Physicians' perceptions about antineutrophil cytoplasmic antibody-associated vasculitis: an online survey report in the time of the COVID-19 pandemic

Systemic vasculitis with latent tuberculosis infection and associated factors: a cross-sectional multicenter study

OBJECTIVES

Systemic vasculitis patients are at a higher risk of developing latent tuberculosis infection (LTBI). However, there is currently no literature elucidating the positivity rate and risk factors for LTBI in systemic vasculitis patients.

METHODS

Our study is a multi-center, cross-sectional study that enrolled systemic vasculitis patients from 13 comprehensive hospitals in China. T-SPOT.TB as the screening method for LTBI, the study investigated the positivity rate of LTBI in systemic vasculitis patients and the factors associated with T-SPOT.TB results.

RESULTS

A total of 191 systemic vasculitis patients were included and the positive rate of T-SPOT.TB was 31.4%. The highest T-SPOT.TB positivity rate was observed in Behçet's syndrome (BD) (72/191, 37.7%). There were statistically significant differences between the LTBI group and non-LTBI group in terms of systemic vasculitis type (P = 0.010), albumin levels (P = 0.034), erythrocyte sedimentation rate (P = 0.016), and corticosteroid dosage (P = 0.047). Multivariate regression analysis revealed that smoking history (aOR = 3.809, 95%CI: 1.341-10.817) and BD (aOR = 2.106, 95%CI: 1.042-4.254) were independent risk factors of T-SPOT.TB postive results, besides decreased lymphocyte count (aOR = 0.114, 95%CI: 0.013-0.973), and high-dose glucocorticoids use (aOR = 0.386, 95%CI: 0.149-1.003) were independent risk factors of T-SPOT.TB negative results.

CONCLUSIONS

The prevalence of LTBI is high in systemic vasculitis patients, especially those with BD or smoking history. Patients with decreased lymphocyte counts and high-dose glucocorticoid use are more likely to have a negative T-SPOT.TB results. Therefore, LTBI screening should be performed based on the characteristics of the patient during the diagnosis and treatment of systemic vasculitis. Key Points • We explored the positivity rate and risk factors of LTBI in systemic vasculitis patients from 13 hospitals in China. • There were 191 systemic vasculitis patients in our study. The positive rate of T-SPOT.TB was 31.4%. The predominant type of systemic vasculitis was BD, with a T-SPOT.TB positive rate of 44.4%. The second type was TA, with a T-SPOT.TB positive rate of 25.0%. • The prevalence of LTBI is high in systemic vasculitis patients, especially those with Behçet's syndrome or smoking history. Decreased lymphocyte counts and high-dose glucocorticoid use are more likely to have a negative T-SPOT.TB results. • LTBI screening using T-SPOT.TB should be conducted during the diagnosis and treatment of systemic vasculitis.

Healthcare professionals' knowledge and perceptions of post-stroke rehabilitation in the peripandemic period: an online cross-sectional survey

The COVID-19 pandemic has profoundly affected healthcare systems, particularly post-stroke rehabilitation centers. The elevated severity of strokes and delayed hospital admissions caused numerous hurdles to rehabilitation administration during the peri-pandemic period. This study surveyed healthcare professionals' knowledge and perceptions of post-stroke rehabilitation during this period. An online cross-sectional survey was administered from September 17, 2023 to February 23, 2024, utilizing the SurveyMonkey platform. The questionnaire included 30 questions addressing participant baseline characteristics, knowledge of definitions and experiences, post-stroke rehabilitation procedures, obstacles encountered during the peri-pandemic period, and the utilization of telerehabilitation. Only complete responses from health professionals were considered. This report utilized convenience sampling. Data were analyzed via descriptive statistics and chi-square tests, with a significance threshold of p < 0.05. A total of 79 health professionals, predominantly physiatrists, neurologists, and physiotherapists, from eight countries participated in the study. Over half of the participants (64.6%) indicated the existence of a dedicated department for post-stroke rehabilitation. Significant obstacles comprised an absence of advanced rehabilitative treatments (60.8%), inadequately skilled workers (50.6%), and restricted space for rehabilitation (46.8%). Telerehabilitation was regarded as a feasible option by 45.6% of participants; nonetheless, obstacles, including patients' telecommunication proficiency and the possibility of diagnostic inaccuracies, were acknowledged. Complementary therapies, such as music and dance therapy, received favorable evaluations from 67.1% to 63.3% of respondents, respectively. The pandemic reduced rehabilitation admissions due to infection concerns (75.9%) and increased multimorbidity cases among patients (48.1%). The study underscores the pandemic's negative effect on post-stroke rehabilitation, emphasizing the necessity for multidisciplinary, customized therapy and enhanced integration of telerehabilitation to overcome access barriers. Addressing obstacles regarding infrastructure, training, and access to advanced approaches, particularly in a post-pandemic context, is essential to improving rehabilitation outcomes.

Prognostic analysis of Pneumocystis jirovecii pneumonia in patients with systemic vasculitides: a retrospective cohort study

OBJECTIVES

Pneumocystis jirovecii pneumonia (PJP) is a serious complication of autoimmune and inflammatory diseases. This study aimed to describe the characteristics of PJP in patients with various systemic vasculitides and explore potential prognostic factors.

METHOD

Data on 62 enrolled PJP patients with systemic vasculitis were analyzed. Patients were stratified based on the outcomes. Prognostic factors were investigated using Cox-regression models. Characteristics of patients with and without interstitial lung disease (ILD) were compared.

RESULTS

Among 62 vasculitis-PJP patients, 48 had anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), with microscopic polyangiitis (MPA) being the most common subtype (28 patients). MPA (HR 4.33, p = 0.001), concomitant aspergillosis (HR 2.68, p = 0.019), and higher D-dimer at PJP diagnosis (HR 1.07, p = 0.004) were independent adverse prognostic factors for overall survival. Stable disease activity of vasculitis was an independent favorable prognostic factor (HR 0.28, p = 0.027). Patients with MPA were older than non-MPA patients (median age: 69 vs. 58 years, p = 0.001); both ILD and fibrotic ILD were more prevalent in MPA patients (ILD: 78.6% vs. 35.3%, p = 0.001; fibrotic ILD: 57.1% vs. 11.8%, p < 0.001). At the diagnosis of PJP, patients with preexisting ILD had higher counts of white cells, lymphocytes, and neutrophils, as well as higher levels of immunoglobulin (Ig) G and IgA, than patients without preexisting ILD.

CONCLUSIONS

MPA was associated with a higher risk of death in patients with vasculitis-PJP, possibly due to a higher prevalence of ILD. In clinical practice, we should pay more attention to the prophylaxis and management of PJP in patients with systemic vasculitis-associated ILD and/or MPA. Key Points • Data from this study showed that MPA was the most common subtype of vasculitis among vasculitis-PJP patients. • Compared with non-MPA patients in this study, patients with MPA were older, had more ILD and fibrotic ILD, and had a poorer prognosis. • In clinical practice, we should pay more attention to the prophylaxis and management of PJP in patients with systemic vasculitis-associated ILD and/or MPA.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

Diagnostic delays in systemic vasculitides

Systemic vasculitides are among the less common disorders encountered in routine rheumatology practice. The low incidence and heterogeneous presentation at onset can potentially lead to delayed diagnosis. Not recognizing these in the early phase may prove detrimental, as some vasculitis may progress to a catastrophic course with major morbidity or mortality. The causes of diagnostic delay may vary among different types of vasculitis and may also be disease-, patient-, or physician-related. Disease-related factors include the myriad presentations with diverse and non-specific symptoms, mimicking other conditions like infections. In addition, some forms have prolonged prodromal phases before evident organ damage. Limited awareness among healthcare professionals, particularly outside rheumatology, and a lack of readily available diagnostic tools contribute to missed diagnoses. Delays in seeking care due to non-specific symptoms or lack of access to specialist care can worsen outcomes. The economic burden also increases with delayed diagnosis and damage accrual when the disease remains unrecognized or untreated for prolonged periods. Although the causes of vasculitis are numerous, including secondary causes, in this review, we focus on diagnostic delays in primary vasculitides and suggest potential steps to identify and treat these diseases early. These include educating both healthcare professionals and the public about the signs and symptoms of vasculitis; expanding the rheumatology workforce and facilitating timely referrals; implementing readily available and reliable tests for early detection; and streamlining care and diagnostic pathways. Such measures have the potential to improve the overall outcomes of the disease, with prolonged remission, minimal damage accrual, and improved quality of life.

Eosinophilic Granulomatosis With Polyangiitis Following COVID-19 Vaccination: A Case Report

The current emergence of the coronavirus disease 2019 (COVID-19) pandemic and the possible side effects of COVID-19 mRNA vaccination remain worrisome. Few cases of vaccination-related side effects, such as vasculitis, have been reported. Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a type of vasculitis characterized by the histological richness of eosinophils, asthma, polyneuropathy, sinusitis, and skin or lung involvement. Here, we report the first case of new onset EGPA following COVID-19 vaccination in Korea. A 71-year old woman developed a skin rash and presented with progressive weakness of the upper and lower extremities after the BNT162b2 vaccination (Pfizer-BioNTech). She was diagnosed with EGPA and her symptoms improved after systemic steroid and immunosuppressant therapy. Although it is very rare, clinicians should be aware that EGPA may occur after COVID-19 vaccination.

New-onset systemic vasculitis following SARS-CoV-2 infection and vaccination: the trigger, phenotype, and outcome

The global health crisis caused by the COVID-19 pandemic overwhelmed the capacity of healthcare systems to cope with the rapidly spreading infection and its associated complications. Among these complications, autoimmune phenomena such as systemic vasculitis emerged as a significant challenge. Both the SARS-CoV-2 virus and the vaccines developed to combat it appeared to induce clinical manifestations resembling various types of systemic vasculitis, affecting large, medium, and small vessels. These virus- or vaccine-induced vasculitides exhibited a distinct natural history and course from de novo vasculitis, as they were more responsive to steroid therapy and some mild cases even resolved spontaneously. Notably, there have been no confirmed cases of SARS-CoV-2 infection or vaccination triggering variable vessel vasculitis like Behcet's disease or Kawasaki disease. IgA vasculitis, which is predominantly a pediatric condition, was more prevalent in adults after COVID-19 infection and they had a favorable outcome with glucocorticoid treatment. The impact of immunosuppression, especially B-cell-depleting agents, on the immunogenicity of the vaccine was evident, but there was no significant increase in the incidence of SARS-CoV-2 infection in these patients compared to the general population. Considering their relatively benign course, these post-COVID or post-vaccine vasculitides seem to be amenable to 0.8 to 1 mg/kg prednisolone or equivalent, which could be gradually tapered. The need for immunosuppression and the duration of steroid therapy should be determined on an individual basis. While the world still reels from the perils of a deadly pandemic, the aftermath continues to haunt. Our narrative review aims to explore the effects of COVID and the vaccine on systemic vasculitis, as well as the effect of disease and immunosuppression on the immunogenicity of the COVID vaccine.

The impact of the COVID-19 pandemic on patients with systemic vasculitis: a single-centre retrospective study

This study aimed to study the impact of the COVID-19 pandemic on patients living with systemic vasculitis in Kazakhstan. A single-centre retrospective study of the medical histories of 82 patients was carried out based on the regional clinical hospital of the city for all admissions with systemic vasculitis in the period from January 2019 to December 2021. The following qualitative (gender, disability, concomitant diseases) and quantitative (age, disease experience, laboratory data, etc.) variables were studied. To conduct the study, the criteria for the inclusion and exclusion of patients in the study were determined. According to the results of the study, there is a decrease in the number of hospitalized patients with vasculitis in the rheumatology department of the regional clinical hospital. Compared to 2019, in 2021, the number of hospitalized patients decreased by almost half (Table 1). Out of 82 cases, the most common was Takayasu disease (nonspecific aortoarteritis) (43.9%), IgA-vasculitis (Schenlein-Genoch disease) (31.71%), and they are typical mainly for females of rural origin, who were admitted to the hospital in a comorbid state (p < 0.001). 41.6% of patients have disabilities, and the majority of patients have a II disability group. The average body mass index is 24.2; 27 patients out of the total number of patients suffer from obesity. The most common clinical symptoms of patients with systemic vasculitis were injuries of the musculoskeletal system (75.6%). A negative average correlation was found between the indicators of the level of ESR and haemoglobin, the correlation coefficient is -0.535. The patients had concomitant diseases, such as diabetes mellitus, iron deficiency anaemia, coronary heart disease, hypertension, gastrointestinal tract diseases and hepatitis. Women of reproductive age from rural areas are often diagnosed with systemic vasculitis. A high rate of disability revealed among the patients can be explained by two main factors, the first is that the patients consulted the doctors untimely and the second is that the medical community are insufficiently informed about the management of autoimmune rheumatic diseases, in particular about systemic vasculitis, which hinders timely diagnosis and treatment, respectively. Patients, included in this survey, were mostly suffering from diseases of the musculoskeletal system, but depending on the type of vasculitis, other organs and systems may be affected. Table 1 Frequency of patients with systemic vasculitis over 3 years Year Frequency % p-value 2019 42 51.2 χ² = 12.463^a; p = 0.002 2020 23 28.0 2021 17 20.7 Total 82 100.0.

SARS-COV-2 INFECTION AS A POSSIBLE TRIGGER FOR MICROSCOPIC POLYANGIITIS: CASE REPORT AND MINI-REVIEW

The paper presents a clinical case of MPA in a 67-year-old woman following COVID-19, characterized by significant difficulties when working with the early etiological verification of diagnosis. The patient presented with polyarthritis affecting the upper and lower limbs, fever, and comorbid urological pathology in the form of urolithiasis and recurrent cystitis. This clinical presentation, hyperuricemia, azotaemia and anemia were mistakenly interpreted as chronic kidney disease: gouty nephropathy, gouty arthritis, which masked the underlying disease for a long time delaying the timely MPA diagnosis and treatment. Given that MPA is a multisystemic disease, it is essential to enhance awareness and knowledge of healthcare professionals of various specialties regarding AAVs and MPA in particular, as evidenced by the online survey data during COVID-19 pandemic among doctors in 21 countries.