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Ando M, Goto A, Yamasue M, Usagawa Y, Oka H, Shigenaga T, Kadota JI. Pulmonary-Limited Granulomatosis with Polyangiitis Coexisting with Mixed Connective Tissue Disease. TOHOKU J EXP MED 2018; 242:109-114. [PMID: 28592713 DOI: 10.1620/tjem.242.109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic disease characterized by necrotizing, granulomatous vasculitis of the upper and lower respiratory tracts and glomerulonephritis, and is classified as a classical or limited form. The classical form of GPA demonstrates the involvement of the upper respiratory tract, sinuses, lungs and kidneys, whereas the limited form is characterized by the lack of the renal involvement with female predominance. On the other hand, mixed connective tissue disease (MCTD) shows the clinical and laboratorial features of systemic lupus erythematosus, systemic sclerosis and polymyositis, along with high titers of anti-ribonucleoprotein antibodies and is characterized by good response to corticosteroid therapy and favorable prognosis. We herein report a patient with a history of MCTD that developed into a limited form of GPA (pulmonary-limited GPA). A 39-year-old woman suffered from persistent cough, left back pain and appetite loss. At 21 years of age she was diagnosed with MCTD, but the persistent administration of prednisolone or immunosuppressants was not needed. On admission, high-resolution chest computed tomography showed bilateral, multiple, poorly circumscribed nodules and masses, some of which showed cavitation. A surgical lung biopsy demonstrated granulomas with vasculitis surrounding the necrotic lesions. She was diagnosed with pulmonary-limited GPA. In conclusion, we should recognize that GPA may develop during the disease course of MCTD even after prolonged disease remission. To prevent progression to an irreversible state, physicians should consider a surgical lung biopsy for the diagnosis in patients suspected of having pulmonary-limited GPA.
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Affiliation(s)
- Masaru Ando
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Akihiko Goto
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Mari Yamasue
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Yuko Usagawa
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Hiroaki Oka
- Department of Internal Medicine, Tenshindo Hetsugi Hospital
| | | | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
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Tubery A, Fortenfant F, Combe B, Abreu I, Bossuyt X, Chretien P, Desplat-Jégo S, Fabien N, Hue S, Johanet C, Lakomy D, Vincent T, Daïen CI. Clinical association of mixed connective tissue disease and granulomatosis with polyangiitis: a case report and systematic screening of anti-U1RNP and anti-PR3 auto-antibody double positivity in ten European hospitals. Immunol Res 2017; 64:1243-1246. [PMID: 27618831 DOI: 10.1007/s12026-016-8861-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report here the case of a 50-years-old man treated for mixed connective tissue disease (MCTD) positive for anti-U1 ribonucleoprotein (U1RNP) antibodies who secondarily developed a granulomatosis with polyangiitis (GPA) associated with anti-proteinase 3 anti-neutrophil cytoplasmic antibodies (PR3-ANCA). We then evaluated the frequency of the association between anti-U1RNP and anti-PR3-ANCA antibodies by a systematic retrospective study in ten European hospitals. Overall, out of 11,921 samples analyzed for both auto-antibodies, 18 cases of anti-U1RNP and anti-PR3-ANCA double positivity were found and only one patient presented with both MCTD and GPA symptoms. Our retrospective analysis indicates that anti-U1RNP and anti-PR3-ANCA antibodies double positivity is infrequent and very rarely associated with both MTCD and GPA. Our observation describes for the first time the coexistence of MTCD and severe GPA in a Caucasian patient. Association of anti-U1RNP and ANCA antibodies was rarely reported in the literature. Eleven cases of MCTD and ANCA vasculitis have been reported to date, with only two cases with anti-PR3-ANCA association, and only one vasculitis. The seven other cases reported in the literature presented with an association of MCTD and microscopic polyangiitis which appears to be a more frequent presentation than MTCD associated with GPA.
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Affiliation(s)
- Amandine Tubery
- Department of Rheumatology, Lapeyronie Hospital, Montpellier University, Montpellier, France.
| | - Françoise Fortenfant
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, Hôpital Rangueil, 31059, Toulouse, Cedex 9, France
| | - Bernard Combe
- Department of Rheumatology, Lapeyronie Hospital, Montpellier University, Montpellier, France
| | - Isabelle Abreu
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Departamento Universitário de Imunologia, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056, Lisbon, Portugal
| | - Xavier Bossuyt
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Microbiology and Immunology, Catholic University of Leuven, Louvain, Belgium
- Department of Laboratory Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Pascale Chretien
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, CHU Bicetre, 94270, Kremlin Bicêtre, France
| | - Sophie Desplat-Jégo
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of biological Immunology, UMR CNRS/AMU 7259, LBM AP-HM et Aix-Marseille-Université, 13005, Marseille, France
| | - Nicole Fabien
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Benite Cedex, 69495, France
| | - Sophie Hue
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, CHU Henri Mondor - Service d'Immunologie Biologique, 94010, Créteil, France
| | - Catherine Johanet
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, AP-HP hôpital Saint-Antoine, UFR 967, Faculté de medecine, Université Pierre et Marie Curie, 75571, Paris Cedex 12, France
| | - Daniela Lakomy
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, CHU Dijon, 21079, Dijon, Cedex, France
| | - Thierry Vincent
- Groupe d'Etude de l'Auto-Immunité (GEAI), 49933, Angers, France
- Department of Immunology, St Eloi Hospital, Montpellier University, CHRU Montpellier, 34295, Montpellier Cedex 5, France
| | - Claire I Daïen
- Department of Rheumatology, Lapeyronie Hospital, Montpellier University, Montpellier, France
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Konstantinov KN, Harris AA, Barry M, Murata GH, Tzamaloukas AH. Sustained remission of antineutrophil cytoplasmic antibody-mediated glomerulonephritis and nephrotic syndrome in mixed connective tissue disease. J Clin Med Res 2013; 5:316-21. [PMID: 23864923 PMCID: PMC3712889 DOI: 10.4021/jocmr1391w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2013] [Indexed: 11/29/2022] Open
Abstract
A woman diagnosed with mixed connective tissue disease (MCTD) developed an anti-myeloperoxidase (MPO) antineutrophil cytoplasmic antibody (ANCA) and nephrotic syndrome with normal serum creatinine. Percutaneous kidney biopsy showed pauci-immune glomerulonephritis with superimposed immune complex deposition. After treatment with cyclophophamide and prednisone, proteinuria decreased progressively to a level of 0.4 g/g creatinine, ANCA became undetectable, while serum creatinine remained normal seven years after the beginning of treatment. Sustained remission of nephrotic proteinuria with preserved renal function may follow treatment of ANCA-mediated disease developing in patients with MCTD.
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Murakami M, Shimane K, Takahashi H, Tomiyama J, Nagashima M. ANCA-associated vasculitis with dual ANCA positivity in coexistence with mixed connective tissue disease. Mod Rheumatol 2013. [DOI: 10.3109/s10165-012-0619-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masanori Murakami
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Kenichi Shimane
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Hiroshi Takahashi
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
| | - Junji Tomiyama
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masakazu Nagashima
- Department of Rheumatology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-Ku, Tokyo 130-8575, Japan
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ANCA-associated vasculitis with dual ANCA positivity in coexistence with mixed connective tissue disease. Mod Rheumatol 2012; 23:156-61. [PMID: 22391860 DOI: 10.1007/s10165-012-0619-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
We here report a rare case of dual antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in a 38-year-old Japanese woman previously diagnosed with mixed connective tissue disease. The patient was found to be positive for myeloperoxidase- and proteinase 3-ANCA, and was diagnosed with AAV following admission to hospital with fervescence, polyarthralgia, purpura, and asymmetric numbness of the extremities. Examination of her genetic background revealed that she carried HLA-DR9, which confers risk of both diseases in Japanese populations.
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Soltész P, Kerekes G, Dér H, Szücs G, Szántó S, Kiss E, Bodolay E, Zeher M, Timár O, Szodoray P, Szegedi G, Szekanecz Z. Comparative assessment of vascular function in autoimmune rheumatic diseases: considerations of prevention and treatment. Autoimmun Rev 2011; 10:416-25. [PMID: 21281743 DOI: 10.1016/j.autrev.2011.01.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 01/08/2011] [Indexed: 12/31/2022]
Abstract
Numerous autoimmune-inflammatory rheumatic diseases have been associated with accelerated atherosclerosis or other types of vasculopathy leading to increased cardio- and cerebrovascular disease risk. Traditional risk factors, as well as the role of systemic inflammation including cytokines, chemokines, proteases, autoantibodies, adhesion receptors and others have been implicated in the development of these vascular pathologies. The characteristics of vasculopathies may significantly differ depending on the underlying disease. While classical accelerated atherosclerosis has been associated with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or spondyloarthropathies (SpA), obliterative vasculopathy may rather be characteristic for systemic sclerosis (SSc) or mixed connective tissue disease (MCTD). Antiphospholipid antibodies have been implicated in vasculopathies underlying SLE, antiphospholipid syndrome (APS), RA and MCTD. There is also heterogeneity with respect to inflammatory risk factors. Cytokines, such as tumor necrosis factor-α (TNF-α) or interleukin 6 (IL-6) and immune complexes are primarily involved in arthritides, such as RA, SpA, as well as in SLE. On the other hand, autoantibodies including anti-oxLDL anti-cardiolipin and anti-β2GPI are rather involved in SLE- and APS-associated vasculopathies. Regarding the non-invasive assessment of vascular function, endothelial dysfunction, overt atherosclerosis and vascular stiffness may be indicated by brachial artery flow-mediated vasodilation (FMD), common carotid intima-media thickness (ccIMT) and aortic pulse-wave velocity (PWV), respectively. These abnormalities have been described in most inflammatory rheumatic diseases. While ccIMT and stiffness are relatively stable, FMD may be influenced by many confounding factors. In addition to traditional vasculoprotection, immunosuppressive agents including corticosteroids, traditional and biologic DMARDs may have significant vascular and metabolic effects. The official EULAR recommendations on the assessment and management of cardiovascular disease in arthritides have just been published, and similar recommendations in connective tissue diseases are to be developed soon.
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Affiliation(s)
- Pál Soltész
- University of Debrecen Medical and Health Sciences Center, Institute of Medicine, Third Department of Medicine, Angiology and Intensive Care Unit, Debrecen, Hungary
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