used for ANCA detection/quantification and to harmonize the results given to clinicians by ensuring that international reference reagents are used by laboratories and the diagnostic industry. Finally, the author has attempted to summarize the role that ANCA are currently believed to play in the immuno-inflammatory events that take place in tissues and that affect small vessels in idiopathic vasculitis. The review concludes that the presence of ANCA is likely to become an important criterion for diagnosing idiopathic small vessel vasculitis.
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Affiliation(s)
- Allan Wiik
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S, Denmark.
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COHEN TERVAERT JANWILLEM, DAMOISEAUX JAN. Fifty years of antineutrophil cytoplasmic antibodies (ANCA) testing: do we need to revise the international consensus statement on testing and reporting on ANCA? APMIS 2009:55-9. [DOI: 10.1111/j.1600-0463.2009.02478.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kelley JM, Edberg JC, Kimberly RP. Wegener's granulomatosis: a model of auto-antibodies in mucosal autoimmunity. Clin Immunol 2009; 134:104-12. [PMID: 19482554 DOI: 10.1016/j.clim.2009.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 04/30/2009] [Indexed: 10/20/2022]
Abstract
Wegener's granulomatosis (WG) is an autoimmune condition marked by vasculitis of small and medium sized vessels particularly affecting the upper respiratory tract and kidneys. There is a strong mucosal component similar to other autoimmune conditions such as systemic lupus erythematosus and Behçet's disease. While the pathogenesis of WG is not completely known, auto-antibodies such as IgG ANCAs have been implicated in endovascular damage and modulation of neutrophil/monocyte responses by Fc receptor (FcR) signaling. Due to the substantial mucosal involvement in WG (oral, nasal, and upper respiratory tract involvement), it is probable that IgA antibodies (perhaps IgA ANCAs) play a role in disease. Given discrepancies in associating ANCA levels with disease activity, future work should determine if IgA ANCAs are present in WG patients and examine the biology underlying the ANCAs' signaling partners--the FcRs.
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Affiliation(s)
- James M Kelley
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, USA
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Comfere NI, Macaron NC, Gibson LE. Cutaneous manifestations of Wegener?s granulomatosis: a clinicopathologic study of 17 patients and correlation to antineutrophil cytoplasmic antibody status. J Cutan Pathol 2007; 34:739-47. [PMID: 17880578 DOI: 10.1111/j.1600-0560.2006.00699.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Wegener's granulomatosis (WG), a systemic vasculitis, can be associated with cutaneous signs and symptoms before, during or after the diagnosis of systemic disease. METHODS We reviewed clinical and histologic features of cutaneous lesions from 17 patients with WG. The temporal relationship between development of cutaneous symptoms and onset of systemic disease was determined, and antineutrophil cytoplasmic antibody (ANCA) status of the patients was also established. RESULTS In six patients, systemic and cutaneous disease developed concurrently. In eight patients, cutaneous disease developed after patients received the diagnosis of systemic disease. In three patients, cutaneous disease preceded systemic disease. Cytoplasmic ANCA or proteinase-3-ANCA [c-ANCA/proteinase 3 (PR3)-ANCA] serologic test results were negative for one patient when cutaneous disease developed, and one patient had c-ANCA/PR3-ANCA seroconversion a year before systemic disease developed. Histopathologic features of cutaneous WG were not limited to leukocytoclastic vasculitis; they also included acneiform perifollicular and dermal granulomatous inflammation and palisaded neutrophilic and granulomatous inflammation. CONCLUSIONS Patients with WG can present initially with cutaneous symptoms. Histopathologic patterns vary, but leukocytoclastic vasculitis is most commonly noted. Patients with WG and skin lesions are likely to have positive c-ANCA/PR3-ANCA serologic test results.
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Affiliation(s)
- Nneka I Comfere
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Tamiya H, Tani K, Miyata J, Sato K, Urata T, Lkhagvaa B, Otsuka S, Shigekiyo S, Sone S. Defensins- and cathepsin G-ANCA in systemic lupus erythematosus. Rheumatol Int 2006; 27:147-52. [PMID: 16900373 DOI: 10.1007/s00296-006-0173-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 07/08/2006] [Indexed: 01/27/2023]
Abstract
In this study, we examined the content of antineutrophil cytoplasmic antibodies (ANCA) against defensins and cathepsin G in sera from systemic lupus erythematosus (SLE) patients and their significance in estimating the activity of SLE. Defensins- and cathepsin G-ANCA in sera from 28 patients with SLE, eight patients with rheumatoid arthritis (RA) and eight patients with microscopic polyangitis (mPA) were measured by ELISA. Significantly increased defensins- and cathepsin G-ANCA were found in sera of patients with SLE and mPA when compared with the value of normal controls. Though significantly higher defensins- and cathepsin G-ANCA were detected in both active and inactive SLE patients, the value in active SLE patients was significantly higher than inactive SLE patients. After the therapy with high dose of prednisolone, the serum level of defensins- and cathepsin G-ANCA was decreased, and this decrease was sustained for at least 16 weeks. This study suggests that defensins- and cathepsin G-ANCA may serve as useful markers of the disease activity of SLE.
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Affiliation(s)
- Hiroyuki Tamiya
- Department of Internal Medicine and Molecular Therapeutics, Institute of Health Biosciences, The University of Tokushima Graduate School, 18-15 Kuramoto-cho3, Tokushima, 770-8503, Japan
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Kokolina E, Alexopoulos E, Dimitriadis C, Vainas A, Giamalis P, Papagianni A, Ekonomidou D, Memmos D. Immunosuppressive therapy and clinical evolution in forty-nine patients with antineutrophil cytoplasmic antibody-associated glomerulonephritis. Ann N Y Acad Sci 2006; 1051:597-605. [PMID: 16127000 DOI: 10.1196/annals.1361.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Immunosuppressive therapy and clinical evolution were studied in 49 patients (29 females) with antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis. The mean age of patients at presentation was 55 years, and the mean (+/-SD) follow-up was 43 months (+/-33) (range, 3-140). Among the 49 patients, 10 had biopsy-proven Wegener's granulomatosis, 33 microscopic polyangiitis, 2 Churg-Strauss syndrome, and 4 idiopathic crescentic glomerulonephritis. IgG ANCA autoantibodies were detected in all patients. Induction therapy included pulses and oral administration of methylprednisolone (MP) with oral administration of cyclophosphamide (CP) and plasma exchange in patients with alveolar hemorrhage and serum creatinine (SCr) levels >/= 6 mg/dL. CP was converted to azathioprine (AZA) or mycophenolate mofetil (MMF) after 3-6 months of therapy. Low doses of MP with or without AZA or MMF were administered until the end of follow-up. Therapy institution resulted in remission of disease in all patients. The mean SCr levels decreased from 4.9 mg/dL (+/-2.5) at the onset of the disease to 2.8 mg/dL (+/-1.7) (P > 0.0001), and 3.2 mg/dL (+/-2.3) (P > 0.0001) after 3 and 6 months, respectively. At the end of follow-up, 17 (35%) patients progressed to end-stage renal disease after 34 months (+/-29) (range, 3-98), and 30 (61%) patients maintained sufficient renal function. Two patient deaths were attributed to immunosuppression. Patients with high SCr levels at diagnosis and severe interstitial fibrosis found in renal biopsy had poor renal outcome (P > 0.01 and P > 0.02, respectively). Induction therapy with MP and CP seems to be the regimen of choice in patients with ANCA-associated glomerulonephritis. Early diagnosis and therapy institution as well as long-term treatment lead to acceptable renal survival.
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Affiliation(s)
- E Kokolina
- Department of Nephrology, Aristotle University, Hippokration General Hospital, 13 Kath Rossidou Str., 54655-Thessaloniki, Greece.
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Nakamura N, Yaegaki M, Sugawara T, Shirato KI, Kumasaka R, Nakamura M, Shimada M, Fujita T, Murakami R, Osawa H, Yamabe H, Okumura K. Acute Tubulointerstitial Nephritis with Antineutrophil Cytoplasmic Antibody. Int J Organ Transplant Med 2006. [DOI: 10.1016/s1561-5413(09)60227-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Frankel SK, Cosgrove GP, Fischer A, Meehan RT, Brown KK. Update in the Diagnosis and Management of Pulmonary Vasculitis. Chest 2006; 129:452-465. [PMID: 16478866 DOI: 10.1378/chest.129.2.452] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The term vasculitis encompasses a number of distinct clinicopathologic disease entities, each of which is characterized pathologically by cellular inflammation and destruction of the blood vessel wall, and clinically by the types and locations of the affected vessels. While multiple classification schemes have been proposed to categorize and simplify the approach to these diseases, ultimately their diagnosis rests on the identification of particular patterns of clinical, radiologic, laboratory, and pathologic features. While lung involvement is most commonly seen with the primary idiopathic, small-vessel or antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides of Wegener granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome, one should remember that medium-vessel vasculitis (ie, classic polyarteritis nodosa), large-vessel vasculitis (ie, Takayasu arteritis), primary immune complex-mediated vasculitis (ie, Goodpasture syndrome), and secondary vasculitis (ie, systemic lupus erythematosus) can all affect the lung. However, for the purpose of this review, we will focus on the ANCA-associated vasculitides.
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Affiliation(s)
- Stephen K Frankel
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Gregory P Cosgrove
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Aryeh Fischer
- Division of Rheumatology, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Richard T Meehan
- Division of Rheumatology, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO.
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Sais G, Vidaller A. Role of direct immunofluorescence test in cutaneous leukocytoclastic vasculitis. Int J Dermatol 2005; 44:970-1; author reply 971. [PMID: 16336539 DOI: 10.1111/j.1365-4632.2004.02462.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sinico RA, Di Toma L, Maggiore U, Bottero P, Radice A, Tosoni C, Grasselli C, Pavone L, Gregorini G, Monti S, Frassi M, Vecchio F, Corace C, Venegoni E, Buzio C. Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. ACTA ACUST UNITED AC 2005; 52:2926-35. [PMID: 16142760 DOI: 10.1002/art.21250] [Citation(s) in RCA: 395] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Churg-Strauss syndrome (CSS) is classified among the so-called antineutrophil cytoplasmic antibody-associated systemic vasculitides (AASVs) because of its clinicopathologic features that overlap with the other AASVs. However, while antineutrophil cytoplasmic antibodies (ANCAs) are consistently found in 75-95% of patients with Wegener's granulomatosis or microscopic polyangiitis, their prevalence in CSS varies widely and their clinical significance remains uncertain. We undertook this study to examine the prevalence and antigen specificity of ANCAs in a large cohort of patients with CSS. Moreover, we evaluated the relationship between ANCA positivity and clinicopathologic features. METHODS Immunofluorescence and enzyme-linked immunosorbent assay were used to determine the presence or absence of ANCAs in 93 consecutive patients at the time of diagnosis. The main clinical and pathologic data, obtained by retrospective analysis, were correlated with ANCA status. RESULTS ANCAs were present by immunofluorescence in 35 of 93 patients (37.6%). A perinuclear ANCA (pANCA) pattern was found in 26 of 35 patients (74.3%), with specificity for myeloperoxidase (MPO) in 24 patients, while a cytoplasmic ANCA pattern, with specificity for proteinase 3, was found in 3 of 35 patients (8.6%). Atypical patterns were found in 6 of 30 patients with anti-MPO antibodies (20.0%). ANCA positivity was associated with higher prevalences of renal disease (51.4% versus 12.1%; P < 0.001) and pulmonary hemorrhage (20.0% versus 0.0%; P = 0.001) and, to a lesser extent, with other organ system manifestations (purpura and mononeuritis multiplex), but with lower frequencies of lung disease (34.3% versus 60.3%; P = 0.019) and heart disease (5.7% versus 22.4%; P = 0.042). CONCLUSION ANCAs are present in approximately 40% of patients with CSS. A pANCA pattern with specificity for MPO is found in most ANCA-positive patients. ANCA positivity is mainly associated with glomerular and alveolar capillaritis.
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Affiliation(s)
- Renato A Sinico
- Dipartimento di Nefrologia e Immunologia, Azienda Ospedaliera Ospedale San Carlo Borromeo, Milan, Italy.
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Samarkos M, Loizou S, Vaiopoulos G, Davies KA. The Clinical Spectrum of Primary Renal Vasculitis. Semin Arthritis Rheum 2005; 35:95-111. [PMID: 16194695 DOI: 10.1016/j.semarthrit.2005.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The vasculitides are potentially severe and often difficult to diagnose syndromes. Many forms of vasculitis may involve the kidneys. This review will focus on the clinical and histopathological aspects of renal involvement in the systemic vasculitides. METHODS We searched the MEDLINE database using as key terms the MeSH terms and textwords for different forms of vasculitis and for renal involvement, creating a database of more than 2200 relevant references. RESULTS The frequency of renal involvement in vasculitis varies among different syndromes. It is more frequent in Wegener's granulomatosis and microscopic polyarteritis, while it is uncommon to rare in other forms of vasculitis such as Behçet's disease and relapsing polychondritis. The vessels affected include the renal artery in Takayasu arteritis, medium-size renal parenchymal artery in classic polyarteritis nodosa, and glomerular involvement in Wegener's granulomatosis and microscopic polyarteritis. The clinical expression of renal vasculitis depends on the size of the affected vessels and includes renovascular hypertension, isolated nonnephrotic proteinuria, interstitial nephritis, and glomerulonephritis, which can be rapidly progressive. Diagnosis is established by a combination of history, clinical manifestations, laboratory findings (eg, urine sediment, urine protein, antineutrophil cytoplasmic antibodies), imaging techniques (renal angiography, especially when there is a suspicion of medium-to-large vessel disease, and chest radiograph), and finally, renal biopsy. Prognosis varies from unfavorable in the rapidly progressive glomerulonephritis of microscopic polyarteritis, which can lead to renal failure, chronic dialysis, and renal transplantation, to benign, as in the case of Henoch Schonlein purpura, in which the majority of patients recover. CONCLUSIONS The manifestations and prognosis of renal vasculitis range widely. Renal involvement greatly influences prognosis and dictates the need for early and prompt immunosuppressive therapy. Thus, the clinician should be alert for the timely diagnosis and treatment of renal vasculitis.
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Affiliation(s)
- Michael Samarkos
- 5th Department of Internal Medicine, Evangelismos Hospital, Athens, Greece.
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Gibson LE, Hairston BR, Belt RJ, el-Azhary R. Destructive facial T-cell lymphoma: the difficulty in diagnosis of pyoderma-like processes. Int J Dermatol 2005; 44:579-83. [PMID: 15985028 DOI: 10.1111/j.1365-4632.2004.02035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Lawrence E Gibson
- Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Slot MC, Links TP, Stegeman CA, Tervaert JWC. Occurrence of antineutrophil cytoplasmic antibodies and associated vasculitis in patients with hyperthyroidism treated with antithyroid drugs: A long-term followup study. ACTA ACUST UNITED AC 2005; 53:108-13. [PMID: 15696557 DOI: 10.1002/art.20927] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To test whether antineutrophil cytoplasmic antibodies (ANCA) and ANCA-associated vasculitis (AAV) are not only induced during treatment with antithyroid drugs, but can also become evident when medication has been ceased, possibly after years. METHODS Patients who visited our hospital for the treatment of hyperthyroidism were included (n = 207). Treatment consisted of antithyroid medications, radioactive iodide, thyroidectomy, or a combination of these treatment options. Patients were retested 3-6 years later to evaluate long-term effects of antithyroid drugs. Patients were tested for the presence of ANCA and, if positive, evaluated for the presence of AAV. RESULTS Of 209 patients with hyperthyroidism, 12 patients (6%) were positive for myeloperoxidase- (MPO-), proteinase 3-, or human leukocyte elastase-ANCA. Seventy-seven of 209 patients were retested; 1 patient who had not been treated with antithyroid drugs had developed MPO-ANCA. In 3 of 6 patients previously positive, ANCA could still be detected. The presence of ANCA was highly associated with treatment with antithyroid drugs (odds ratio 11.8 [95% confidence interval 1.5-93.3]). Of 13 patients with a positive ANCA result on enzyme-linked immunosorbent assay, AAV with glomerulonephritis was diagnosed in 4 (31%). CONCLUSION The presence of ANCA with or without vasculitis is associated with previous treatment with antithyroid drugs, possibly after years.
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Affiliation(s)
- Marjan C Slot
- University Hospital Groningen, Groningen, The Netherlands.
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Ando Y, Okada F, Matsumoto S, Mori H. Thoracic Manifestation of Myeloperoxidase-Antineutrophil Cytoplasmic Antibody (MPO-ANCA)-Related Disease. J Comput Assist Tomogr 2004; 28:710-6. [PMID: 15480049 DOI: 10.1097/01.rct.0000135280.79012.c7] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the pulmonary CT findings of patients with serum evidence of the myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). METHODS The pulmonary CT scans of 62 patients with serum evidence of MPO-ANCA (51 with microscopic polyangiitis, 11 with Churg-Strauss syndrome) were retrospectively assessed with regard to parenchymal, pleural, and mediastinal abnormalities. RESULTS On the CT scans, abnormal findings were seen in 51 of the patients (82%, n = 62). Of the patients, the CT findings consisted of ground-glass attenuation in 48 of the patients (94%, n = 51), consolidation in 40 (78%), and thickening of bronchovascular bundles in 26 (51%). Pathologically, these findings corresponded to alveolar hemorrhages, interstitial chronic inflammation in the alveolar septa, vasculitis, or fibrosis. These abnormalities were predominantly seen in peripheral lung parenchyma (n = 37). CONCLUSION The CT findings in patients with MPO-ANCA consisted mainly of ground-glass attenuation and consolidation in the peripheral lung. These findings, although nonspecific, are considered as pulmonary involvement in patients with MPO-ANCA.
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Affiliation(s)
- Yumiko Ando
- Department of Academic Radiology, Oita University Faculty of Medicine, Idaigaoka, Hasama-machi, Oita 879-5593, Japan.
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Takagi D, Nakamaru Y, Maguchi S, Furuta Y, Fukuda S. Clinical features of bilateral progressive hearing loss associated with myeloperoxidase-antineutrophil cytoplasmic antibody. Ann Otol Rhinol Laryngol 2004; 113:388-93. [PMID: 15174767 DOI: 10.1177/000348940411300509] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this study, we analyzed the clinical features, diagnostic criteria, treatment, and outcome of atypical bilateral progressive hearing loss associated with myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). The evaluation was made by audiogram and laboratory data in 6 cases treated at Hokkaido University Hospital. We measured MPO-ANCA by enzyme-linked immunosorbent assay; the result was positive in all cases. The hearing loss developed bilaterally and progressed to total deafness within several weeks. The onset of hearing loss was not simultaneous in the 2 ears. Methylprednisolone pulse therapy was effective in 9 ears. Three ears showed no improvement; 2 of the 3 ears had already exhibited total deafness at the first visit. After the treatment, the titer of MPO-ANCA decreased in all patients. The level of MPO-ANCA should be tested in patients with bilateral progressive hearing loss of unknown origin and can be used as a marker of the disease's activity.
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Affiliation(s)
- Dai Takagi
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Tur BS, Süldür N, Ataman S, Tutkak H, Atay MB, Düzgün N. Anti-neutrophil cytoplasmic antibodies in patients with rheumatoid arthritis: clinical, biological, and radiological correlations. Joint Bone Spine 2004; 71:198-202. [PMID: 15182790 DOI: 10.1016/j.jbspin.2003.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2003] [Accepted: 04/23/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and the associations of anti-neutrophil cytoplasmic antibodies (ANCA) and subtypes with clinical, biological, and radiological findings in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS This is a transversal study of 85 patients with RA (followed in Ibn-i Sina Hospital, Ankara University School of Medicine) with disease duration of 8.7 +/- 6.4 years. Besides clinical, biological, and radiological disease activity parameters, ANCA and ANCA against myeloperoxidase (MPO) and proteinase 3 (PR3) were examined. RESULTS The prevalence of ANCA, perinuclear ANCA (p-ANCA) and atypical ANCA (a-ANCA) were 18% (15/85 patients), 6% and 12%, respectively. Anti-MPO was found in six patients while anti-PR3 was not found. No significant association could be found between clinical, biological, and radiological disease activity assessments and ANCA (including indirect immunoflorescence subtypes). Similarly, ANCA were not associated with features suggestive of underlying vasculitis (noticed in 11/85 patients), and/or other extra-articular features. CONCLUSIONS Our results confirm that ANCA of various specificities (mainly a-ANCA) occur in a minority of RA. However, those ANCA were not associated with more severe RA, including the 6/85 patients positive for MPO (who were all free from vasculitis). The over-representation in RA sera of a-ANCA, as compared to p-ANCA, should be further studied.
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Affiliation(s)
- Birkan Sonel Tur
- Department of Physical Medicine and Rehabilitation, Ankara University School of Medicine, Ankara, Turkey.
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Stone JH, Talor M, Stebbing J, Uhlfelder ML, Rose NR, Carson KA, Hellmann DB, Burek CL. Test characteristics of immunofluorescence and ELISA tests in 856 consecutive patients with possible ANCA-associated conditions. ACTA ACUST UNITED AC 2003; 13:424-34. [PMID: 14635320 DOI: 10.1002/1529-0131(200012)13:6<424::aid-art14>3.0.co;2-q] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the test characteristics of immunofluorescence (IF) and enzyme-linked immunosorbent assays (ELISA) in a consecutive series of patients under evaluation for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS Using stored sera, we performed a cross-sectional study on 856 consecutive patients tested prospectively for ANCA by IF, Based on guidelines from the 1994 Chapel Hill Consensus Conference (CHCC), we determined each patient's underlying diagnosis by a medical records review without regard to their ANCA status (the CHCC guidelines do not require ANCA as a prerequisite for diagnosis). We grouped patients with forms of vasculitis commonly associated with ANCA into one of 4 types of AAV: Wegener's granulomatosis (n = 45), microscopic polyangiitis (n = 12), Churg-Strauss syndrome (n = 4), and pauci-immune glomerulonephritis (n = 8). We also classified patients without clinical evidence of AAV (92% of all patients tested) into 5 predefined categories of disease (including "other") and an additional category for no identifiable disease. In a blinded fashion, we then performed ELISAs on the stored serum for antibodies to proteinase-3 (PR3) and myeloperoxidase (MPO) and calculated the test characteristics for both ANCA assay techniques. RESULTS Sixty-nine of the 856 patients (8.1%) had clinical diagnoses of AAV based on CHCC guidelines. The positive predictive value (PPV) of ELISA for AAV was superior to that of IF, 83% versus 45%. For patients with both positive IF tests and positive ELISA tests, the PPV increased to 88%. Both IF and ELISA had high negative predictive values (97% and 96%, respectively). Positive ELISA tests were associated with higher likelihood ratios (LR) than IF (54.2 [95% CI = 26.3, 111.5] versus 9.4 [95% CI = 6.9, 12.7]). The LR of both a positive IF and a positive ELISA was 82.1 (95% CI = 33.3, 202.5). CONCLUSIONS Compared with IF, an ELISA test fo ANCA was associated with a substantially higher PPV and LR for AAV. This fact, combined with the greater sensitivity of IF, suggests that an effective testing strategy is to perform ELISA tests only on samples that are positive for ANCA by IF.
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Affiliation(s)
- J H Stone
- Department of Medicine, Johns Hopkins University Vasculitis Center, 1830 E. Monument Street, Suite 7500, Baltimore, MD 21205, USA
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Affiliation(s)
- Lawrence E Gibson
- Division of Laboratory Dermatology, Department of Laboratory Medicine and Pathology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Wiik A. Autoantibodies in vasculitis. Arthritis Res Ther 2003; 5:147-52. [PMID: 12723981 PMCID: PMC165052 DOI: 10.1186/ar758] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2003] [Revised: 03/05/2003] [Accepted: 03/14/2003] [Indexed: 11/10/2022] Open
Abstract
Before the mid-1980s the only autoantibody widely used to assist in diagnosing vasculitic disease was IgG antibody to the alpha(3) domain of the noncollagenous part of type IV collagen (anti-glomerular basement membrane). Since that time, antineutrophil cytoplasmic antibodies (ANCAs) directed at the azurophilic granule proteins proteinase-3 and myeloperoxidase have been established as clinically useful autoantibodies to support a diagnosis of Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and limited forms of these primary, small vessel necrotizing and often granulomatous vasculitides. The establishment of standardized methods for identifying those antibodies was needed before they could be used in clinical practice. The levels of both types of ANCAs tend to increase in parallel with the degree of clinical disease activity, and they decrease with successful immunosuppressive therapy. More than one assay may have to be used to discover imminent exacerbations in proteinase-3-ANCA associated syndromes. Although autoantibodies to endothelial cells may be important players in the pathogenesis of several vasculitic conditions, they have not gained clinical popularity because of lack of standardized detection methods.
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Affiliation(s)
- Allan Wiik
- Department of Autoimmunology, Statens Serum Institut, Copenhagen, Denmark.
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Frankel SK, Sullivan EJ, Brown KK. Vasculitis: Wegener granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa, and Takayasu arteritis. Crit Care Clin 2002; 18:855-79. [PMID: 12418444 DOI: 10.1016/s0749-0704(02)00031-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Identification, diagnosis, and management of the primary vasculitides and their attendant complications is a challenging task for the critical care physician. However, with appropriate therapy, the morbidity and mortality of these diseases can be markedly improved and allow the individual patient to return to their previous functional state.
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Affiliation(s)
- Stephen K Frankel
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO 80206, USA
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Popa ER, Franssen CFM, Limburg PC, Huitema MG, Kallenberg CGM, Tervaert JWC. In vitro cytokine production and proliferation of T cells from patients with anti-proteinase 3- and antimyeloperoxidase-associated vasculitis, in response to proteinase 3 and myeloperoxidase. ARTHRITIS AND RHEUMATISM 2002; 46:1894-904. [PMID: 12124874 DOI: 10.1002/art.10384] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate in vitro proliferative responses of CD4+ T cells and generation of specific cytokines induced by stimulation of peripheral blood mononuclear cells (PBMCs) from patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis with the autoantigens proteinase 3 (PR3) and myeloperoxidase (MPO). METHODS PBMCs from vasculitis patients with PR3 ANCA or MPO ANCA and from healthy controls were stimulated for 7 days with PR3, MPO, or control stimuli. Proliferation of CD4+ T cells was assessed by flow cytometry, using the proliferation marker Ki-67. Levels of the pro-proliferative cytokines interleukin-2 (IL-2) and IL-6 and of the Th1 and Th2 cytokines interferon-gamma (IFN gamma) and IL-10 in culture supernatants were determined. RESULTS PR3 and MPO induced proliferative responses in CD4+ T cells from individual patients with ANCA-associated vasculitides and healthy controls in vitro. Neither PR3 nor MPO elicited significant IL-2 production. Levels of IL-6 were highest after stimulation with PR3 but low after stimulation with MPO, independent of study group. Stimulation with PR3, and to a lesser extent with MPO, induced a Th2 cytokine milieu, characterized by high production of IL-6 and IL-10 and low production of IFN gamma in patients and controls. CONCLUSION PR3 and MPO promote proliferation of CD4+ T cells from patients with ANCA-associated vasculitides, but also cross-stimulate T cells from healthy individuals. Strong IL-10 production elicited by PR3 in vitro may act as an inhibitory signal for T cell proliferation and may have an important immunoregulatory function in vivo.
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Affiliation(s)
- E R Popa
- Department of Clinical Immunology, University Hospital Groningen, Groningen, The Netherlands.
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Russell KA, Wiegert E, Schroeder DR, Homburger HA, Specks U. Detection of anti-neutrophil cytoplasmic antibodies under actual clinical testing conditions. Clin Immunol 2002; 103:196-203. [PMID: 12027425 DOI: 10.1006/clim.2001.5200] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) are a useful diagnostic tool for Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA). To maximize diagnostic utility, current guidelines recommend dual testing by standard indirect immunofluorescence (IIF) and target antigen-specific assays. Most published data come from specialized research laboratories, not reflecting the performance of assays under routine clinical conditions. Therefore, we compared the performance of standard IIF, PR3-, and MPO-ANCA-specific direct ELISA, and a PR3-ANCA-specific capture ELISA used alone and in combination under routine clinical conditions. Consecutive serum samples (615) submitted for routine ANCA testing over a 10-month period were assayed. Diagnoses were WG/MPA (n = 86), other autoimmune disease (n = 118), and various others (n = 411). The combination of PR3-ANCA and MPO-ANCA ELISA had the highest sensitivity (72.1%), and C-ANCA determination using IIF, the highest specificity (99.6%). While maintaining maximal diagnostic accuracy, significant labor savings are achieved by screening for WG/MPA by ELISA followed by confirmatory IIF.
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Affiliation(s)
- Kimberly A Russell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Abstract
Classic polyarteritis nodosa (PAN) is a segmentary leucocytoclastic vasculitis that affects small- and medium-sized arteries. In 1931, Lindberg (Acta Med Scand 1931; 76: 183-225) described the existence of a cutaneous variant of PAN, without visceral involvement and with a more favourable prognosis. We present four patients diagnosed with cutaneous PAN in our hospital between 1987 and 1998. The study group was composed of three women and one child, whose ages ranged from 11 to 70 years old. The follow-up period was between 2 and 13 years. Each patient was submitted for an initial clinical, histological and laboratory evaluation and subsequent follow-up. The presence of nodules was the most frequent cutaneous lesion, preferentially located in the lower limbs. The erythrocyte sedimentation rate was the only parameter that was altered in all patients. Cutaneous biopsies from all patients showed a segmentary leucocytoclastic vasculitis in the arteries of the deep dermis and/or hypodermis. Direct immunofluorescence was positive in just one patient. No visceral involvement was found in any patient. There is confusion about the correct definition of cutaneous PAN. Some clinical findings, such as nodules or livedo reticularis, typical of cutaneous PAN suggest a good prognosis; however, we consider that it is necessary to evaluate these patients for systemic involvement for the possibility of arteritis in other organs as the term polyarteritis suggests.
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Affiliation(s)
- A Bauzá
- Department of Dermatology, University Clinic of Navarra, School of Medicine, Pamplona, Spain
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40
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Wiik AS. Clinical use of serological tests for antineutrophil cytoplasmic antibodies. What do the studies say? Rheum Dis Clin North Am 2001; 27:799-813, vi-vii. [PMID: 11723765 DOI: 10.1016/s0889-857x(05)70236-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Trustworthy and clinically useful laboratory test results depend on high quality laboratory knowledge and performance and on close collaboration with experienced clinicians. Just like a diagnosis can only be made by contrasting it to a number of differential diagnoses, a prototype autoantibody profile can only be recognized if autoantibodies that partially mimic the former are just as well-known. In antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitides the characteristic autoantibody profile can only be demonstrated by use of at least two different methodologies and an assay-specific cut-off selection that clearly distinguishes between strongly positive and disease control low positive to negative values. Local serum banks containing samples from patients with well-characterized chronic immunoinflammatory diseases and ANCA-associated vasculitides are needed for such important studies whether in-house or commercial assays are used.
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Affiliation(s)
- A S Wiik
- Department of Autoimmunology, Statens Serum Institut, Copenhagen, Denmark.
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41
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Mannik M, Merrill CE, Wener MH. Antibodies to human myeloperoxidase in glomerular immune deposits of systemic lupus erythematosus. Lupus 2001; 9:607-13. [PMID: 11035436 DOI: 10.1191/096120300678828758] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antibodies to human myeloperoxidase and cathepsin G have been detected in the serum of some patients with systemic lupus erythematosus. Therefore, the presence of antibodies to human myeloperoxidase and cathepsin G was examined in glomerular immune deposits. Glomerular basement membrane fragments were prepared from renal tissues obtained at autopsy from 19 patients with systemic lupus erythematosus. IgG was extracted from the glomerular basement membrane fragments and tested with sensitive immunoassays for antibodies to myeloperoxidase and cathepsin G. Antibodies to cathepsin G were not detected in the extracts but antibodies to human myeloperoxidase were found in extracts of one specimen. In the extract with 6M guanidine hydrochloride these antibodies were enriched 103-fold, compared to the initial supernatant of glomeruli, which served as a serum surrogate. The recovered antibodies to myeloperoxidase accounted for 12% of the recovered IgG. These findings add autoantibodies to human myeloperoxidase to the list of antibodies that have been shown to be present in glomerular immune deposits of patients with lupus glomerulonephritis.
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Affiliation(s)
- M Mannik
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA 98195-6428, USA.
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Girard T, Mahr A, Noël LH, Cordier JF, Lesavre P, André MH, Guillevin L. Are antineutrophil cytoplasmic antibodies a marker predictive of relapse in Wegener's granulomatosis? A prospective study. Rheumatology (Oxford) 2001; 40:147-51. [PMID: 11257150 DOI: 10.1093/rheumatology/40.2.147] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate the predictive value of testing for antineutrophil cytoplasmic antibodies (ANCA) in 55 patients with systemic Wegener's granulomatosis (WG) included in a randomized, prospective trial comparing corticosteroids and oral or pulse cyclophosphamide. METHODS All 55 patients received corticosteroids. A cyclophosphamide pulse of 0.7 g/m2 was given at the time of diagnosis. After the first pulse, the patients were assigned at random to receive either pulse or oral cyclophosphamide (2 mg/kg/day), independently of ANCA results. ANCA were sought using an immunofluorescence assay and an attempt was made to correlate them with relapse of WG. ANCA were monitored throughout the study. RESULTS At the time of diagnosis, ANCA were detected in 48 (87%) patients, with a cytoplasmic labelling pattern in 44 and a perinuclear pattern in four. ANCA follow-up was available for 50 patients. ANCA disappeared in 34 patients and persisted in nine. For 79% of the patients, the clinical course improved with the disappearance of ANCA and deteriorated with their persistence or increased titre. Among the patients who were initially ANCA-positive, 23 relapses occurred. Relapses were more frequent when ANCA remained positive or reappeared [13/19 ANCA-positive patients vs 3/29 ANCA-negative patients (P<0.01)]. Nine relapses (39%) occurred in patients with persistent ANCA, and ANCA reappearance preceded relapse in eight (35%). The mean time between inclusion and relapse did not differ between the patients who became ANCA-negative and those who were persistently ANCA-positive (14.6+/-13.2 vs 14.4+/-8.2 months). The mean time to ANCA disappearance was similar for the patients who relapsed and those who did not. Corticosteroids and pulse or oral cyclophosphamide did not significantly modify the time to ANCA disappearance. Throughout the study, seven patients were ANCA-negative. CONCLUSION Although ANCA positivity was associated with relapse, discordance between cytoplasmic ANCA and disease activity was not unusual. In the absence of clinical manifestations, ANCA titres alone can serve as a warning signal but not indicate whether to adjust or initiate treatment.
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Affiliation(s)
- T Girard
- Service de Médecine Interne, Hôpital Avicenne, Université Paris-Nord, 125, rue de Stalingrad, 93009 Bobigny Cedex, France
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43
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Abstract
The identification of circulating autoantibodies contributes to the correct diagnosis as well as to the follow-up of rheumatic diseases. Some autoantibodies are even included in diagnostic and classification criteria for these types of autoimmune diseases. There are several relatively specific screening and identification methods for the measurement of autoantibodies available. The type of assay crucially influences the diagnostic value of the parameters. In general, routine laboratories should prefer enzyme immunoassays (ELISA) using well characterized antigens, although ELISA tests tend to produce more false-positive and true weakly positive results, which reduce their positive predictive value. Therefore one should be aware that laboratory results can only be properly interpreted when there is a correlation with the clinical situation and when the limitations of the technologies used for autoantibody identification have been taken into consideration. A diagnostic algorithm consisting of screening and identification steps should be established by each laboratory in order to create a rational, evidence-based and cost-effective basis for the diagnosis of rheumatic diseases.
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Affiliation(s)
- A Griesmacher
- Institute of Laboratory Diagnostics, Kaiser-Franz-Josef-Hospital, Vienna, Austria.
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44
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Wiik A. Methods for the detection of anti-neutrophil cytoplasmic antibodies. Recommendations for clinical use of ANCA serology and laboratory efforts to optimize the informative value of ANCA test results. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 2001; 23:217-29. [PMID: 11591099 DOI: 10.1007/s002810100076] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Wiik
- Department of Autoimmunology, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen, S., Denmark.
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45
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Induction of neutrophil responsiveness to myeloperoxidase antibodies by their exposure to supernatant of degranulated autologous neutrophils. Blood 2000. [DOI: 10.1182/blood.v96.8.2822.h8002822_2822_2827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antibodies against myeloperoxidase (MPO) and proteinase 3 (PR3) are the predominant autoantibodies present in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Their binding to the corresponding antigen on the surface of polymorphonuclear neutrophils (PMNs) is believed to trigger the disease process. Cytokines released during an inflammatory reaction are thought to prime resting PMNs, making them responsive to autoantibodies. In the present study we found that MPO but not PR3 could be detected on the cell surface of unstimulated PMNs after incubation with the supernatants of activated autologous PMNs. MPO was shown to be acquired from these supernatants, because PMNs did not express MPO when the supernatants were specifically MPO-depleted. In addition, purified soluble MPO bound to unstimulated PMNs. Unstimulated PMNs that had passively acquired MPO released oxygen radicals when incubated with monoclonal antibody anti-MPO or the immunoglobulin G fraction of a patient with MPO-ANCA. The data presented here suggest that, in ANCA-associated vasculitis, soluble MPO released by activated PMNs may bind to unstimulated PMNs, thereby making them reactive to anti-MPO antibodies. This mechanism of dispersing PMN activation would be specific for MPO-ANCA and may explain differences in the pathologic and clinical expression of MPO-ANCA versus PR3-ANCA vasculitis.
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46
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Induction of neutrophil responsiveness to myeloperoxidase antibodies by their exposure to supernatant of degranulated autologous neutrophils. Blood 2000. [DOI: 10.1182/blood.v96.8.2822] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Antibodies against myeloperoxidase (MPO) and proteinase 3 (PR3) are the predominant autoantibodies present in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Their binding to the corresponding antigen on the surface of polymorphonuclear neutrophils (PMNs) is believed to trigger the disease process. Cytokines released during an inflammatory reaction are thought to prime resting PMNs, making them responsive to autoantibodies. In the present study we found that MPO but not PR3 could be detected on the cell surface of unstimulated PMNs after incubation with the supernatants of activated autologous PMNs. MPO was shown to be acquired from these supernatants, because PMNs did not express MPO when the supernatants were specifically MPO-depleted. In addition, purified soluble MPO bound to unstimulated PMNs. Unstimulated PMNs that had passively acquired MPO released oxygen radicals when incubated with monoclonal antibody anti-MPO or the immunoglobulin G fraction of a patient with MPO-ANCA. The data presented here suggest that, in ANCA-associated vasculitis, soluble MPO released by activated PMNs may bind to unstimulated PMNs, thereby making them reactive to anti-MPO antibodies. This mechanism of dispersing PMN activation would be specific for MPO-ANCA and may explain differences in the pathologic and clinical expression of MPO-ANCA versus PR3-ANCA vasculitis.
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47
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Abstract
This article presents a brief review of the clinical value of antineutrophil cytoplasmic antibodies (ANCA) in the diagnosis and management of patients with various forms of vasculitis. ANCA assay methodology and testing recommendations are reviewed. The patterns of reactivity of ANCA observed by indirect immunofluorescence, the antigens recognized by ANCA, and the sensitivity, specificity, and positive predictive value of ANCA for diagnosis of different vasculitides are described. In addition, the spectrum of drugs and nonvasculitic diseases that are associated with ANCA and need to be differentiated from true ANCA-positive vasculitides are reviewed. When properly utilized and cautiously interpreted, ANCA are a useful, noninvasive diagnostic tool in the differential diagnosis of vasculitis.
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Affiliation(s)
- V Rus
- Division of Rheumatology and Clinical Immunology, University of Maryland Medical School, 10 South Pine Street, 8-34 MSTF, Baltimore, MD 21201-1192, USA.
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48
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Chikazawa H, Nishiya K, Matsumori A, Hashimoto K. Immunoglobulin isotypes of anti-myeloperoxidase and anti-lactoferrin antibodies in patients with collagen diseases. J Clin Immunol 2000; 20:279-86. [PMID: 10939715 DOI: 10.1023/a:1006667703202] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
To investigate the prevalence and clinical relevance of immunoglobulin (Ig) isotypes of antimyeloperoxidase (MPO) and antilactoferrin (LF) antibodies in collagen diseases, enzyme-linked immunosorbent assay was employed to detect the Ig isotypes of both antibodies. The purified proteins of MPO and LF were used as two major representative antigens for anti-neutrophil cytoplasmic antibodies (ANCA) with a perinuclear staining pattern by an indirect immunofluorescent technique. We examined 131 serum samples from 79 patients with rheumatoid arthritis (RA), 32 with systemic lupus erythematosus (SLE), 14 with progressive systemic sclerosis (PSS), 6 with polymyositis/dermatomyositis (PM/DM), and 5 with idiopathic crescentic glomerulonephritis who served as positive controls and 36 healthy subjects who served as controls. A limited number of patients with RA (4-10%), SLE (6-9%), and PSS (7-14%) but not PM/DM showed positive IgG or IgA anti-MPO antibody (MPO-ANCA) but not IgM MPO-ANCA. However, 10-20% of RA, 40-60% of SLE, 20-36% of PSS but none of the PM/DM patients showed positive IgG, IgA, or IgM anti-LF antibody (LF-ANCA). MPO- and LF-ANCA positivity in RA patients was correlated with markers of disease activity such as the erythrocyte sedimentation rate, C-reactive protein, and serum Ig levels. IgG LF-ANCA but not MPO-ANCA positivity in SLE patients also was correlated with the disease activity index but not with clinical features. Neither MPO- nor LF-ANCA positivity in PSS patients was correlated with any clinical features. Overall, both MPO- and LF-ANCA were found mainly in RA, SLE, and PSS patients but not in PM/DM patients. The Ig isotypes of MPO- and LF-ANCA frequently belonged to both IgG and IgA and rarely to the IgM class. Both MPO- and LF-ANCA positivity reflected disease activity in RA and SLE rather than specific organ involvement.
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Affiliation(s)
- H Chikazawa
- Second Department of Internal Medicine, Kochi Medical School, Nankoku City, Japan
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49
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Franssen CF, Stegeman CA, Kallenberg CG, Gans RO, De Jong PE, Hoorntje SJ, Tervaert JW. Antiproteinase 3- and antimyeloperoxidase-associated vasculitis. Kidney Int 2000; 57:2195-206. [PMID: 10844589 DOI: 10.1046/j.1523-1755.2000.00080.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Antiproteinase 3- and antimyeloperoxidase-associated vasculitis. Wegener's granulomatosis, microscopic polyangiitis, and idiopathic pauci-immune necrotizing crescentic glomerulonephritis (NCGN) are strongly associated with antineutrophil cytoplasmic autoantibodies (ANCAs) directed against either proteinase 3 (anti-PR3) or myeloperoxidase (anti-MPO). This has led some investigators to prefer combining these diseases under the common heading of ANCA-associated vasculitides. However, it is increasingly recognized that there are characteristic differences between patients with anti-PR3 and those with anti-MPO-associated vasculitis. This review focuses on the clinical, histopathologic, and possibly pathophysiologic differences between anti-PR3- and anti-MPO-associated vasculitis. Although there is considerable overlap, the anti-PR3- and anti-MPO-associated vasculitides are each characterized by particular clinical and histopathological findings. Extrarenal organ manifestations and respiratory tract granulomas occur more frequently in patients with anti-PR3 than in those with anti-MPO. Anti-PR3-positive patients with NCGN generally have a more dramatic deterioration of their renal function compared with anti-MPO-positive patients. The term "ANCA-associated vasculitis" is considered as a useful concept in the presence of systemic vasculitis. Likewise, in the presence of vasculitis, the terms "anti-PR3-associated vasculitis" and "anti-MPO-associated vasculitis" are useful concepts.
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Affiliation(s)
- C F Franssen
- Department of Internal Medicine, Divisions of Nephrology and Clinical Immunology, University Hospital Groningen, Groningen, The Netherlands.
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50
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Abstract
Autoimmune hepatitis (AIH) is a rare disease, characterized by female predominance, hypergammaglobulinemia, autoantibodies, association with HLA DR3 and HLA DR4 and a good response to immunosuppression. Different subtypes of AIH may be distinguished, based on differences in the autoantibody patterns. AIH type 1 is characterized by anti-nuclear (ANA) and/or anti-smooth muscular (SMA) autoantibodies. AIH type 2 is characterized by liver/kidney microsomal autoantibodies (LKM). AIH type 3 may be distinguished by autoantibodies to soluble liver proteins (SLA) or the liver pancreas antigen (LP). AIH-2 affects predominantly pediatric patients and is characterized by a more severe clinical course, a higher frequency of relapse under immunosuppressive treatment and a more frequent progression to cirrhosis. In contrast, AIH types 1 and 3 show a higher age of onset and a better long-term response to immunosuppressive treatment. At present, the treatment of choice is prednisone alone or a combination with prednisone and azathioprine. Both treatment protocols show high survival rates. However, a rate of 13% of treatment failures and the failure to induce permanent remission in most patients underlines the urgent need to develop additional treatment regimens. A yet unknown genetic predisposition is believed to act as the underlying etiological factor in AIH. This genetic predisposition includes a few known risk factors such as the presence of HLA DR3 or HLA DR4, deletions of C4A alleles and female gender. Furthermore, it has to be postulated that defects in immunoregulatory genes exist. A model for such defects may be the autoimmune polyglandular syndrome type 1 (APS1), which results from the defects in a single gene, the autoimmune regulator type 1 (AIRE-1). Patients with APS1 suffer from mucocutaneous candidiasis and a number of organ-specific autoimmune diseases. Characteristic is a high variability in the number and character of the disease components in APS1, indicating that other genetic and environmental factors may strongly modulate the outcome of disease. Environmental factors may comprise chemical influences, such as nutritional compounds and drugs, or virus infections. Several drugs or chemicals were shown to induce hepatitis with autoimmune involvement, e.g. tienilic acid, dihydralazine and halothane. Adduct formation of an activated metabolite is believed to act as a trigger and to induce a specific immune response. Similarly, viruses were repeatedly shown to trigger autoimmune hepatitis. In virus infections, sequence similarities between viral and self-proteins may trigger autoimmune processes and the simultaneous presence of inflammatory cytokines during virus infection may further increase the risk of developing self-perpetuating autoimmune reactions which overshoot.
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Affiliation(s)
- P Obermayer-Straub
- Department of Gastroenterology and Hepatology, Hannover Medical School, Germany
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