Cutting edge issues in the Churg-Strauss syndrome

Acute myocardial infarction induced by eosinophilic granulomatosis with polyangiitis: A case report

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem disease characterized by allergic rhinitis, asthma, and a significantly high eosinophil count in the peripheral blood. It mainly involves the arterioles and venules. When the coronary arteries are invaded, it can lead to acute myocardial infarction (AMI), acute heart failure, and other manifestations that often lead to death in the absence of timely treatment.

CASE SUMMARY

A 69-year-old man was admitted to the emergency department due to chest pain for more than 1 h. He had a past history of bronchial asthma and chronic obstructive pulmonary disease and was diagnosed with AMI and heart failure. Thrombus aspiration of the left circumflex artery and percutaneous transluminal coronary angioplasty were performed immediately. After surgery, the patient was admitted to the intensive care unit. The patient developed eosinophilia, and medical history taking revealed fatigue of both thighs 1 mo prior. Local skin numbness and manifestations of peripheral nerve involvement were found on the lateral side of the right thigh. Skin biopsy of the lower limbs pathologically confirmed EGPA. The patient was treated with methylprednisolone combined with intravenous immunoglobulin and was discharged after 21 d. On follow-up at 7 d after discharge, heart failure recurred. The condition improved after cardiotonic and diuretic treatment, and the patient was discharged.

CONCLUSION

Asthma, impaired cardiac function, and eosinophilia are indicative of EGPA. Delayed diagnosis often leads to heart involvement and death.

Treatment and its side effects in ANCA-associated vasculitides - Study based on POLVAS registry data

PURPOSE

The aim of this study is to present the treatment modalities and associated side effects in a Polish nation-wide ANCA-associated vasculitides (AAV) patients' cohort.

MATERIALS AND METHODS

Retrospective analysis of patients diagnosed with AAV between 1990 and 2016, included in the POLVAS registry was performed. Standard descriptive statistic methods were used with an emphasis on the treatment modalities.

RESULTS

There were 625 patients diagnosed with AAV included in this study: 417 cases of granulomatosis with polyangiitis (GPA; 66.7%), 106 cases of microscopic polyangiitis (MPA; 17.0%) and 102 cases of eosinophilic granulomatosis with polyangiitis (EGPA; 16.3%). The mean age at the date of diagnosis was 50.4 (±15.7) years and the median observational period amounted to 4.0 (2.0-8.0) years. Glucocorticosteroids (GCs) were the medicaments most frequently used for remission induction (593/622; 95.3%), followed by cyclophosphamide (487/622; 78.3%), rituximab (44/622; 7.1%), and methotrexate (39/622; 6.3%). GCs were also most frequently administered for maintenance therapy (499/592; 84.3%), followed by azathioprine (224/592; 37.8%), methotrexate (136/592; 23.0%) and mycophenolate mofetil (99/592; 16.7%). The median cumulative doses of cyclophosphamide and rituximab equalled 7.99 g (4.18-14.0) and 2000 mg (1500-2800), respectively. The most commonly observed adverse events included: infections - 214/551 cases (38.8%), which were associated with the time of observation (OR = 1.05; 95% CI 1.01-1.10), the use of GCs intravenous pulses (OR = 2.76; 95% CI 1.68-4.54) and need for haemodialysis (OR = 1.73; 95% CI 1.10-2.71).

CONCLUSIONS

Polish patients with AAV were predominantly treated according to appropriate guidelines. The most frequent adverse events were typical for usually administered immunosuppressive treatment.

Transcript- and protein-level analyses of the response of human eosinophils to glucocorticoids

Glucocorticoids are first-line agents for the treatment of many eosinophil-associated disorders; however, their effects on human eosinophils remain poorly understood. To gain an unbiased, genome-wide view of the early transcriptional effects of glucocorticoids on human eosinophils in vivo, RNA sequencing was performed on purified blood eosinophils obtained before and 30, 60, and 120 minutes after administration of a single dose of oral prednisone (1 mg/kg) to three unrelated healthy subjects with hypereosinophilia of unknown significance. The resulting dataset is of high quality and suitable for differential expression analysis. Flow cytometry and qPCR were then performed on three additional cohorts of human subjects, to validate the key findings at the transcript and protein levels. The resulting datasets provide a resource for understanding the response of circulating human eosinophils to glucocorticoid administration.

Head and Neck Manifestations of Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review

OBJECTIVE

To conduct the first and only systematic review of the existing literature on head and neck manifestations of eosinophilic granulomatosis with polyangiitis to guide clinical decision making for the otolaryngologist.

DATA SOURCES

PubMed, Cochrane Library, Scopus, and LILACS.

REVIEW METHODS

A systematic review of the aforementioned sources was conducted per the PRISMA guidelines.

RESULTS

From an initial 574 studies, 28 trials and reports were included, accounting for a total of 1175 patients with eosinophilic granulomatosis with polyangiitis. Among clinical and cohort studies, 48.0% to 96.0% of all included patients presented with head and neck manifestations. In a distinct group of patients detailed in case reports describing patients presenting with head and neck manifestations, patients on average fulfilled 4.6 diagnostic criteria per the American College of Rheumatology. Furthermore, 95.8% of reported cases were responsive to steroids, and 60% required additional therapy.

CONCLUSION

Otolaryngologists are in a unique position for the early diagnosis and prevention of late complications of eosinophilic granulomatosis with polyangiitis. The American College of Rheumatology criteria should be relied on in the diagnostic workup. Close surveillance of these patients in a multidisciplinary fashion and with baseline complete blood counts, chest radiographs, and autoimmune laboratory tests is often necessary. Such patients with head and neck manifestations of the disease are nearly always responsive to steroids and often require additional immunosuppressive therapy or surgical intervention in cases of cranial neuropathies, temporal bone involvement, and refractory symptoms.

Autoimmunity in 2013

The peer-reviewed publications in the field of autoimmunity published in 2013 represented a significant proportion of immunology articles and grew since the previous year to indicate that more immune-mediated phenomena may recognize an autoimmune mechanism and illustrated by osteoarthritis and atherosclerosis. As a result, our understanding of the mechanisms of autoimmunity is becoming the paradigm for translational research in which the progress in disease pathogenesis for both tolerance breakdown and inflammation perpetuation is rapidly followed by new treatment approaches and clinical management changes. The similarities across the autoimmune disease spectrum outnumber differences, particularly when treatments are compared. Indeed, the therapeutics of autoimmune diseases are based on a growing armamentarium that currently includes monoclonal antibodies and small molecules which act by targeting molecular markers or intracellular mediators with high specificity. Among the over 100 conditions considered as autoimmune, the common grounds are well illustrated by the data reported for systemic lupus erythematosus and rheumatoid arthritis or by the plethora of studies on Th17 cells and biomarkers, particularly serum autoantibodies. Further, we are particularly intrigued by studies on the genomics, epigenetics, and microRNA at different stages of disease development or on the safe and effective use of abatacept acting on the costimulation of T and B cells in rheumatoid arthritis. We are convinced that the data published in 2013 represent a promising background for future developments that will exponentially impact the work of laboratory and clinical scientists over the next years.

The challenge of treating orphan disease

Uncommon or orphan diseases are less frequently addressed in mainstream medical journals and, as a consequence, their understanding and clinical recognition may rely on case series or anecdotal data with limited guidelines and management directions. The study of selected underrepresented autoimmune and allergy conditions is the subject of the present issue of Clinical Reviews in Allergy and Immunology to provide peculiar perspectives on common and rare themes. First, allergy remains a major concern for physicians worldwide despite the limited developments over the past years, particularly for antigens such as mite or Alternaria alternata, and due to the increasing incidence of drug hypersensitivity. Second, the female predominance of autoimmune diseases such as systemic sclerosis is well recognized but enigmatic, and a unifying hypothesis remains elusive. Third, the management of conditions triggered by infectious agents as in Guillain-Barre syndrome or mixed cryoglobulinemia is challenging, and clinical guidelines are needed in the setting of infections and autoimmunity. Fourth, gamma-delta T cells represent major players in innate immunity and are the subject of extensive studies in autoimmune diseases to provide new therapeutic targets for disease prevention or modulation in the near future. Ultimately, we acknowledge the major developments in the broad fields of rheumatology and immunology and expect that microbiota definition, epigenetics studies, and microRNA analysis will provide new exciting avenues toward the understanding and treatment of chronic and acute inflammation.

Ischemic and Hemorrhagic Strokes due to Eosinophilic Granulomatosis with Polyangiitis

BACKGROUND

We report a case of ischemic and hemorrhagic strokes occurring almost simultaneously in a patient diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) previously known as Churg-Strauss vasculitis. To our knowledge, this is the first known case.

METHODS

A 59-year-old man presented with a 2-month history of bilateral leg weakness, difficulty ambulating, and dyesthesias. While in the hospital, he developed acute right hand weakness, and magnetic resonance imaging of the brain revealed multiple, bilateral ischemic infarcts. After a few days, he acutely became unresponsive and was found to have a large left frontal hematoma and underwent emergent hematoma evacuation. His weakness was unexplained by the infarcts based on location and so a peripheral process was suspected.

RESULTS

Nerve conduction studies showed severe axonal sensorimotor neuropathy. A sural nerve biopsy showed necrotizing vasculitis, consistent with EGPA.

CONCLUSIONS

EGPA is the rarest of the antineutrophilic cytoplasmic antibody vasculitides. The peripheral nervous system is frequently involved, but the central nervous system can also be affected. The vasculitis damages the vessel walls, which leads either to stenosis or to dilatation, resulting in ischemic or bleeding consequences which can occur simultaneously, such as in this case. Caution should be exercised when prescribing antiplatelet therapy to such patients.

Factors that predict in-hospital mortality in eosinophilic granulomatosis with polyangiitis

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic small-vessel vasculitis associated with asthma, eosinophilia, and necrotizing vasculitis. EGPA is potentially life-threatening and often involves peripheral neuropathies, peptic ulcers, cerebral vessel disease, and cardiovascular disease. However, there is limited understanding of the prognostics factors for patients with EGPA. We investigated the clinical features and factors affecting patients' in-hospital mortality, using a national inpatient database in Japan.

METHODS

We retrospectively collected data of EGPA patients who required hospitalization between July 2010 and March 2013, using the Diagnosis Procedure Combination database. We evaluated EGPA patients' characteristics and performed multivariate logistic regression analyses to assess the factors associated with in-hospital mortality.

RESULTS

A total of 2195 EGPA patients were identified. The mean age was 61.9 years, 42.1% (924/2195) were male, and 41.6% (914/2195) had emergent admission. In-hospital deaths occurred in 97/2195 patients (4.4%). Higher in-hospital mortality was associated with age older than 65 years, disturbance of consciousness on admission, unscheduled admission, respiratory disease, cardio-cerebrovascular disease, renal disease, sepsis, and malignant disease on admission. Lower mortality was associated with female gender and peripheral neuropathies.

CONCLUSIONS

Our study revealed the clinical features of EGPA patients who required hospitalization and the factors associated with their mortality. These results may be useful for physicians when assessing disease severity or treatments for hospitalized EGPA patients.

Churg-Strauss angiitis

Churg-Strauss angiitis is a rare vasculitic disorder affecting small- and medium-sized blood vessels. It is clinically characterized by the presence of a wide spectrum of multisystem organ involvement, with allergic rhinitis, asthma and peripheral blood eosinophilia as the most typical manifestations. The authors describe 2 cases of Churg-Strauss angiitis from an urban community of Southern Louisiana, exhibiting an atypical presentation with myocardial ischemia and cerebrovascular complications. Epidemiology, pathophysiology and clinical overview are presented. The therapeutic management is also discussed.

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): evolutions in classification, etiopathogenesis, assessment and management

PURPOSE OF REVIEW

Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome) is a peculiar hybrid condition of a systemic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and a hypereosinophilic disorder with frequent lung involvement that occurs in people with asthma. This review focuses on areas of evidence or persistent uncertainty in the classification, epidemiology, clinical presentation, diagnosis, prognosis and management of EGPA and attempts to identify clues to the mechanisms in the development or course of the disease.

RECENT FINDINGS

The 2013 revision of the EGPA definition formally placed the disease in the subset of ANCA-associated vasculitides. Recently published large case series underlined that the presence of ANCAs, found in 30-40% of EGPA, determines distinct but partly overlapping disease expression and the major detrimental effect of heart involvement on survival. There is some evidence that asthma in EGPA resembles a nonallergic eosinophilic asthma phenotype. Encouraging results have been reported for the treatment of EGPA with rituximab or with the eosinophil-targeted antiinterleukin-5 agent mepolizumab.

SUMMARY

The understanding of EGPA continues to advance, but many gaps in knowledge remain. The nomenclature remains a source of conceptual variance in terms of demonstrated presence or not of vessel inflammation or ANCAs in the diagnosis of EGPA. Distinguishing EGPA from hypereosinophilic syndromes can be problematic, and an understanding of the mechanistic relation between the vasculitis and the eosinophilic proliferation is profoundly lacking. Some evidence suggests distinct disease phenotypes, but this concept has not yet been translated to phenotype-adapted therapy.

Clinical features and prognostic factors of Churg-Strauss syndrome

BACKGROUND/AIMS

Churg-Strauss syndrome (CSS) is a rare systemic necrotizing small-vessel vasculitis, with accompanying bronchial asthma, eosinophilia, and eosinophilic infiltration of various tissues. The purposes of our study were to characterize the clinical features of CSS and to identify factors associated with CSS prognosis in Koreans.

METHODS

Medical records were reviewed retrospectively for all physician-diagnosed CSS patients in the Seoul National University Hospital between January 1990 and March 2011.

RESULTS

Data from 52 CSS patients were analyzed. The respiratory tract was the most commonly involved organ (90.4%). Renal involvement was less frequent in antineutrophilic cytoplasmic antibody (ANCA)(-) patients than in ANCA(+) patients (p = 0.048). Clinical remission occurred in 95.3% of patients, but 16.3% of them relapsed. Patients who maintained remission for more than 6 months were relatively older (median, 51 years) at diagnosis (p = 0.004), had been diagnosed in earlier stages (p = 0.027), showed more frequent respiratory involvement (p = 0.024) and generalized symptoms (p = 0.039), and showed less frequent cutaneous involvement (p = 0.030) than those who did not achieve persistent (> 6 months) remission. Patients who achieved persistent remission also showed higher C-reactive protein (CRP) levels (p = 0.031) than those who did not.

CONCLUSIONS

ANCA(-) CSS patients showed less frequent renal involvement. Characteristics of good responders were older age, diagnosis at earlier stages, less cutaneous involvement, more respiratory involvement, high CRP values, and more generalized symptoms.

The autoimmune side of heart and lung diseases

The elevated cardiovascular morbidity in rheumatoid arthritis, systemic lupus erythematosus, and the antiphospholipid syndrome is well known, as well as the pulmonary involvement observed in these conditions and to a major extent in systemic sclerosis. These manifestations constitute a major challenge for clinicians involved in patient management. Moreover, several issues regarding the link between autoimmune rheumatic diseases and cardio pulmonary morbidity remain largely enigmatic. The mechanistic role of certain autoantibodies frequently observed in association with heart and lung diseases or the pathogenetic link between chronic inflammation and the pathways leading to atherosclerosis or pulmonary vascular changes are yet to be elucidated. As such, these questions as well as treatment strategies are of common interest to rheumatologists, immunologist, pulmonologists, and cardiologists and thus call for an interdisciplinary approach. This paradigm has been well established for rare conditions such as the Churg-Strauss syndrome. Nowadays, it seems that this approach should be expanded to encompass more common conditions such as coronary heart disease, pulmonary arterial hypertension or dilated cardiomyopathy. The present issue of Clinical Reviews in Allergy and Immunology addresses the new knowledge and concepts of autoimmune-related cardiopulmonary diseases. The issue derives from the 2010 International Autoimmunity Meeting held in Ljubljana, Slovenia and is thus timely and dedicated to the latest developments in this new multidisciplinary field.

The impact of current health-related quality of life on future health outlook in patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, autoimmune small and medium vessel vasculitis. EGPA is accompanied by asthma and involves mainly the blood vessels of the lungs, gastrointestinal system, and peripheral nerves; however, the skin, kidneys, and heart may be also affected. To investigate if patients with EGPA experience reduced health-related quality of life (HRQOL), and the effect of this parameter on their own perception of future health outlook. Twenty-six EGPA patients are in disease remission and completed a custom-designed questionnaire and the Medical Outcomes Study Short Form 36 (SF-36). Using the RAND method, eight HRQOL dimensions were calculated: general health, physical functioning, emotional role limitations, physical role limitations, social functioning, mental health, bodily pain, and vitality. Using norm-based scores, the HRQOL of patients was compared with that of the general population. EGPA patients had decreased HRQOL across all eight dimensions of the SF-36. Patients with higher mental component score felt more positive about their future health, while patients with low physical component score were likely not to feel negatively about their future health. Also, 36 % of older patients (>50 years) had a positive outlook compared to 47 % of younger patients (<50 years) and patients with a longer disease course were much less likely to have a positive outlook (30 % positive) than those with a shorter course (50 % positive). Although not statistically significant, these correlations warrant further investigation with a larger patient population. Despite being in disease remission, EGPA patients had decreased quality of life, which in turn influenced their perception of their future health outlook.

[Pulmonary allergic reactions]

Allergic diseases of the lungs may affect the airways, the pulmonary parenchyma and the pulmonary vessels. The most relevant representatives are allergic asthma, hypersensitivity pneumonitis, bronchopulmonary aspergillosis and the Churg-Strauss syndrome. The type of allergic reaction and the pathophysiological consequences vary considerably between these entities. New drugs target specific mechanisms based on new insights into the pathogenetic processes of the underlying disease.