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Asano Y, Matsumoto Y, Miyazaki T, Ishizu A, Morizane S, Hayashi K, Yamamura Y, Hiramatsu S, Miyawaki Y, Morishita M, Ohashi K, Watanabe H, Watanabe KS, Kawabata T, Sada KE, Makino H, Wada J. Simultaneous development of IgA vasculitis and eosinophilic granulomatosis with polyangiitis. Mod Rheumatol Case Rep 2019; 4:63-69. [PMID: 33086980 DOI: 10.1080/24725625.2019.1673528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Immunoglobulin A (IgA) vasculitis (IgAV) is a small vessel vasculitis presenting cutaneous purpura, arthralgias and/or arthritis, acute enteritis and glomerulonephritis caused by deposition of the IgA1-mediated immune complex. Eosinophilic granulomatosis with polyangiitis (EGPA) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) characterised by eosinophil-rich and granulomatous inflammation in small to medium-sized vessels. Both IgAV and EGPA are classified as autoimmune systemic vasculitis, but the pathogenesis of immune complex-mediated IgAV and that of pauci-immune EGPA are different. Here we report a rare case of simultaneous development of IgAV and EGPA presenting palpable purpura and numbness in a patient with a history of asthma. Histological examination revealed leukocytoclastic vasculitis with deposition of IgA, IgM and C3 in the upper dermis and necrotising vasculitis with eosinophilic infiltration and granulomatous formation in the lower dermis and subcutaneous fat, indicating the existence of IgAV and EGPA. Our case provides evidence of concurrent development of two different types of vasculitis, which may affect disease-associated complications, therapeutic strategy and prognosis.
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Affiliation(s)
- Yosuke Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinori Matsumoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Akihiro Ishizu
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Shin Morizane
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keigo Hayashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuriko Yamamura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sumie Hiramatsu
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiko Morishita
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiji Ohashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruki Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Katsue Sunahori Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoko Kawabata
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hirofumi Makino
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Amber KT, Maglie R, Solimani F, Eming R, Hertl M. Targeted Therapies for Autoimmune Bullous Diseases: Current Status. Drugs 2019; 78:1527-1548. [PMID: 30238396 DOI: 10.1007/s40265-018-0976-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Autoimmune bullous skin disorders are rare but meaningful chronic inflammatory diseases, many of which had a poor or devastating prognosis prior to the advent of immunosuppressive drugs such as systemic corticosteroids, which down-regulate the immune pathogenesis in these disorders. Glucocorticoids and adjuvant immunosuppressive drugs have been of major benefit for the fast control of most of these disorders, but their long-term use is limited by major side effects such as blood cytopenia, osteoporosis, diabetes mellitus, hypertension, and gastrointestinal ulcers. In recent years, major efforts were made to identify key elements in the pathogenesis of autoimmune bullous disorders, leading to the identification of their autoantigens, which are mainly located in desmosomes (pemphigus) and the basement membrane zone (pemphigoids). In the majority of cases, immunoglobulin G, and to a lesser extent, immunoglobulin A autoantibodies directed against distinct cutaneous adhesion molecules are directly responsible for the loss of cell-cell and cell-basement membrane adhesion, which is clinically related to the formation of blisters and/or erosions of the skin and mucous membranes. We describe and discuss novel therapeutic strategies that directly interfere with the production and regulation of pathogenic autoantibodies (rituximab), their catabolism (intravenous immunoglobulins), and their presence in the circulation and extravascular tissues such as the skin (immunoadsorption), leading to a significant amelioration of disease. Moreover, we show that these novel therapies have pleiotropic effects on various proinflammatory cells and cytokines. Recent studies in bullous pemphigoid suggest that targeting of immunoglobulin E autoantibodies (omalizumab) may be also beneficial. In summary, the introduction of targeted therapies in pemphigus and pemphigoid holds major promise because of the high efficacy and fewer side effects compared with conventional global immunosuppressive therapy.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of Illinois at Chicago, 808 Wood St. Room 377, Chicago, IL, 60612, USA.
| | - Roberto Maglie
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - Farzan Solimani
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology, Philipps University, Baldingerstr., 35043, Marburg, Germany.
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Navarro-Triviño F, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Navarro-Triviño FJ, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:323-330. [PMID: 29429551 DOI: 10.1016/j.ad.2017.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 10/16/2017] [Accepted: 11/05/2017] [Indexed: 12/23/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) replacement therapy has been used in immune deficiency diseases for more than 50 years. The indications for this treatment have evolved, however, and IVIG therapy is now used in various diseases in which the immune system plays a prominent role. IVIG therapy has carved out a niche in dermatology for the treatment of such conditions as dermatomyositis, autoimmune bullous diseases, and toxic epidermal necrolysis. Special attention has been paid to this therapy in recent years. New guidelines have been published and should be taken into consideration in dermatology. This review provides a practical guide to IVIG use in our specialty.
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Affiliation(s)
- F J Navarro-Triviño
- Unidad de Dermatología Médico-Quirúrgica y Venereología, Hospital Comarcal Santa Ana, Motril, España.
| | - I Pérez-López
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - R Ruíz-Villaverde
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
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Abstract
Eosinophilic lung diseases especially comprise eosinophilic pneumonia or as the more transient Löffler syndrome, which is most often due to parasitic infections. The diagnosis of eosinophilic pneumonia is based on characteristic clinical-imaging features and the demonstration of alveolar eosinophilia, defined as at least 25% eosinophils at BAL. Peripheral blood eosinophilia is common but may be absent at presentation in idiopathic acute eosinophilic pneumonia, which may be misdiagnosed as severe infectious pneumonia. All possible causes of eosinophilia, including drug, toxin, fungus related etiologies, must be thoroughly investigated. Extrathoracic manifestations should raise the suspicion of eosinophilic granulomatosis with polyangiitis.
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Tsuchida M, Fukushima T, Makino K, Miida H, Kuwabara T. [Case report of effective intravenous immunoglobulin for lower limbs pain in steroid-resistant eosinophilic granulomatosis with polyangiitis]. Rinsho Shinkeigaku 2015; 54:231-3. [PMID: 24705839 DOI: 10.5692/clinicalneurol.54.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 58-year-old woman with bronchial asthma. The onset of the disease was marked by numbness in the right lower extremity, for which she was hospitalized 10 days later. The patient presented with sensory impairment and muscle weakness in the distal regions of both lower limbs, acute pain, purpura, and a leukocyte count of 2.4 × 10(4)/μl (59.2% eosinophils). Nerve conduction tests revealed a decrease in the amplitude of the compound muscle action potential in all 4 extremities. Skin biopsy results led to the diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA). Steroid pulse therapy and oral steroid therapy were initiated but did not resolve the acute pain or numbness. However, intravenous immunoglobulin (IVIg) was administered at day 28 after the beginning of the steroid treatment, and the pain started to improve immediately afterward. In some cases, IVIg can be effective in the treatment of intense pain in peripheral neuropathy associated with steroid-resistant EGPA.
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Pego PM, Câmara IA, Andrade JP, Costa JM. Intravenous immunoglobulin therapy in vasculitic ulcers: a case of polyarteritis nodosa. AUTOIMMUNITY HIGHLIGHTS 2013; 4:95-9. [PMID: 26000148 PMCID: PMC4389026 DOI: 10.1007/s13317-013-0048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 01/21/2013] [Indexed: 11/16/2022]
Abstract
Introduction Polyarteritis nodosa (PAN) is a systemic necrotizing medium-size-vessel vasculitis with variable clinical manifestations. Diagnosis is confirmed by histology or angiography. The mainstay of treatment is corticosteroids alone or combined with cyclophosphamide (CYF). Case report Seventy-one-year-old female, follow-up started in 1997 at the age of 56 for suspected relapsing febrile viral exanthema. Skin biopsy was performed and the diagnosis of lymphomatoid papulosis was made, with complete response to treatment with dapsone. In 2005, she presented with arthralgia, lower limb (LL) edema, livedo reticularis and elevated erythrocyte sedimentation rate (ESR). PAN was confirmed on histology and visceral angiography; antineutrophil cytoplasmic antibodies (ANCA) were negative. She responded to prednisolone but relapsed in 2006. Twelve cycles of CYF were administered, with clinical, angiographic and analytical improvement. In 2008, a new relapse occured with LL neuropathic pain and ESR elevation. Electromyogram (EMG) confirmed axonal sensory polyneuropathy (PNP). Azathioprine was started with a poor response. A second EMG, 12 months later in 2009 still evidenced PNP, and nerve biopsy confirmed vasculitic neuropathy. In 2010, she had ulcers in LL and iron-deficient anemia. She started intravenous immunoglobulin (IVIG) for six cycles, achieving ulcer healing, absence of pain, no anemia and ESR normalization. Discussion IVIG therapy has proven benefit in Kawasaki disease, also showing efficacy in refractory ANCA-associated vasculitis. In PAN, only very few case reports show benefit. In this case, IVIG therapy induced total remission of LL ulcers and PNP, suggesting that it may be useful in selected cases of refractory PAN.
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Affiliation(s)
- Petra M Pego
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - Inês Aguiar Câmara
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - José Pedro Andrade
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - João Matos Costa
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
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Matsumoto T, Otsuka K, Kawamoto M, Nagata K, Tachikawa R, Imai Y, Oka N, Tomii K. Efficacy of early intravenous immunoglobulin for eosinophilic granulomatosis with polyangiitis with drastically progressive neuropathy: a synopsis of two cases. Intern Med 2013; 52:913-7. [PMID: 23583996 DOI: 10.2169/internalmedicine.52.8889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Two women, 66-year-old and 63-year-old, were admitted for drastically progressive neuropathy, and diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). Steroid pulse therapy failed to exert effect upon neuropathy, so we administered early intravenous immunoglobulin (IVIG) for fear of immobilization of neuropathy. This resulted in marked improvement in neuropathy without apparent side effects. Recent evidence suggests the efficacy of IVIG for steroid refractory neuropathy associated with EGPA, but has previously been administered during the chronic phase resulting in slow improvement. Our two successfully treated cases indicate the efficacy of early IVIG in preventing the immobilization of neuropathy, especially in progressive cases.
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Affiliation(s)
- Takeshi Matsumoto
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan.
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Asashima H, Inokuma S, Yamada H. Step by step improvement of peripheral polyneuropathy associated with Churg-Strauss syndrome by six courses of high-dose intravenous immunoglobulin therapy. Allergol Int 2012; 61:503-5. [PMID: 22722815 DOI: 10.2332/allergolint.12-le-0431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Uchiyama M, Mitsuhashi Y, Yamazaki M, Tsuboi R. Elderly cases of Churg-Strauss syndrome: case report and review of Japanese cases. J Dermatol 2011; 39:76-9. [PMID: 22133207 DOI: 10.1111/j.1346-8138.2011.01316.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Churg-Strauss syndrome (CSS) is a vasculitis usually thought to affect comparatively young individuals, however, elderly cases of CSS are being reported increasingly. We report two elderly cases of CSS and review 123 cases of CSS reported in Japan between 2003 and 2010. The two patients showed typical features of CSS such as asthma, chronic sinusitis, purpura and mononeuritis multiplex. The biopsy specimens demonstrated leukocytoclastic vasculitis with infiltration of eosinophils. Both patients responded well to oral prednisolone. The age of the CSS cases we reviewed ranged from the teens to the 80s, with 47.2% of the patients aged 60 years or older. These patients tended more frequently to have complications such as gastrointestinal involvement, and a higher mortality rate. Elderly cases of CSS are not rare. Correct diagnosis at an earlier stage and careful, long-term follow up are of particular importance in preventing a fatal outcome.
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Affiliation(s)
- Masaki Uchiyama
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan.
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Kobayashi D, Wada Y, Takata T, Koya T, Murakami S, Ozawa T, Aizawa Y, Kuroda T, Nakano M, Narita I. A severe form of Churg-Strauss syndrome complicated with acute cardiac failure and rapidly progressive peripheral neuropathy--a possible effect of intravenous immunoglobulin therapy. Intern Med 2011; 50:925-9. [PMID: 21498944 DOI: 10.2169/internalmedicine.50.4648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of Churg-Strauss syndrome (CSS) complicated by severe cardiac failure and peripheral neuropathy. Two courses of methylprednisolone pulse therapy were unable to control the disease activity. Repeated intravenous administration of high-dose human immunoglobulin (IVIg) was added together with intravenous cyclophosphamide pulse therapy (IVCY), and the patient's cardiac function and neurological symptoms were gradually ameliorated without any adverse event. Although glucocorticoid and cyclophosphamide comprise the standard therapy for patients with CSS, a number of patients with severe complications appear to be resistant to such conventional treatment. IVIg is thought to be an effective therapeutic option for such patients.
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Affiliation(s)
- Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Department of Medicine II, Niigata University Graduate School of Medical and Dental Sciences, Japan.
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Vaitla PM, McDermott EM. The role of high-dose intravenous immunoglobulin in rheumatology. Rheumatology (Oxford) 2010; 49:1040-8. [DOI: 10.1093/rheumatology/keq021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.
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Affiliation(s)
- Anthony P Fernandez
- Department of Dermatology and Cutaneous Surgery, Unversity of Miami Miller School of Medicine, Miami, Florida, USA
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Taniguchi M, Tsurikisawa N, Higashi N, Saito H, Mita H, Mori A, Sakakibara H, Akiyama K. Treatment for Churg-Strauss syndrome: induction of remission and efficacy of intravenous immunoglobulin therapy. Allergol Int 2007; 56:97-103. [PMID: 17460439 DOI: 10.2332/allergolint.r-07-142] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Indexed: 11/20/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is characterized by the presence of asthma, eosinophilia, and small-vessel vasculitis with granuloma. It is a distinct entity, as determined from all classifications of systemic vasculitis. The poor prognostic factors in CSS are renal insufficiency, cardiomyopathy, severe gastrointestinal (GI) tract, and central nervous systems (CNS) involvement. The initial management of CSS should include a high dose of a corticosteroid: prednisone at 1 mg/kg/day or its equivalent for methylprednisolone with tapering over 6 months. In patients with severe or rapidly progressing CSS, the administration of methylprednisolone pulse at 1 g/body/day for 3 days is recommended. When corticosteroid therapy does not induce remission, or when patients have poor prognostic factors, immunosuppressive cytotoxic therapy is indicated. However, some patients with severe CSS often show resistance to conventional treatment. We think that IVIG therapy is a hopeful candidate for second-line treatment for CSS patients, particularly in the case of neuropathy and/or cardiomyopathy, which are resistant to conventional therapy. However, there is not much evidence supporting the effectiveness of IVIG in CSS, and the mechanisms underlying the action of IVIG remain unclear. Now we are performing clinical trials of IVIG therapy for CSS patients who are resistant to conventional treatment, through a nationwide double-blinded placebo-controlled study in Japan.
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Affiliation(s)
- Masami Taniguchi
- National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan.
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Hot A, Perard L, Coppere B, Simon M, Bouhour F, Ninet J. Marked improvement of Churg-Strauss vasculitis with intravenous gamma globulins during pregnancy. Clin Rheumatol 2007; 26:2149-2151. [PMID: 17486292 DOI: 10.1007/s10067-007-0628-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Revised: 03/24/2007] [Accepted: 04/11/2007] [Indexed: 01/18/2023]
Abstract
Churg-Strauss syndrome (CSS) is an extremely rare disease, and even less common in women of childbearing age. Patients with severe disease or those who are un-responsive to corticosteroids are usually treated with cytotoxic drugs, especially cyclophosphmide. Intravenous immunoglobulin (IVIg) has became a promising, but not completely accepted, form of treatment for systemic vasculitis that is un-responsive to standard therapy. We report a case of a woman who presented with a CSS flare during pregnancy. Because of mono-neuritis, treatment with IVIg was instituted with successful results. Our case not only supports the beneficial effect of IVIg in CSS, but it also illustrates its successful and safe use in a patient who was pregnant. We discuss the indication of IVIg during the course of anti-neutrophil cytoplasm antigen (ANCA) vasculitis during the pregnancy.
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Affiliation(s)
- Arnaud Hot
- Service de Medecine Interne, Hôpital Edouard Herriot, 3 Place Arsonval, Lyon, CEDEX 03, 69003, France.
| | - Laurent Perard
- Service de Medecine Interne, Hôpital Edouard Herriot, 3 Place Arsonval, Lyon, CEDEX 03, 69003, France
| | - Brigitte Coppere
- Service de Medecine Interne, Hôpital Edouard Herriot, 3 Place Arsonval, Lyon, CEDEX 03, 69003, France
| | - Marie Simon
- Service de Medecine Interne, Hôpital Edouard Herriot, 3 Place Arsonval, Lyon, CEDEX 03, 69003, France
| | - Françoise Bouhour
- Service de Neurologie, Hôpital Pierre Wertheimer, 59, Boulevard Pinel, Bron, 69394, France
| | - Jacques Ninet
- Service de Medecine Interne, Hôpital Edouard Herriot, 3 Place Arsonval, Lyon, CEDEX 03, 69003, France
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Tsurikisawa N. [Asthma-related diseases. Churg-Strauss syndrome]. ACTA ACUST UNITED AC 2006; 95:1493-500. [PMID: 16955936 DOI: 10.2169/naika.95.1493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Churg-Strauss syndrome (CSS) is a rare multi-system vasculitis; some cases have been reported in Korea. The aim of this study is to describe the clinical features, treatment outcome, and long-term follow-up of CSS from a single Korean medical center. Between 1995 and 2004, seventeen patients were diagnosed with CSS at the Department of Medicine of the Samsung Medical Center, Sungkyunkwan University School of Medicine. The diagnosis of CSS is based on the classification criteria of the American Collage of Rheumatology. All patients had asthma. As in other case series, the lung, peripheral nervous system, and skin were the most commonly involved organs. During the active stage of the disease, most of the patients exhibited peripheral blood eosinophilia and an elevated serum eosinophil cationic protein level. Ten patients were treated with pulses of methylprednisolone followed by tapering and cyclophosphamide, and the others were treated with corticosteroids alone. The outcomes after long-term follow-up were generally good. One patient who was refractory to initial treatment died of heart failure during the follow-up period. CSS was highly variable in its presentation and course. The manifestations may range from mild symptoms to life-threatening conditions. The outcome after long-term follow-up was as good as that of previous studies.
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Affiliation(s)
- Mi-Jung Oh
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam-Hee Kwon
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Chull Choi
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Takigawa N, Kawata N, Shibayama T, Tada A, Kimura G, Munemasa M, Soda R, Takahashi K. Successful treatment of a patient with severe Churg-Strauss syndrome by a combination of pulse corticosteroids, pulse cyclophosphamide, and high-dose intravenous immunoglobulin. J Asthma 2005; 42:639-41. [PMID: 16266953 DOI: 10.1080/02770900500263822] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 24-year-old woman with a 4-year history of bronchial asthma suffered from bloody sputum, numbness of the extremities, elevated eosinophil count, and hypoxemia. A diagnosis of alveolar hemorrhage was made by bronchoalveolar lavage. Echocardiogram revealed severe hypokinesis of the left ventricular wall. Her respiratory condition deteriorated despite administration of pulse corticosteroids. A second pulse corticosteroids and pulse cyclophosphamide followed by high-dose intravenous immunoglobulin brought about a dramatic improvement of alveolar hemorrhage, cardiac impairment, and peripheral neuropathy. Levels of antimyeloperoxidase-antineutrophil cytoplasmic antibodies, soluble thrombomodulin, soluble interleukin-2 receptor, eosinophil cationic protein were elevated and returned to the normal range in remission. The combination of pulse corticosteroids, pulse cyclophosphamide, and high-dose intravenous immunoglobulin seemed effective for the acute phase of severe Churg-Strauss syndrome.
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Affiliation(s)
- Nagio Takigawa
- Department of Internal Medicine, National Hospital Organization, Minami-Okayama Medical Center, Okayama, Japan.
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Danieli MG, Cappelli M, Malcangi G, Logullo F, Salvi A, Danieli G. Long term effectiveness of intravenous immunoglobulin in Churg-Strauss syndrome. Ann Rheum Dis 2004; 63:1649-54. [PMID: 15547090 PMCID: PMC1754837 DOI: 10.1136/ard.2003.015453] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To study the long term effectiveness of intravenous immunoglobulin and plasmapheresis associated with prednisone and cyclophosphamide in Churg-Strauss syndrome. SUBJECTS and methods: We studied 18 subjects with new onset Churg-Strauss syndrome. All received the "standard" treatment based on prednisone (1 mg/kg/day for 1 month and then slowly tapered) and cyclophosphamide (2 mg/kg/day for 6 months in severe cases). In nine patients, synchronised cycles with plasmapheresis and intravenous immunoglobulin (2 g/kg) were repeated monthly for 6 months and every other month for a further three cycles. Clinical (disease activity monitored by Birmingham vasculitis activity score (BVAS) and damage index (modified Rankin score)) and functional (C reactive protein, blood eosinophil count, and electromyogram-electoneurogram) parameters were collected during treatment and the 3 year follow up period. RESULTS After 12 months, all patients in the treatment group and four (44%) in the control group were in remission. At the end of the 3 year follow up period, we documented significant differences in BVAS (p<0.01), global damage (p<0.02), modified Rankin score (p<0.04), and the daily maintenance prednisone dose (p<0.002) between the two groups. We found a tendency towards lower frequency of relapse and incidence of osteoporosis in the treatment group. CONCLUSION Complete clinical and functional recovery with a long term stable remission and a low incidence of side effects can be achieved by intravenous immunoglobulin associated with plasmapheresis in patients with Churg-Strauss syndrome.
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Affiliation(s)
- M G Danieli
- Istituto Clinica Medica Generale, Ematologia ed Immunologia Clinica, Polo Didattico Scientifico, Via Tronto 20, 60020, Torrette di Ancona, Italy.
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21
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Semple D, Keogh J, Forni L, Venn R. Clinical review: Vasculitis on the intensive care unit -- part 2: treatment and prognosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:193-7. [PMID: 15774077 PMCID: PMC1175906 DOI: 10.1186/cc2937] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The second part of this review addresses the treatment and prognosis of the vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg–Strauss syndrome and polyarteritis nodosa. Treatment regimens consist of an initial remission phase with aggressive immunosuppression, followed by a more prolonged maintenance phase using less toxic agents and doses. This review focuses on the initial treatment of fulminant vasculitis, the mainstay of which remains immunosuppression with steroids and cyclophosphamide. For Wegener's granulomatosis and microscopic polyangiitis plasma exchange can be considered for first-line therapy in patients with acute renal failure and/or pulmonary haemorrhage. Refractory disease is rare and is usually due to inadequate treatment. The vasculitides provide a particular challenge for the critical care team. Particular aspects of major organ support related to these conditions are discussed. Effective treatment has revolutionized the prognosis of these conditions. However, mortality is still approximately 50% for those requiring admission to intensive care unit. Furthermore, there is a high morbidity associated with both the diseases themselves and the treatment.
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Affiliation(s)
- David Semple
- Specialist Registrar Renal Medicine, Worthing Hospital, Worthing, UK
| | - James Keogh
- Specialist Registrar Anaesthetics, Worthing Hospital, Worthing, UK
| | - Luigi Forni
- Consultant Physician, Worthing Hospital, Worthing, UK
| | - Richard Venn
- Consultant Anaesthetist, Worthing Hospital, Worthing, UK
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22
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Tsurikisawa N, Taniguchi M, Saito H, Himeno H, Ishibashi A, Suzuki S, Akiyama K. Treatment of Churg-Strauss syndrome with high-dose intravenous immunoglobulin. Ann Allergy Asthma Immunol 2004; 92:80-7. [PMID: 14756469 DOI: 10.1016/s1081-1206(10)61714-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In some patients with Churg-Strauss syndrome (CSS), especially those with myocardial or neural involvement, conventional treatment with corticosteroids with or without cyclophosphamide is not effective. OBJECTIVE To examine the effects of intravenous high-dose immunoglobulin (IVIG) in patients with CSS who showed poor responsiveness to conventional treatment. METHODS We consecutively selected patients with CSS who showed any organ involvement despite corticosteroid treatment with or without cyclophosphamide. The diagnosis was based on the classification criteria of the American College of Rheumatology. IVIG therapy was performed with a dose of 400 mg/kg of immunoglobulin daily for 5 days. Neuropathy was evaluated with the manual muscle strength test and by the skin temperature of affected sites. Cardiac function was examined with ejection fraction by echocardiography and 2 imaging tests of myocardium (iodine 123 metaiodobenzylguanidine and thallium 201). RESULTS The manual muscle strength test results were improved, and the skin temperature of both hands and legs was increased by IVIG therapy. In 5 patients with heart failure, the mean +/- SD ejection fraction of the left ventricle increased from 35.2% +/- 13.9% to 61.0% +/- 10.1% (P < .02). The uptake of iodine 123 metaiodobenzylguanidine of the myocardium increased, indicating that the myocardial viability was improved. The thallium 201 images revealed the presence of perfusion defects, which were improved by IVIG therapy. CONCLUSIONS Patients with CSS who are resistant to corticosteroid treatment with or without cyclophosphamide may be treated effectively with IVIG therapy.
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Affiliation(s)
- Naomi Tsurikisawa
- Clinical Research Center of Sagamihara National Hospital, Sagamihara, Kanagawa-ken, Japan.
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23
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Kamali S, Cefle A, Sayarlioglu M, Gul A, Inanc M, Ocal L, Aral O, Konice M. Experience with monthly, high-dose, intravenous immunoglobulin therapy in patients with different connective tissue diseases. Rheumatol Int 2004; 25:211-4. [PMID: 14722731 DOI: 10.1007/s00296-003-0422-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Accepted: 10/25/2003] [Indexed: 11/27/2022]
Abstract
We aimed to investigate the efficacy and safety profile of high-dose intravenous immunoglobulin (HD-IVIG) therapy in patients with severe systemic lupus erythematosus (SLE), inflammatory muscle disease (IMD), Wegener's granulomatosis (WG), and/or concurrent infection who failed to respond to standard therapies. We evaluated the records of eight patients with SLE, eight with IMD, and four with WG who were treated with HD-IVIG (2 g/kg per month for 1-12 months) for active disease in 19 patients and concurrent infection in three (mycobacterial in two with SLE and cytomegaloviral in one with WG). Systemic lupus erythematosus disease activity index (SLEDAI) scores before and after HD-IVIG were statistically analysed. Remission was achieved in 14 cases (70%). The SLEDAI scores significantly decreased in patients with SLE (P=0.02). No serious side effect was observed. High-dose IVIG may be used as an adjunctive treatment in connective tissue diseases that do not respond to standard therapies or as alternative treatment for patients with concurrent severe infections or for whom immunosuppressives are contraindicated.
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Affiliation(s)
- Sevil Kamali
- Department of Rheumatology, Division of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, Turkey.
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24
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Hellmich B, Gross WL. Recent progress in the pharmacotherapy of Churg-Strauss syndrome. Expert Opin Pharmacother 2004; 5:25-35. [PMID: 14680433 DOI: 10.1517/14656566.5.1.25] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Churg-Strauss syndrome (CSS) is a primary systemic vasculitis occurring primarily in patients with asthma. Unlike other small vessel vasculitides, CSS is characterised by blood and tissue eosinophilia. Corticosteroids are the therapy of first choice for all stages of the disease when active vasculitis needs to be treated rapidly. In patients with severe disease and organ- or life-threatening manifestation, the addition of cyclophosphamide appears to improve the outcome and reduces the incidence of relapses. In cases with an apparently better prognosis and less severe disease, methotrexate can be given as a corticosteroid-sparing agent in order to reduce the cumulative dose of corticosteroids, which is generally high in most cases as long-term administration of corticosteroids is often inevitable in order to control asthma, even if the vasculitis is inactive. In very severe cases of CSS, cyclophosphamide and corticosteroids may be insufficient to induce remission. In these cases, anti-TNF blocking agents such as infliximab or etanercept, may be added for a limited period of time. As this intense immunosuppression increases the risk for infections, a prophylaxis with sulfamethoxazole/trimethoprim is advised. Alternatively, the administration of recombinant IFN-alpha can be a effective when given on a short-term basis in otherwise refractory cases. Whether a continuous administration of immunosuppressive agents in addition to corticosteroids can reduce the frequency of relapses in CSS who are in remission is still unknown. As relapses occur in > 25% of all patients, studies addressing the prevention of relapses in CSS are highly desirable in the future.
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Affiliation(s)
- Bernhard Hellmich
- Poliklinik für Rheumatologie, Universitätsklinikum Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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25
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Abstract
Intravenous immunoglobulin (IVIG) preparations are fractionated from a plasma pool of several thousand donors. IVIG contain immune antibodies and physiologic autoantibodies. Immune antibodies reflect the immunologic experience of the donor population. This fraction of IVIG preparations is useful for replacement therapy and passive immunisation. Natural autoantibodies are able to react with the immune system of the recipient of IVIG and are suggested to help to correct immune deregulation. Immunomodulatory and anti-inflammatory properties are based on multiple mechanisms of action which are described. These mechanisms are effective concomitantly and synergistically at every occasion of use of IVIG in inflammatory and autoimmune disorders.
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Affiliation(s)
- H U Simon
- Department of Pharmacology, University of Bern, Switzerland; ZLB Bioplasma AG, Bern, Switzerland
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26
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Abstract
Churg-Strauss syndrome is a rare diffuse vasculitis that is almost invariably accompanied by severe asthma. Although overall prognosis is good, and treatment with prednisone alone or in combination with immunosuppressive drugs is usually successful, severe asthma typically persists. Diffuse organ involvement of Churg-Strauss syndrome, especially cardiovascular and rare involvement of the CNS and renal system, suggests a poorer prognosis than usual, and can be fatal. The cause of Churg-Strauss syndrome is unknown, but its characteristic histological findings and association with asthma distinguish it from other vasculitides. Controversy surrounds the use of asthma drugs-especially antileukotrienes--and development of the disorder. We review the epidemiological evidence for an association of drug treatment with Churg-Strauss syndrome, the diverse diagnostic and pathological criteria for this syndrome, and treatment options.
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Affiliation(s)
- Imre Noth
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, and Committees on Clinical Pharmacology and Pharmacogenetics and Molecular Medicine, University of Chicago, Chicago, IL, USA
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27
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28
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Abstract
The Churg Strauss Syndrome is an eosinophil-associated small vessel vasculitis. Although its pathogenesis may be distinctive and the association with severe late-onset asthma typical, the clinical features during the vasculitic phase widely overlap with those of the other forms of necrotizing vasculitis, and no single clinical or histologic feature is pathognomic of the condition. Renal involvement is common, although usually mild, and even when severe it tends to respond well to treatment. The prognosis for both patient and renal survival with adequate treatment is in general good. The optimal treatment strategy, however, is uncertain, and may differ from that for the other vasculitides. In particular, in contrast to Wegener's granulomatosis, the need for routine cyclophosphamide treatment is unconfirmed and requires further study.
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Affiliation(s)
- J A Eustace
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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29
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Abstract
Intravenous immunoglobulin (IVIG) has been used for many years to treat patients with primary immunodeficiencies. More recently, IVIG has been shown to have anti-inflammatory activity when used at substantially higher concentrations. A number of studies have examined the efficacy of IVIG in allergic diseases. For patients with severe refractory asthma, sinusitis, atopic dermatitis, and urticaria, IVIG offers an alternative therapy with relatively few side-effects. Although the mechanism by which IVIG may attenuate the allergic response is still undetermined, clinical studies have shown that immunoglobulin therapy can decrease serum IgE levels and increase glucocorticoid binding affinity, while in vitro studies have shown that IVIG can decrease T-cell secretion of TH2 cytokines. Further studies are needed to confirm the initial encouraging results seen in allergic patients with severe, resistant disease.
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Affiliation(s)
- N Rabinovitch
- Department of Pediatrics, National Jewish Medical and Research Center, Denver, CO, USA
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30
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Affiliation(s)
- V Cottin
- Service de Pneumologie, Hôpital Cardiovasculaire et Pneumologique, Louis Pradel, Université Claude Bernard, Lyon, France
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31
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Ciaccia A, Ferrari M, Facchini FM, Caramori G, Fabbri L. Pulmonary vasculitis: classification, clinical features, and management. Clin Rev Allergy Immunol 1997; 15:73-95. [PMID: 9209803 DOI: 10.1007/bf02828279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- A Ciaccia
- Laboratorio di Ricerca sull'Asma Bronchiale, Azienda Ospedaliera S. Anna, Ferrara, Italy
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32
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Affiliation(s)
- E R Stiehm
- Department of Pediatric Immunology, University of California-Los Angeles Medical School, USA
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33
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Abstract
With the advent of numerous commercial preparations of intravenous immunoglobulin preparations since 1981, it is now possible to administer these preparations in significant quantities to cause elevation of serum immunoglobulin levels both in patients with antibody-deficient states and in those with normal circulating immunoglobulin levels. This led to a report of dramatic improvement of thrombocytopenia in a child with agammaglobulinemia following the use of intravenous immunoglobulin preparations for recurrent infections, and further studies in both children and adults with associated symptoms suggested therapeutic efficacy of intravenous immunoglobulin preparations in controlling autoimmune symptoms.
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Affiliation(s)
- L W Klassen
- University of Nebraska Medical Center, Omaha, USA
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34
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Jordan SC. Treatment of systemic and renal-limited vasculitic disorders with pooled human intravenous immune globulin. J Clin Immunol 1995; 15:76S-85S. [PMID: 8613496 DOI: 10.1007/bf01540897] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Idiopathic crescentic glomerulonephritis is characterized by an absence of immunohistological evidence of immune deposits, often with evidence of segmental glomerular necrosis. Such pauciimmune crescentic glomerulonephritis is the most common renal manifestation seen in patients with Wegener's granulomatosis, polyarteritis nodosa, and glomerulonephritis associated with other systemic vasculitic disorders (i.e., Churg-Strauss syndrome). Recently, the idiopathic crescentic glomerulonephritides, either in renal-limited form or in association with other systemic vasculitic disorders, were found to have in common a serologic marker, antineutrophil cytoplasmic autoantibodies. These cytoplasmic and perinuclear antineutrophil cytoplasmic autoantibodies are specific for constituents of neutrophil primary granules and monocyte lysosomes. As serologic markers for vasculitic disorders, they are also felt to be directly involved in the pathogenesis of necrotizing vascular injury. In vitro, both perinuclear and cytoplasmic antineutrophil cytoplasmic autoantibodies are capable of causing cytokine-primed neutrophils to undergo degranulation and respiratory burst, releasing toxic oxygen species and lytic enzymes. Anti-idiotype antibodies which inhibit antineutrophil cytoplasmic autoantibodies in vitro, in a V region-dependent manner, are found in pooled human gamma-globulin preparation. Intravenous immune globulin infusions in vivo have produced dramatic improvements in the necrotizing vascular injury produced by antineutrophil cytoplasmic autoantibodies, and a rapid reduction in these autoantibody levels is seen post-intravenous immune globulin infusion in most patients. The proposed mechanisms of action of intravenous immune globulin in vasculitic disorders include Fc-dependent mechanisms, and F(ab')2-dependent mechanisms are likely important. Intravenous immune globulin infusions appear to have an important place in the management of the necrotizing vascular injury. Blinded, randomized, placebo-controlled trials will be necessary to establish definitely intravenous immune globulin as a therapeutic option in vasculitic disorders.
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Affiliation(s)
- S C Jordan
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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35
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Adlakha A, Rao K, Adlakha K, Ryu JH. A case of pediatric Wegener's granulomatosis with recurrent venous thromboses treated with intravenous immunoglobulin and laryngotracheoplasty. Pediatr Pulmonol 1995; 20:265-8. [PMID: 8606857 DOI: 10.1002/ppul.1950200410] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- A Adlakha
- Department of Internal Medicine, Mayo Graduate School of Medicine, Rochester MN 55905, USA
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36
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Affiliation(s)
- R I Schiff
- Division of Allergy and Immunology, Duke University Medical Center, Dunham, NC 27710
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37
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Lhote F, Guillevin L, Godeau P. [Allergic angiitis with granulomatosis: the Churg and Strauss syndrome]. Rev Med Interne 1994; 15 Suppl 2:226s-233s. [PMID: 8079075 DOI: 10.1016/s0248-8663(05)82240-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Churg-Strauss Syndrome is a disorder characterized by pulmonary and systemic necrotizing vasculitis, extravascular granulomas, and eosinophilia occurring almost exclusively in patients with asthma or a history of allergy. The clinical manifestations most commonly associated with asthma are mononeuritis multiplex, gastrointestinal, cutaneous, cardiac and renal involvement. ANCA are found in 2/3 of the patients with Churg-Strauss Syndrome and are usually p-ANCA. The treatment of Churg-Strauss Syndrome relies on corticosteroids and cyclophosphamide.
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Affiliation(s)
- F Lhote
- Service de médecine interne, hôpital Delafontaine, Saint-Denis, France
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38
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Abstract
Progress in the treatment of systemic vasculitis have permitted a decrease of mortality but with an increase in iatrogenic morbidity. Steroids remain the cornerstone of the treatment but precise modalities and other concomitant treatments are depending upon the type of vasculitis. In most cases, systemic vasculitis are primary and the treatment, although important, is symptomatic. However, in some cases such as hepatitis B virus-induced polyarteritis nodosa or hepatitis C virus-induced cryoglobulinemia, the treatment can be etiologic and is directed against the antigen responsible for the systemic vasculitis. In the future, a better understanding of pathological mechanisms, particularly of etiologic factors, and new treatment such as monoclonal antibodies should increase the prognosis of systemic vasculitis.
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Affiliation(s)
- P Cacoub
- Service de médecine interne, hôpital de La Pitié-Salpêtrière, Paris, France
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39
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Tuso P, Moudgil A, Hay J, Goodman D, Kamil E, Koyyana R, Jordan SC. Treatment of antineutrophil cytoplasmic autoantibody-positive systemic vasculitis and glomerulonephritis with pooled intravenous gammaglobulin. Am J Kidney Dis 1992; 20:504-8. [PMID: 1442764 DOI: 10.1016/s0272-6386(12)70265-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antineutrophil cytoplasmic autoantibody (ANCA) is considered a serological marker for disease activity in patients with ANCA(+) systemic vasculitis. Recently, ANCA has been implicated as a pathogenic antibody that may be associated with neutrophil degranulation and release of lytic enzymes. Since intravenous gammaglobulin (IVIG) is known to contain antiidiotypic antibodies to ANCA, which could decrease the activity of the later, we chose to treat two patients with symptomatic ANCA(+) systemic vasculitis and glomerulonephritis with high-dose IVIG. The first patient, a 66-year-old man, developed rapidly progressive renal failure despite treatment with intravenous (IV) cyclophosphamide. The second patient, a 14-year-old boy, had relapsed 3 months after cessation of treatment with prednisone and cyclophosphamide. Both patients improved dramatically after treatment with IVIG, with the former recovering renal function within 11 days of therapy. In both patients, a concomitant reduction in serum ANCA titers was also observed. The second patient is currently in a sustained remission 14 months after his last IVIG dose on no other medication. These cases provide clinical evidence that IVIG has therapeutic benefit in modifying the immune-mediated injury associated with ANCA(+) systemic vasculitis and glomerulonephritis. In addition, IVIG may provide an additional safe therapeutic option to clinicians treating patient's with ANCA(+) vasculitis and glomerulonephritis who are not responsive to or are experiencing toxicity from conventional therapy.
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Affiliation(s)
- P Tuso
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
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40
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Stiehm ER. Recent progress in the use of intravenous immunoglobulin. CURRENT PROBLEMS IN PEDIATRICS 1992; 22:335-48. [PMID: 1424756 DOI: 10.1016/0045-9380(92)90022-q] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- E R Stiehm
- Division of Pediatric Immunology and Allergy, UCLA Medical Center
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