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Cler SJ, Ogden MA, Farrell NF, Roland LT, Diffie CE, Schneider JS. When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. Am J Otolaryngol 2024; 45:104207. [PMID: 38176206 DOI: 10.1016/j.amjoto.2023.104207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients. OBJECTIVE Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics. METHODS Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review. RESULTS 467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review. CONCLUSION GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.
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Affiliation(s)
- Samuel J Cler
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America.
| | - M Allison Ogden
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Nyssa Fox Farrell
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Lauren T Roland
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Colin E Diffie
- Washington University in St. Louis School of Medicine, Department of Medicine, Division of Rheumatology, United States of America
| | - John S Schneider
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
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Reggiani F, L’Imperio V, Calatroni M, Pagni F, Sinico RA. Renal involvement in eosinophilic granulomatosis with polyangiitis. Front Med (Lausanne) 2023; 10:1244651. [PMID: 37790127 PMCID: PMC10544898 DOI: 10.3389/fmed.2023.1244651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a necrotizing vasculitis, which typically affects small-to medium-sized blood vessels. It is characterized by the presence of tissue infiltrates rich in eosinophils, along with the formation of granulomatous lesions. About 40% of cases have positive anti-neutrophil cytoplasm antibodies (ANCA), with predominant perinuclear staining, and anti-myeloperoxidase (anti-MPO) specificity in about 65% of cases. Typical manifestations of EGPA include the late onset of asthma, nasal and sinus-related symptoms, peripheral neuropathy, and significant eosinophilia observed in the peripheral blood. In contrast to granulomatosis with polyangiitis and microscopic polyangiitis, renal involvement in EGPA is less frequent (about 25%) and poorly studied. Necrotizing pauci-immune crescentic glomerulonephritis is the most common renal presentation in patients with ANCA-positive EGPA. Although rarely, other forms of renal involvement may also be observed, such as eosinophilic interstitial nephritis, mesangial glomerulonephritis, membranous nephropathy, or focal sclerosis. A standardized treatment for EGPA with renal involvement has not been defined, however the survival and the renal outcomes are usually better than in the other ANCA-associated vasculitides. Nonetheless, kidney disease is an adverse prognostic factor for EGPA patients. Larger studies are required to better describe the renal involvement, in particular for patterns different from crescentic glomerulonephritis, and to favor the development of a consensual therapeutic approach. In this article, in addition to personal data, we will review recent findings on patient clinical phenotypes based on ANCA, genetics and the impact of biological drugs on disease management.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Vincenzo L’Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS (Scientific Institute for Research, Hospitalization and Healthcare) Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS (Scientific Institute for Research, Hospitalization and Healthcare) Fondazione San Gerardo dei Tintori, Monza, Italy
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Jinno Y, Kozu Y, Hiranuma H, Maruoka S, Gon Y. A Changing Anti-Neutrophil Cytoplasmic Antibody Profile in a Patient With a Diagnosis of Eosinophilic Granulomatosis With Polyangiitis. J Med Cases 2023; 14:299-306. [PMID: 37692370 PMCID: PMC10482595 DOI: 10.14740/jmc4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/25/2023] [Indexed: 09/12/2023] Open
Abstract
This report describes a hitherto unique case of eosinophilic granulomatosis with polyangiitis (EGPA), a subtype of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The patient was an 81-year-old man whose clinical course involved notable changes in the ANCA profile, specifically a transition from positive proteinase 3 (PR3)-ANCA to myeloperoxidase (MPO)-ANCA, followed by simultaneous positivity for both. The patient's medical history included bronchial asthma, allergic rhinitis, sinusitis, and multiple comorbidities. Despite being initially PR3-ANCA-positive, subsequent admissions demonstrated MPO-ANCA positivity along with eosinophilic manifestations, highlighting the complexity of diagnosis of EGPA. Diagnostic evaluation included imaging, serological markers, and clinical symptoms, which collectively supported the classification of EGPA. Notably, this case challenges the conventional diagnostic paradigms and emphasizes the evolving nature of ANCA profiles in vasculitis. The shift in ANCA profile prompted a reevaluation of the patient's diagnosis and treatment strategy. This case underscores the importance of considering fluctuations in ANCA in patients with a diagnosis of EGPA, management decisions, and potential implications for disease progression. Further research is warranted to elucidate the mechanisms underlying changes in ANCA and their clinical significance in vasculitis.
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Affiliation(s)
- Yusuke Jinno
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Kozu
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hisato Hiranuma
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shuichiro Maruoka
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuhiro Gon
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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Bloom JL, Langford CA, Wechsler ME. Therapeutic Advances in Eosinophilic Granulomatosis with Polyangiitis. Rheum Dis Clin North Am 2023; 49:563-584. [PMID: 37331733 DOI: 10.1016/j.rdc.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis that affects a variety of organ systems. Historically, glucocorticoids and a variety of other immunosuppressants were used to abrogate the inflammation and tissue injury associated with EGPA. The management of EGPA has evolved greatly during the last decade with the development of novel targeted therapeutics that have resulted in significantly improved outcomes for these patients, with many more novel targeted therapies emerging.
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Affiliation(s)
- Jessica L Bloom
- Section of Rheumatology, Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue B-311, Aurora, CO 80045, USA
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44195, USA
| | - Michael E Wechsler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, J215, 1400 Jackson Street, Denver, CO 80206, USA.
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Garcia-Blanco MJ, Rodeles FJ, Muñoz L, Lopez-Anguita S, Ruiz-Esteban R. Eosinophilic Granulomatosis With Polyangiitis Presentation After Nandrolone Withdrawal. Cureus 2023; 15:e42973. [PMID: 37671218 PMCID: PMC10475853 DOI: 10.7759/cureus.42973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
A 41-year-old man was admitted to the Emergency Department with bilateral numbness in lower extremities and left femoral palsy. He also reported constitutional symptoms, vomiting and non-bloody diarrhoea for the last several months. He had a previous history of eosinophilic asthma with erratic follow-up. During admission, eosinophil count was 66% of white blood cells. Sural nerve biopsy revealed vasculitis with eosinophilic infiltration. Further evaluations consisted of colonoscopy and nasal endoscopy that confirmed eosinophil infiltrates on colonic ulcers and nasal polypi. The patient was started on systemic corticosteroids and cyclophosphamide. Among his personal records, he had been taking nandrolone decanoate without medical prescription, and had withdrawn a few years before the first asthma exacerbation.
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Affiliation(s)
- Maria J Garcia-Blanco
- Department of Internal Medicine, Hospital Central de la Defensa - Gomez Ulla, Madrid, ESP
- Medicine, Universidad de Alcala, Alcalá de Henares, ESP
| | | | - Laura Muñoz
- Department of Internal Medicine, Hospital Central de la Defensa - Gomez Ulla, Madrid, ESP
| | - Sergio Lopez-Anguita
- Department of Neurology, Hospital Central de la Defensa - Gomez Ulla, Madrid, ESP
| | - Raul Ruiz-Esteban
- Department of Internal Medicine, Hospital Central de la Defensa - Gomez Ulla, Madrid, ESP
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Quirce S, Cosío BG, España A, Blanco R, Mullol J, Santander C, del Pozo V. Management of eosinophil-associated inflammatory diseases: the importance of a multidisciplinary approach. Front Immunol 2023; 14:1192284. [PMID: 37266434 PMCID: PMC10229838 DOI: 10.3389/fimmu.2023.1192284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023] Open
Abstract
Elevated eosinophil counts in blood and tissue are a feature of many pathological processes. Eosinophils can migrate and accumulate in a wide variety of tissues and, by infiltrating a target organ, can mediate the development of several inflammatory diseases. The normalization of eosinophilia is a common biomarker of a treatable trait and can also be used as a prognostic and predictive biomarker since it implies a reduction in type 2 inflammation that contributes to disease pathogenesis. Biological therapies targeting this cell type and its proinflammatory mediators have been shown to be effective in the management of a number of eosinophilic diseases, and for this reason they constitute a potential common strategy in the treatment of patients with various multimorbidities that present with type 2 inflammation. Various biological options are available that could be used to simultaneously treat multiple target organs with a single drug, bearing in mind the need to offer personalized treatments under the umbrella of precision medicine in all patients with eosinophil-associated diseases (EADs). In addition to reviewing these issues, we also discuss a series of perspectives addressing the management of EAD patients from a multidisciplinary approach, with the collaboration of health professionals from different specialties who manage the different multimorbidities that frequently occur in these patients. We examine the basic principles of care that this multidisciplinary approach must cover and present a multidisciplinary expert opinion regarding the ideal management of patients with EADs, from diagnosis to therapeutic approach and follow-up.
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Affiliation(s)
- Santiago Quirce
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Department of Allergology, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Borja G. Cosío
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Department of Respiratory Medicine, Hospital Universitari Son Espases, Fundación Instituto de Investigación Sanitaria Islas Baleares (IdiSBa), Palma de Mallorca, Spain
| | - Agustín España
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Ricardo Blanco
- Department of Rheumatology, Hospital Universitario Marqués de Valdecilla, Immunology Group, Instituto de Investigación Sanitaria Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Joaquim Mullol
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Rhinology Unit and Smell Clinic, Ear, Nose and Throat (ENT) Department, Hospital Clínic de Barcelona, Universitat de Barcelona (UB) - Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Cecilio Santander
- Department of Gastroenterology and Hepatology, Hospital Universitario La Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa (IIS-IP), Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Victoria del Pozo
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Immunoallergy Laboratory, Immunology Department, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
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Romero Gómez C, Hernández Negrín H, Ayala Gutiérrez MDM. [Eosinophilic granulomatosis with polyangiitis]. Med Clin (Barc) 2023; 160:310-317. [PMID: 36774291 DOI: 10.1016/j.medcli.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 02/11/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis characterized by the presence of asthma associated with eosinophilia, eosinophilic infiltration of different organs, and vasculitis of small and medium-sized vessels. Although classified as anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, it occurs in less than half of the patients. The disease is infrequent, typically appearing in patients with asthma and affecting multiple organs such as lung, skin and peripheral nervous system. Treatment has been based on the use of glucocorticoids and immunosuppressants. In recent years, progress has been made in the knowledge of the pathophysiology, in treatment with the inclusion of biologic agents, the classification criteria have been revised and new therapeutic recommendations have been published.
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Affiliation(s)
- Carlos Romero Gómez
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, España.
| | - Halbert Hernández Negrín
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, España
| | - María Del Mar Ayala Gutiérrez
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, España
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Paroli M, Gioia C, Accapezzato D. New Insights into Pathogenesis and Treatment of ANCA-Associated Vasculitis: Autoantibodies and Beyond. Antibodies (Basel) 2023; 12:antib12010025. [PMID: 36975372 PMCID: PMC10045085 DOI: 10.3390/antib12010025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of rare systemic diseases affecting small-caliber vessels. The damage caused by AAV mainly involves the lung and kidneys. AAV includes three different types: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Although the different phenotypic forms of AAV share common features, recent studies have shown that there are significant differences in terms of pathogenetic mechanisms involving both the adaptive and innate immune systems. Advances in our understanding of pathogenesis have enabled the development of immuno-targeted therapies. This review illustrates the characteristics of the various forms of AAV and the new therapies available for this disease that can have lethal consequences if left untreated.
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Affiliation(s)
- Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Li R, Chen Y, Zhang S, Peng L, Zhou J, Fei Y, Zhang W, Zhao Y, Zeng X. Clinical characteristics and long-term outcome of patients with gastrointestinal involvement in eosinophilic granulomatosis with polyangiitis. Front Immunol 2023; 13:1099722. [PMID: 36713417 PMCID: PMC9879136 DOI: 10.3389/fimmu.2022.1099722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Objective This study aims to investigate clinical characteristics, potential risk factors, as well as long-term outcome in EGPA patients with GI involvement. Methods A total of 94 EGPA patients were included in this cohort study. We retrospectively reviewed the clinical data, treatment, and outcome of 21 EGPA patients with GI involvement and compared them with other 73 EGPA patients without GI involvement. Multivariate logistic regression was used to find potential risk factors associated with GI involvement in EGPA patients. Results Compared with EGPA patients without GI involvement, EGPA patients with GI involvement had higher level of hs-CRP (65.1 (24.5-138.9) vs. 21.3 (5.7-39.1) mg/L, p=0.005), higher grades of Birmingham vasculitis activity score (BVAS) (20 (13-29.5) vs. 12 (16-19), p=0.022), higher Five Factor Score (FFS) (1 (1-2) vs. 0 (0-1), p<0.001), and were more likely to have weight loss (66.7% vs. 38.4%, p=0.021) at baseline. In EGPA patients with GI involvement, the most common gastrointestinal symptoms were abdominal pain (90.5%) and diarrhea (42.9%). Weight loss was identified as a potential risk factor for GI involvement in EGPA patients (OR = 4.304, 95% CI 1.339-13.841). During follow-up, EGPA patients with GI involvement showed lower 1-year cumulative survival rate (75.2% vs. 100.0%, P <0.0001) and 3-year cumulative survival rate (67.7% vs. 100.0%, P<0.0001), lower long-term remission rate (33.3% vs. 86.3%, P<0.001), but higher 1-year cumulative relapse rate (19.2% vs. 3.8%, P=0.03) and 3-year cumulative relapse rate (54.6% vs. 13.1%, P<0.001) compared with patients without GI involvement. Conclusion EGPA patients with GI involvement had distinct features from those without GI involvement, including higher hs-CRP level, higher BVAS and FFS scores. EGPA patients with GI involvement showed lower cumulative survival rate, lower long-term remission rate and higher cumulative relapse rate compared with those without GI involvement.
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Affiliation(s)
- Rongli Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Yingying Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China,*Correspondence: Jiaxin Zhou, ; Yunyun Fei,
| | - Yunyun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China,*Correspondence: Jiaxin Zhou, ; Yunyun Fei,
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), The Ministry of Education Key Laboratory, Beijing, China
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Amelotti N, Mapelli M, Guglielmo M, Pires MIFB, Campodonico J, Majocchi B, Ribatti V, Vettor G, Baggiano A, Catto V, Basso C, Pontone G, Agostoni P. What's behind your eosinophilic myocarditis? A case of Churg-Strauss syndrome diagnosed during acute heart failure. ESC Heart Fail 2022; 10:709-715. [PMID: 36259268 PMCID: PMC9871676 DOI: 10.1002/ehf2.14172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare multisystem disorder; cardiac involvement may include eosinophilic myocarditis. A 67-year-old woman presented with 1-week history of dyspnoea and orthopnoea. She had a history of adult-onset asthma and peripheral eosinophilia. The investigations showed T-wave inversion on lateral leads, peripheral eosinophilia, elevated troponin and BNP values, and severe biventricular systolic dysfunction with diffuse hypokinesia and apical akinesia. Computed tomography excluded coronary disease and showed bilateral basal ground-glass opacities, air-space consolidation, and bilateral reticular-nodular pattern. Cardiac magnetic resonance findings were compatible with active myocardial inflammation. An endomyocardial biopsy (EMB) confirmed the diagnosis of eosinophilic myocarditis, and a therapy with oral corticosteroids and heart failure medications was started.
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Affiliation(s)
- Nicola Amelotti
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly
| | - Massimo Mapelli
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly,Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of Milan20122MilanItaly
| | | | | | | | | | | | - Giulia Vettor
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly
| | - Andrea Baggiano
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly,Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of Milan20122MilanItaly
| | - Valentina Catto
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPaduaItaly
| | | | - Piergiuseppe Agostoni
- Heart Failure UnitCentro Cardiologico Monzino, IRCCSMilanItaly,Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of Milan20122MilanItaly
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Vasandani N, Isaac M, Bajwa A, Sheehan M, Nugent E. A Surgical Presentation of Churg-Strauss Syndrome. Cureus 2022; 14:e24342. [PMID: 35607552 PMCID: PMC9123405 DOI: 10.7759/cureus.24342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 11/08/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) or Churg-Strauss syndrome (CSS) is a rare, autoimmune vasculitis usually affecting small and medium-sized blood vessels in its later phases. It is a diffuse, systemic, multisystem disease that is reported to present with gastrointestinal manifestations but very rarely as an acute abdomen secondary to eosinophilic peritonitis. A 28-year-old relatively healthy male with a pre-existing diagnosis of inactive pulmonary sarcoidosis presented to the emergency department with an acute abdomen. After an exploratory laparotomy, multi-specialty involvement, and extensive investigations to exclude other differentials, a diagnosis of EGPA was made. The patient was treated with systemic glucocorticoids initially, followed by a tapering course of steroids and anti-interleukin 5 monoclonal antibodies as maintenance upon remission. EGPA can manifest in a myriad of ways including an acute abdomen, and medical treatment is useful in managing this presentation. Surgeons should be aware of the atypical causes of acute abdomen and should routinely broaden their differential diagnosis to include medical pathologies.
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Jiang XD, Guo S, Zhang WM. Acute myocardial infarction induced by eosinophilic granulomatosis with polyangiitis: A case report. World J Clin Cases 2021; 9:10702-10707. [PMID: 35005004 PMCID: PMC8686141 DOI: 10.12998/wjcc.v9.i34.10702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/03/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Xuan-Dong Jiang
- Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Jinhua 322100, Zhejiang Province, China
| | - Shan Guo
- Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Jinhua 322100, Zhejiang Province, China
| | - Wei-Min Zhang
- Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Jinhua 322100, Zhejiang Province, China
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13
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Civelli VF, Narang VK, Sharma R, Sharma R, Kim J, Bhandohal J, Moosavi L, Cobos E. A Progressive Case of Eosinophilic Myocarditis Due to Eosinophilic Granulomatosis With Polyangiitis in a Caucasian Male. J Investig Med High Impact Case Rep 2021; 8:2324709620966855. [PMID: 33054423 PMCID: PMC7570297 DOI: 10.1177/2324709620966855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Vasculitis is an inflammatory process involving blood vessels of various sizes, including the small vessels in the kidneys to the large vessels, such as the aorta. This inflammatory condition is usually autoimmune in nature and is associated with involvement of many locations, such as the sinuses, lungs, kidneys, and even the heart. Specifically, eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis that may initially hide as asthma, allergic rhinitis, and/or sinusitis. However, it is known to become a lethal disease once progressed to include cardiovascular manifestations. It is important to remember EGPA as a differential for any patient with a history of asthma, allergic rhinitis, and/or sinusitis who also presents with cardiovascular complaints and eosinophilia. Treatment recommendations focus on immunosuppression in such cases. In this article, we discuss the case of a 62-year-old male, with a known history of asthma, who presented to the emergency department with concern for his chest pain and right-sided weakness. He was later diagnosed with EGPA with eosinophilic myocarditis. Diagnosis and treatment are described.
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Affiliation(s)
| | | | | | | | - Jessica Kim
- Touro University of California, Vallejo, CA, USA
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14
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Kondo I, Arai Y, Sakamoto E, Katagiri D, Hinoshita F. The First Case of Eosinophilic Granulomatosis with Polyangiitis Simultaneously Demonstrating Various Clinical Manifestations with Retroperitoneal Fibrosis and Membranous Nephropathy. Intern Med 2021; 60:1963-1969. [PMID: 33518573 PMCID: PMC8263185 DOI: 10.2169/internalmedicine.6399-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The first case of eosinophilic granulomatosis with polyangiitis (EGPA) simultaneously demonstrating various clinical manifestations, including retroperitoneal fibrosis (RPF) causing hydronephrosis and membranous nephropathy (MN) leading to nephrotic syndrome, is presented. There have been no previous case reports demonstrating the simultaneous onset of these three disease categories with significant complex pathologies. This case was successfully managed by providing adequate combination therapies according to each disease category, leading to complete remission (CR) of all three diseases. In conclusion, we believe this case is extremely rare and clinically suggestive, and that these findings can be applied to a future phenotype-tailored treatment strategy for EGPA.
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Affiliation(s)
- Isao Kondo
- Department of Nephrology, National Center for Global Health and Medicine, Japan
| | - Yohei Arai
- Department of Nephrology, National Center for Global Health and Medicine, Japan
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Emi Sakamoto
- Department of Nephrology, National Center for Global Health and Medicine, Japan
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, Japan
| | - Fumihiko Hinoshita
- Department of Nephrology, National Center for Global Health and Medicine, Japan
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15
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Korman AM, Chung CG. Eosinophilic Granulomatosis With Polyangiitis. JAMA Dermatol 2021; 157:722. [PMID: 33881454 DOI: 10.1001/jamadermatol.2020.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Abraham M Korman
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus
| | - Catherine G Chung
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus.,Department of Pathology, The Ohio State University, Columbus
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16
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MacDonald-Nethercott M, Ples D, Woitek R, Beddowes E. Ossified diagnosis: sarcoidosis masquerading as metastatic breast cancer. BMJ Case Rep 2021; 14:14/5/e237516. [PMID: 33972292 PMCID: PMC8112402 DOI: 10.1136/bcr-2020-237516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 40-year-old woman was referred to the Breast Unit with a solid lump in her right breast. Investigations revealed an invasive lobular carcinoma. The patient underwent a right-sided mastectomy and sentinel lymph node (LN) biopsy, which confirmed axillary LN involvement. The postsurgery staging CT showed unusual enlargement of mediastinal and hilar LN bilaterally. This was consistent with positron emission tomography/CT and MRI, which further established the presence of several bone lesions. Determining the pathology within the LN and bones was pivotal in providing an accurate diagnosis and deciding subsequent management. However, histopathological analysis of the initial endobronchial ultrasound-guided fine-needle aspiration biopsy of mediastinal LN failed to identify definitive metastatic breast cancer cells. The case was extensively discussed in several multidisciplinary team meetings. Collective evidence, including clinical presentation, comparative imaging analysis, and further biopsies confirmed sarcoidosis with bone involvement-mimicking metastatic disease.
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Affiliation(s)
| | - Diana Ples
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ramona Woitek
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Emma Beddowes
- Department of Oncology, Cancer Research UK Cambridge Research Institute, Cambridge, Cambridgeshire, UK
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17
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Dahiya A, Chao C, Younger J, Kar J, Baldwin BM, Cohen MV, Joseph S, Chowdhry A, Figarola MS, Malozzi C, Nasser MF, Nabeel Y, Shah R, Kennen JM, Aneja A, Khalil S, Ragab S, Mohammed O, Moustafa T, Hamdy A, Ahmed S, Heny A, Taher M, Ganigara M, Dhar A, Misra N, Alzubi J, Pannikottu K, Jabri A, Hedge V, Kanaa'n A, Lahorra J, de Waard D, Horne D, Dhillon S, Sweeney A, Hamilton-Craig C, Katikireddi VS, Wesley AJ, Hammet C, Johnson JN, Chen SSM. Society for Cardiovascular Magnetic Resonance 2019 Case of the Week series. J Cardiovasc Magn Reson 2021; 23:44. [PMID: 33794918 PMCID: PMC8015162 DOI: 10.1186/s12968-020-00671-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022] Open
Abstract
The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.
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Affiliation(s)
- Arun Dahiya
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Griffith University School of Medicine, Gold Coast, QLD, Australia
| | - Charles Chao
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - John Younger
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Julia Kar
- Departments of Mechanical Engineering and Pharmacology, University of South Alabama, Mobile, AL, USA
| | - Bryant M Baldwin
- Departments of Mechanical Engineering and Pharmacology, University of South Alabama, Mobile, AL, USA
| | - Michael V Cohen
- Department of Cardiology, University of South Alabama, Mobile, AL, USA
| | - Shane Joseph
- Department of Cardiology, University of South Alabama, Mobile, AL, USA
| | - Anam Chowdhry
- Department of Cardiology, University of South Alabama, Mobile, AL, USA
| | - Maria S Figarola
- Department of Radiology, University of South Alabama, Mobile, AL, USA
| | | | - M Farhan Nasser
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Yassar Nabeel
- Department of Internal Medicine, Division of Cardiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Rajiv Shah
- Department of Radiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - J Michael Kennen
- Department of Radiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ashish Aneja
- Department of Internal Medicine, Division of Cardiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sameh Khalil
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Sara Ragab
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Omnia Mohammed
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Taher Moustafa
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Ahmed Hamdy
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Shimaa Ahmed
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Ahmed Heny
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Maha Taher
- Alfa Scan Radiology Center, Cardiovascular Imaging Department, Cairo, Egypt
| | - Madhusudan Ganigara
- Division of Pediatric Cardiology, Cohen Children's Medical Center of New York-Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Arushi Dhar
- Division of Pediatric Cardiology, Cohen Children's Medical Center of New York-Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Nilanjana Misra
- Division of Pediatric Cardiology, Cohen Children's Medical Center of New York-Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Jafar Alzubi
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Kurian Pannikottu
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Ahmad Jabri
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Vinayak Hedge
- Department of Cardiology, Cleveland Clinic Akron General, Akron, OH, USA
| | - Anmar Kanaa'n
- Department of Cardiology, Cleveland Clinic Akron General, Akron, OH, USA
| | - Joseph Lahorra
- Department of Cardiothoracic Surgery, Cleveland Clinic Akron General, Akron, OH, USA
| | | | - David Horne
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Santokh Dhillon
- Isaac Walton Killam Children's Hospital, Halifax, NS, Canada
| | - Aoife Sweeney
- Department of Rheumatology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Christian Hamilton-Craig
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - V S Katikireddi
- Department of Rheumatology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Allan J Wesley
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Chris Hammet
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | | | - Sylvia S M Chen
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia.
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18
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Belhassen A, Toujani S, El Ouni A, Meddeb Z, Abdelkefi C, Larbi T, Hamzaoui S, Bouslama K. [Characteristics of cardiac involvement in eosinophilic granulomatosis with polyangiitis]. Ann Cardiol Angeiol (Paris) 2021; 71:95-98. [PMID: 33637317 DOI: 10.1016/j.ancard.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
AIM OF THE STUDY Our study aimed to identify the characteristics of cardiac involvement in eosinophilic granulomatosis with polyangiitis (EGPA). METHODS We conducted a retrospective analytic study including EGPA cases diagnosed between 2000 and 2019 in an internal medicine department. Diagnosis was made according to the 1990 American College of Rheumatology criteria and the 2012 Chapel Hill Concensus. RESULTS Eleven EGPA cases were included, 64% of patients were female. Median age at diagnosis was 52 years [42-58]. Heart damage revealed EGPA in 55% of cases with a significant predominance of women (p=0.015). The main cardiac manifestations were myocarditis, ischemic cardiomyopathy due to small vessel vasculitis, cardiac tamponade and intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) mainly showed subendocardial hyposignal in early infusion and late enhancement in the same areas, nodular by locations, associated with impaired left ventricle function and micro-infarctions by distal vasculitis. Cardiac damage was associated to ANCA negativity in 83.3% of cases. The median Birmingham Vasculitis Activity Score version3 (BVAS v3) was 16 [10-17]. Under conventional treatment, no relapses had occurred. The median vasculitis damage index (VDI) was 2 [1-2.3] and the mortality rate was zero after a mean follow-up of 43 months. CONCLUSION Cardiomyopathy is a frequent revealing mode of EGPA. A late onset asthma and hypereosinophilia should guide the diagnosis. As ANCA research often turns out to be negative, histological evidence is recommended in this context. The contribution of cardiac MRI in the diagnosis of EGPA remains to be defined.
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Affiliation(s)
- A Belhassen
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie.
| | - S Toujani
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - A El Ouni
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - Z Meddeb
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - C Abdelkefi
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - T Larbi
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - S Hamzaoui
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - K Bouslama
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
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19
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Chapman FA, Dhaun N, Dweck M, Mills NL. Coronary vasospasm in eosinophilic granulomatosis with polyangiitis. Rheumatology (Oxford) 2020; 59:e144-e146. [DOI: 10.1093/rheumatology/keaa357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Neeraj Dhaun
- Department of Renal Medicine, Royal Infirmary of Edinburgh
| | - Marc Dweck
- BHF Centre for Cardiovascular Science, The University of Edinburgh
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, The University of Edinburgh
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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20
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Ibrahim ME, Deonarine A, Gore PA, Lewis HR, Alvarado EC. The Rash, the Weakness, and the Nephritis: Nerve and Kidney Biopsy Findings in Eosinophilic Granulomatosis With Polyangiitis. Cureus 2020; 12:e11676. [PMID: 33391913 PMCID: PMC7769733 DOI: 10.7759/cureus.11676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present a case of eosinophilic granulomatosis with polyangiitis (EGPA) or Churg-Strauss syndrome in a 66-year Caucasian female who presented with a severe pruritic itch and a progressive upper and lower extremity weakness of unknown duration. The diagnosis of EGPA in this patient remained elusive for an extended period of time due to the absence of respiratory symptoms. In this article, we also discuss the histologic features of EGPA seen in biopsies of the kidney and the nerves and highlight the value they play in diagnosis.
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21
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Venade G, Figueiredo C, Almeida C, Oliveira N, Matos LC. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). ACTA ACUST UNITED AC 2020; 66:904-907. [PMID: 32844923 DOI: 10.1590/1806-9282.66.7.904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/08/2019] [Indexed: 11/21/2022]
Abstract
Churg-Strauss syndrome, Eosinophilic granulomatosis with polyangiitis (EGPA), is a systemic vasculitis that affects small- to medium-sized vessels. It is rare and part of the Anti-neutrophil cytoplasm antibody-associated vasculitis (ANCA) group. We present a 37-year-old man, with a previous history of asthma, that was sent to the ED due to 2 weeks of productive cough, occasional dyspnea on exertion, fever (one week), asthenia, and anorexia. Upon physical examination, he was subfebrile and tachycardic. He had leukocytosis (17.00 x10^9/L) and eosinophilia of 20.0 % (3.4 X10^9/L), creatinine level of 1.5 mg/dL, subtle elevation on liver function tests and CRP of 10.82mg/dL. On Chest X-Ray, there was infiltrate on the right pulmonary base. Due to a strong suspicion of EGPA, he was started on 80mg of prednisolone from admission. ANCA MPO was positive, with the remaining auto-immune study negative. He underwent Thorax CT (under corticotherapy) without relevant changes, as well as bronchoalveolar lavage, without macroscopic signs of alveolar hemorrhage. Because of active urinary sediment, nephrotic proteinuria (6.5g/24h), and acute renal failure he underwent a renal biopsy, which revealed pauci-immune crescentic glomerulonephritis, with predominantly acute findings (in the context of ANCA-MPO Vasculitis - EGPA). After the biopsy, he received three 1g methylprednisolone pulses and was started on Cyclophosphamide. He remained asymptomatic and renal function was restored. This case highlights the importance of integrating all findings in one clinical scenario to prevent a more complex disease diagnosis, with a specific treatment, from being missed.
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22
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Gloor E, Henzi A, Langenegger T, Bodmer M. [Mononeuritis Multiplex: A Diagnostic Challenge]. PRAXIS 2020; 109:509-512. [PMID: 32456580 DOI: 10.1024/1661-8157/a003445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Mononeuritis Multiplex: A Diagnostic Challenge Abstract. Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is a multifaceted disease. Due to the variability in vascular and organ involvement, EPGA can manifest itself very differently. We report a case of a 60-year-old patient with a known bronchial asthma, pansinusitis and newly blood eosinophilia with a rapid-onset mononeuritis multiplex. The diagnosis was confirmed based on a histological examination. After initiation of therapy the patient can walk independently with a mobility aid.
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Affiliation(s)
| | - Anna Henzi
- Institut für Neuropathologie, Universitätsspital Zürich
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23
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Abstract
Dermatologic changes occur in a variety of rheumatic diseases. Skin can be the initial site of involvement, thus providing important clues for an accurate diagnosis based on cutaneous findings. Dermatologic findings can also be an indicator of systemic involvement and prognostic outcome; however, many connective tissue disorders have a wide variety of cutaneous manifestations, with significant overlap between different diseases. These skin signs often precede systemic clinical manifestations. Careful attention to characteristic dermatologic findings in Behçet's disease, systemic lupus erythematosus, rheumatoid arthritis, and various vasculitis can provide prompt therapeutic approaches in the case of life-threatening complications of systemically involved rheumatologic diseases.
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Affiliation(s)
- Burhan Engin
- Department of Dermatology and Venereology, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Ayşegül Sevim
- Department of Dermatology and Venereology, Haydarpasa Numune Research and Teaching Hospital, Istanbul, Istanbul, Turkey
| | - Seher Küçükoğlu Cesur
- Department of Dermatology and Venereology, Altınbaş University, Bahçelievler Medical Park Hospital, Istanbul, Istanbul, Turkey
| | - Yalçın Tüzün
- Department of Dermatology and Venereology, Bahçelievler Medical Park Hospital, Istanbul, Istanbul, Turkey
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24
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Chaudhry MA, Grazette L, Yoon A, Correa A, Fong MW. Churg-Strauss Syndrome Presenting as Acute Necrotizing Eosinophilic Myocarditis: Concise Review of the Literature. Curr Hypertens Rev 2019; 15:8-12. [PMID: 30179138 DOI: 10.2174/1573402114666180903164900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acute eosinophilic myocarditis (EM) is a rare form of heart failure that is characterized by myocardial eosinophilic infiltration usually in association with peripheral eosinophilia. The underlying cause is variable and can include allergic reactions, parasitic infection, idiopathic hypereosinophilic syndrome, malignancy, Loeffler's syndrome, Churg-Strauss syndrome (CSS), early giant cell myocarditis and malignancy. The course is potentially fatal, and early diagnosis and treatment with steroids is essential. CONCLUSION Here, we present an illustrative case of eosinophilic myocarditis secondary to CSS followed by a brief review of epidemiology, pathogenesis, diagnosis and treatment of both disease entities.
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Affiliation(s)
- Muhammad Ali Chaudhry
- Division of Cardiovascular Medicine, Aultman Hospital, Canton, Ohio-44710 OH, United States
| | - Luanda Grazette
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles-90033 CA, United States
| | - Andrew Yoon
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles-90033 CA, United States
| | - Adrian Correa
- Division of Pathology, University of Southern California, Los Angeles-90033 CA, United States
| | - Michael W Fong
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles-90033 CA, United States
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25
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Ortiz JG, Douglas PW, Gill CE, Mehrotra S, Biller J. Mystery Case: Diagnostic challenges in a young patient with hypereosinophilia. Neurology 2019; 89:e159-e165. [PMID: 28947588 DOI: 10.1212/wnl.0000000000004413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Jorge G Ortiz
- From the Departments of Neurology (J.G.O., P.W.D., C.E.G., J.B.) and Pathology (S.M.), Stritch School of Medicine, Loyola University Chicago, IL.
| | - Preston W Douglas
- From the Departments of Neurology (J.G.O., P.W.D., C.E.G., J.B.) and Pathology (S.M.), Stritch School of Medicine, Loyola University Chicago, IL
| | - Chandler E Gill
- From the Departments of Neurology (J.G.O., P.W.D., C.E.G., J.B.) and Pathology (S.M.), Stritch School of Medicine, Loyola University Chicago, IL
| | - Swati Mehrotra
- From the Departments of Neurology (J.G.O., P.W.D., C.E.G., J.B.) and Pathology (S.M.), Stritch School of Medicine, Loyola University Chicago, IL
| | - José Biller
- From the Departments of Neurology (J.G.O., P.W.D., C.E.G., J.B.) and Pathology (S.M.), Stritch School of Medicine, Loyola University Chicago, IL
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26
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Destructive Upper Airway Disease from Eosinophilic Granulomatosis with Polyangiitis (EGPA): The Very First Case. Case Rep Rheumatol 2019; 2019:6173869. [PMID: 31263619 PMCID: PMC6556304 DOI: 10.1155/2019/6173869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/05/2019] [Indexed: 11/18/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem vasculitic disorder that predominantly affects medium- and small-sized blood vessels. EGPA belongs to a group of vasculitides known as anti-neutrophil cytoplasmic antibody- (ANCA-) associated vasculitis (AAV). Upper airway involvement is seen in all ANCA-associated vasculitides, but destructive upper airway disease has never been reported in patients with EGPA. We report the first case of erosive chondritis and saddle nose deformity in a 50-year-old patient suffering from EGPA.
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27
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Abstract
INTRODUCTION The Revised International Chapel Hill Consensus Conference 2012 subdivides vasculitides based on combinations of features that separate different forms of vasculitis into definable categories. Hypereosinophilic vasculitis with sparing of the respiratory tract and renal system is a rare presentation that is yet to be described in the Revised International Chapel Hill Consensus Conference 2012 report that addresses nomenclature of vasculitides. This is a condition that involves a vascular injury due to either a primary eosinophilic vasculitis or an underlying connective tissue disease and it predisposes patients to a prothrombotic state. PATIENT CONCERNS A 39-year-old patient presented with left hand digital ischemia, preceded by Raynaud phenomenon, and vasculitic rash. For 3 months, he was having digital ischemia affecting the left 2nd and 3rd digits in the form of pallor and gangrenous discoloration with a preceding history of a pinpoint pruritic rash affecting his lower limbs that extended to involve the trunk and upper limbs over a short period of time and responded to only a tapering dose of oral steroids. Examination revealed a delayed capillary refill in all left-hand digits and a weak left radial pulse but no bruit. The rest of his peripheral vascular examination was unremarkable. DIAGNOSIS Investigations revealed an absolute eosinophilic count of 4.34 K/μL and erythrocyte sedimentation rate of 44 mm/h. A magnetic resonance angiogram showed a beaded appearance of the left ulnar artery distally and the radial artery branches in the left hand and subsequently was diagnosed with hypereosinophilic vasculitis. INTERVENTIONS He was started on oral prednisone of 1 mg/kg daily orally tapering done as well as azathioprine for maintenance. OUTCOMES Two weeks postdischarge, the patient was seen in the outpatient department where his ischemic symptoms improved, and his skin rash healed. Noticed improvement in his splinter hemorrhages was also detected. He continued to do well on 2 years follow-up CONCLUSION:: This case reflects the importance of frequent reevaluation for vasculitic diseases criteria and nomenclature. Hypereosinophilic vasculitis with absent respiratory and renal involvement is a rare presentation with scarce evidence to guide treatment.
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P-ANCA negative eosinophilic granulomatosis with polyangiitis. Respir Med Case Rep 2019; 27:100830. [PMID: 30989049 PMCID: PMC6446216 DOI: 10.1016/j.rmcr.2019.100830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 11/21/2022] Open
Abstract
Vasculitis refers to inflammation of the systemic vessels. Eosinophilic granulomatosis with polyangiitis (EGPA) is a medium and small vessel vasculitis characterized by hypereosinophilia, pulmonary infiltrates, difficult to treat asthma and polyneuropathies. Diagnosis can often be challenging. In this article, we present a case of a young lady who was diagnosed ANCA negative EGPA.
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Kim MJ, Lee BR, Park JS, Choi YJ, Song MK, Lee S, Suh DI. A pediatric case of eosinophilic granulomatosis with polyangiitis accompanied by heart failure mimicking an asthma attack. ALLERGY ASTHMA & RESPIRATORY DISEASE 2019. [DOI: 10.4168/aard.2019.7.4.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min Jung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Bo Ra Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Soo Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Jung Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Soyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Faverio P, Bonaiti G, Bini F, Vaghi A, Pesci A. Mepolizumab as the first targeted treatment for eosinophilic granulomatosis with polyangiitis: a review of current evidence and potential place in therapy. Ther Clin Risk Manag 2018; 14:2385-2396. [PMID: 30573961 PMCID: PMC6292233 DOI: 10.2147/tcrm.s159949] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Mepolizumab is an anti-interleukin-5 (IL-5) humanized monoclonal antibody that binds to free IL-5. It induces bone marrow eosinophil maturation arrest and decreases eosinophil progenitors and subsequent maturation in the blood and bronchial mucosa. Its use has been extensively studied in severe eosinophilic asthma at a dose of 100 mg subcutaneously (SC) every 4 weeks and, more recently, in other hypereosinophilic syndromes. Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis that may involve multiple organs. Characteristic clinical manifestations are asthma, sinusitis, transient pulmonary infiltrates and neuropathy. Among the numerous pathways involved in the pathogenesis of EGPA, the Th-2 phenotype has a main role, as suggested by the prominence of the asthmatic component, in triggering the release of key cytokines for the activation, maturation and survival of eosinophils. In particular, IL-5 is highly increased in active EGPA and its inhibition can represent a potential therapeutic target. In this scenario, mepolizumab may play a therapeutic role. After some positive preliminary observations on the use of mepolizumab in small case series of EGPA patients with refractory or relapsing disease despite standard of care treatment, a randomized controlled trial was published in 2017. Mepolizumab at a dose of 300 mg administered by SC injection every 4 weeks proved effective in prolonging the period of remission of the disease, allowing for reduced steroid use. The positive results of this study, which met both of the primary endpoints, led to the approval in the USA of mepolizumab in adult patients with EGPA by the Food and Drug Administration in 2017. Therefore, mepolizumab can be officially considered as an add-on therapy with steroid-sparing effect in cases of relapsing or refractory EGPA. However, the most appropriate dose and duration of therapy still need to be determined. Future studies on larger multinational populations with prolonged follow-up are warranted.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
| | - Giulia Bonaiti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
| | - Francesco Bini
- ASST-Rhodense, UOC Pneumologia, Garbagnate Milanese, Milan, Italy
| | - Adriano Vaghi
- ASST-Rhodense, UOC Pneumologia, Garbagnate Milanese, Milan, Italy
| | - Alberto Pesci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy,
- Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy,
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31
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Chai JT, McGrath S, Lopez B, Dworakowski R. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) masquerading as acute ST-elevation myocardial infarction with complete resolution after immunosuppressive therapy: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2018; 2:yty075. [PMID: 31020153 PMCID: PMC6177047 DOI: 10.1093/ehjcr/yty075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/22/2018] [Indexed: 12/26/2022]
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA, formerly known as Churg-Strauss syndrome) is a rare autoimmune condition characterized by inflammation of small- and medium-sized blood vessels, which usually presents with systemic vasculitis preceded by airway allergic hypersensitivity. Case summary Here, we report a highly unusual case of acute ST-elevation myocardial infarction in a young and fit man with no cardiovascular risk factors. His emergency coronary angiography revealed disproportionately severe widespread coronary artery disease. We describe the diagnostic challenges with emphasis on meticulous history-taking (deep hyponasal voice, anosmia, and childhood asthma), supported by timely blood markers (peripheral eosinophilia and raised CRP), and multi-modal imaging (severe paranasal sinusitis on cranial magnetic resonance imaging and multiple lung infiltrates with small patches of ground-glass appearance on thoracic computed tomography), to reach a diagnosis of EGPA coronary vasculitis with particular reference to the American College of Rheumatology EGPA classification. Importantly, with prompt immunosuppression, his coronary lesions resolved completely without the need of any surgical or percutaneous revascularisation. He remained well and asymptomatic on maintenance immunosuppressants at 1 year follow-up. Discussion This case highlighted the rare but recognized involvement of the coronary arteries in systemic EGPA vasculitis, which can sometimes mimic atherosclerotic coronary disease and acute coronary syndrome.
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Affiliation(s)
- Joshua T Chai
- Department of Cardiology, King's College Hospital, Denmark Hill, London, UK
| | - Sam McGrath
- Department of Cardiology, King's College Hospital, Denmark Hill, London, UK
| | - Begoña Lopez
- Department of Rheumatology, King's College Hospital, Denmark Hill, London, UK
| | - Rafal Dworakowski
- Department of Cardiology, King's College Hospital, Denmark Hill, London, UK
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Long DA, Long B, Koyfman A. Clinical mimics: an emergency medicine focused review of pneumonia mimics. Intern Emerg Med 2018; 13:539-547. [PMID: 29582318 DOI: 10.1007/s11739-018-1840-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/19/2018] [Indexed: 12/13/2022]
Abstract
Pneumonia is a common cause of morbidity and mortality in adults in the United States. While pneumonia classically presents with a fever, cough, and shortness of breath, the presentation can vary widely in adults. This review evaluates history and physical examination findings of pneumonia and several conditions that mimic pneumonia. Pneumonia is a potentially deadly disease. History and examination findings are variable in pneumonia, and many conditions mimic pneumonia. These conditions include pulmonary embolism, diffuse interstitial lung disease, endocarditis, vasculitis, diffuse alveolar hemorrhage, acute decompensated heart failure, tuberculosis, lung cancer, and acute respiratory distress syndrome. Emergency clinicians should assess the patient while resuscitation occurs. Early antibiotics and the diagnosis of pneumonia can improve outcomes. Key historical and physical examination findings may lead the clinician to consider other conditions that require immediate management. Using clinical evaluation and adjunctive imaging, these conditions can be diagnosed and treated. Knowledge of pneumonia mimics is vital for the care of patients with respiratory complaints. Pneumonia is common and may be deadly, and emergency clinicians must differentiate conditions that mimic pneumonia. Rapid evaluation and management may alleviate morbidity and mortality for each of these conditions. The history and physical examination, in addition to utilizing imaging modalities such as ultrasound and computed tomography, are vital in diagnosis of pneumonia mimics.
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Affiliation(s)
- Drew Alan Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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Nakamoto K, Saraya T, Ogawa Y, Ishii H, Takizawa H. Comparison of findings on thoracic computed tomography with the severity and duration of bronchial asthma in patients with eosinophilic granulomatosis with polyangiitis. Respir Med 2018; 139:101-105. [PMID: 29857992 DOI: 10.1016/j.rmed.2018.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/26/2018] [Accepted: 05/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis with eosinophilia. EGPA can occur in patients with comorbid bronchial asthma (BA) and other pulmonary diseases. However, because of its rarity, there are few reports on thoracic computed tomography (CT) findings in patients with EGPA, especially in relation to comorbid BA. The aim of this study was to compare between the clinical characteristics of EGPA, the severity and duration of BA, and the findings on thoracic CT. METHODS We retrospectively reviewed the records of patients with EGPA who were admitted to our hospital from 2001 to 2015. All patients satisfied the criteria for EGPA according to American College of Rheumatology or Lanham's criteria. Patients without asthma (n = 2) and those in whom CT was not performed (n = 3) were excluded. RESULTS We identified 31 patients who had EGPA comorbid with BA. The median duration of BA was 6 years. CT revealed parenchymal opacification (ground-glass opacity and/or consolidation; n = 17), airway abnormalities (bronchial wall thickening and/or bronchiectasis; n = 15), pleural effusion (n = 4), interlobular septal thickening (n = 5), and mediastinal lymphadenopathy (n = 4). Importantly, the group with severe BA had a significantly higher incidence of airway abnormalities than the group with mild to moderate BA (81.8% vs 30.0%, P = 0.009). The frequency of airway abnormalities was significantly higher in patients with EGPA who had a history of asthma of 5 years or more than in their counterparts with a shorter asthma history (66.7% vs 10.0%, P = 0.006), particularly bronchial wall thickening (52.4% vs 10.0%, P = 0.046). CONCLUSIONS The most common finding on thoracic CT in patients who had EGPA comorbid with BA was parenchymal opacification followed by airway abnormalities. The severity and duration of BA in these patients may affect the findings on thoracic CT.
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Affiliation(s)
- Keitaro Nakamoto
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Takeshi Saraya
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Yukari Ogawa
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Haruyuki Ishii
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Hajime Takizawa
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
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Barrett G, Keates N, Kyrodimou E, Wilson H. A florid paranasal sinus reaction from a systemic disease. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:295-296. [PMID: 29680226 DOI: 10.1016/j.anorl.2017.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 07/14/2017] [Accepted: 09/26/2017] [Indexed: 10/17/2022]
Affiliation(s)
- G Barrett
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW Exeter, United Kingdom.
| | - N Keates
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW Exeter, United Kingdom
| | - E Kyrodimou
- Department of Histopathology, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW, United Kingdom
| | - H Wilson
- Department of ENT Head and Neck Surgery, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW Exeter, United Kingdom
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Ohnuki Y, Moriya Y, Yutani S, Mizuma A, Nakayama T, Ohnuki Y, Uda S, Inomoto C, Yamamoto S, Nakamura N, Takizawa S. Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome) Complicated by Perforation of the Small Intestine and Cholecystitis. Intern Med 2018; 57:737-740. [PMID: 29269641 PMCID: PMC5874351 DOI: 10.2169/internalmedicine.8975-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of eosinophilic granulomatosis with polyangiitis (EGPA; formerly known as Churg-Strauss syndrome) complicated by perforation of the small intestine and necrotizing cholecystitis. A 69-year-old man with a history of bronchial asthma was admitted with mononeuritis multiplex. The laboratory findings included remarkable eosinophilia. He was treated with corticosteroids and his laboratory indices showed improvement; however, his functional deficits remained. His neuropathy gradually improved after the addition of intravenous immunoglobulin (IVIG). He was subsequently treated with oral prednisolone (40 mg/day) as maintenance therapy. Within a month after finishing IVIG, he developed perforation of the small intestine and necrotizing cholecystitis. Intestinal perforation has often been reported as a gastrointestinal complication of EGPA. In contrast, cholecystitis is a rare complication. We report this case because the manifestation of more than one complication is extremely rare. Gastrointestinal symptoms may be a complication of EGPA itself and/or immunosuppressive treatment.
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Affiliation(s)
- Yoichi Ohnuki
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Yusuke Moriya
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Sachiko Yutani
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Atsushi Mizuma
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Taira Nakayama
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Yuko Ohnuki
- Department of Molecular Life Science Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, Japan
| | - Shuji Uda
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Japan
| | - Chie Inomoto
- Department of Pathology, Tokai University School of Medicine, Japan
| | - Soichiro Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Japan
| | - Naoya Nakamura
- Department of Pathology, Tokai University School of Medicine, Japan
| | - Shunya Takizawa
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
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Appendiceal Perforation in Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss). J Clin Rheumatol 2018; 24:442-444. [PMID: 29293115 DOI: 10.1097/rhu.0000000000000669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Oiwa H, Mokuda S, Matsubara T, Funaki M, Takeda I, Yamawaki T, Kumagai K, Sugiyama E. Neurological Complications in Eosinophilic Granulomatosis with Polyangiitis (EGPA): The Roles of History and Physical Examinations in the Diagnosis of EGPA. Intern Med 2017; 56:3003-3008. [PMID: 28924115 PMCID: PMC5726955 DOI: 10.2169/internalmedicine.8457-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective To investigate the clinical symptoms, the physical and neurological findings, and the clinical course of neurological complications in eosinophilic granulomatosis with polyangiitis (EGPA). Methods A retrospective chart review of EGPA cases managed by two referral hospitals was performed, with a focus on the neurological findings. The study analyzed the symptoms at the onset of EGPA and investigated their chronological relationship. The patient delay (the delay between the onset of symptoms and the initial consultation), and the physician delay (the delay from consultation to the initiation of therapy) were determined and compared. The involved nerves were identified thorough a neurological examination. The cases with central nervous system (CNS) involvement were described. Results The average duration of symptoms prior to the initiating of therapy for sensory disturbances, motor deficits, rash, edema, and fever was 23, 5, 21, 18, and 24 days, respectively. Among the EGPA-specific symptoms, sensory disturbance was often the first symptom (63%), and was usually followed by the appearance of rash within four days (63%). The average physician delay (32.9±38.3 days) was significantly longer than the average patient delay (7.9±7.8 days; p=0.010). Reduced touch sensation in the superficial peroneal area, and weakness of dorsal flexion of the first toe secondary to deep peroneal nerve involvement, were highly sensitive for identifying the presence of peripheral nerve involvement in our series of patients with EGPA. Two cases, with CNS involvement, had multiple skin lesions over their hands and feet (Janeway lesions). Conclusion Japanese physicians are not always familiar with EGPA. It is important for us to consider this disease, when an asthmatic patient complains about the new onset of an abnormal sensation in the distal lower extremities, which is followed several days later by rash.
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Affiliation(s)
- Hiroshi Oiwa
- Department of Rheumatology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Sho Mokuda
- Department of Rheumatology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Tomoyasu Matsubara
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Japan
| | - Masamoto Funaki
- Department of Rheumatology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Ikuko Takeda
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Japan
| | - Takemori Yamawaki
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Kazuhiko Kumagai
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
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Palamara K, Nagarur A, Fintelmann FJ, Kohler MJ, Cortazar FB. Case 32-2017. A 64-Year-Old Man with Dyspnea, Wheezing, Headache, Cough, and Night Sweats. N Engl J Med 2017; 377:1569-1578. [PMID: 29045211 DOI: 10.1056/nejmcpc1703513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kerri Palamara
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Amulya Nagarur
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Florian J Fintelmann
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Minna J Kohler
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
| | - Frank B Cortazar
- From the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Massachusetts General Hospital, and the Departments of Medicine (K.P., A.N., M.J.K., F.B.C.) and Radiology (F.J.F.), Harvard Medical School - both in Boston
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Yılmaz İ, Tutar N, Şimşek ZÖ, Oymak FS, Gülmez İ. Clinical and Serological Features of Eosinophilic and Vasculitic Phases of Eosinophilic Granulomatosis with Poliangiitis: a Case Series of 15 Patients. Turk Thorac J 2017; 18:72-77. [PMID: 29404165 DOI: 10.5152/turkthoracj.2017.16040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 04/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Eosinophilic granulomatosis with poliangiitis (EGPA) which was previously called Churg-Strauss Syndrome, is classified into eosinophilic and vasculitic phases. To characterize the eosinophilic and vasculitic phases of the disease in terms of clinical findings, serology, and treatment. MATERIALS AND METHODS We included 15 EGPA patients in the study. The clinical, serological, and therapeutic characteristics and the treatment responses of the patients were recorded. RESULTS Thirteen patients were classified as being in the eosinophilic phase and two were classified as being in the vasculitic phase of EGPA. Initial symptoms were worsening asthma in all patients (n=15; 100%). All patients had rhinosinusitis, and 66.6% had hypersensitivity to nonsteroidal anti-inflammatory drugs. The two patients in the vasculitic phase did not have nasal polyposis. Pulmonary and nervous system involvement were the most common symptoms. The erythrocyte sedimentation rates (ESRs) of the two patients in the vasculitic phase were 65 mm/h and 55 mm/h, while ESR was normal in eosinophilic-phase patients. Antineutrophil cytoplasmic antibodies (ANCA) was detected in one patient (6.6%) who was in the vasculitic phase (Case 15). The disease was under control with higher doses of methylprednisolone in the vasculitic phase (Case 14: 12 mg/day, Case 15: 10 mg/day) than in the eosinophilic phase. Relapse was detected in the two patients in the vasculitic phase. Oral corticosteroid was not discontinued in any case, and no mortality was reported. CONCLUSION Patients with eosinophilic phase or vasculitic phase EGPA had similar clinical onset. However, higher ESR, ANCA positivity, and extrapulmonary organ involvement were only found in patients in the vasculitic phase. Corticosteroid responsiveness was very good in all patients in the eosinophilic phase, and the disease could be controlled with a very low maintenance dose of a corticosteroid.
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Affiliation(s)
- İnsu Yılmaz
- Department of Chest Diseases, Division of Immunology and Allergy, Erciyes University School of Medicine, Kayseri, Turkey
| | - Nuri Tutar
- Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - Zuhal Özer Şimşek
- Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - Fatma Sema Oymak
- Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - İnci Gülmez
- Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
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40
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Volc S, Maier JC, Röcken M. [Skin diseases due to systemic vasculitides and vasculopathies]. Hautarzt 2017; 67:948-959. [PMID: 27864582 DOI: 10.1007/s00105-016-3896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vasculitis and vasculopathy are two distinct disease entities. Each entity comprises a large number of heterogeneous diseases, which can occur alone or associated with autoimmune, infectious or neoplastic diseases. The terms vasculitis and vasculopathy are often falsely used synonymously. A vasculitis initially causes inflammation of the vessel walls that may result in a secondary occlusion. In contrast, a vasculopathy is a primary occlusion of the vascular lumen, which is followed by inflammation after ischemia and ulceration. In most patients the distinction can be made based on the clinical presentation. A clear clinical diagnosis is then followed by targeted serological, histological and imaging procedures to confirm the clinical diagnosis. On this basis a well-founded treatment can be initiated. In the presence of vasculitis an anti-inflammatory therapy is indicated, whereas in the case of vasculopathy, removal of the vascular occlusion is the main focus. This article provides an overview of the various diseases and addresses the pathogenetic and clinical characteristics used to differentiate the individual disease entities. It also provides an insight into the therapy options and prophylaxis.
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Affiliation(s)
- S Volc
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland
| | - J C Maier
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland
| | - M Röcken
- Universitäts-Hautklinik Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Deutschland.
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41
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A Clinicopathologic Study of Small Intestinal Perforations in Patients With Eosinophilic Granulomatosis With Polyangiitis: A Series of 3 Patients. Int Surg 2017. [DOI: 10.9738/intsurg-d-16-00160.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a vascular disorder of unknown etiology characterized by severe asthma, eosinophilia, and granulomatous vasculitis. It is sometimes associated with gastrointestinal lesions, although perforations are uncommon. Corticosteroids are commonly used in the treatment of patients with EGPA; however, they may impair tissue repair and induce fibrotic changes in the vascular intima, which can lead to vascular occlusion, ischemia, and perforation. The anti-inflammatory properties of corticosteroids may mask symptoms of gastroduodenal ulcers or other intra-abdominal conditions, which can lead to a delay in diagnosis. From January 1, 2001 to December 31, 2014, 71 patients underwent surgery for small intestinal perforations. Of these, 4 operations were performed on 3 patients with EGPA who were receiving corticosteroids. We retrospectively reviewed the clinical and pathologic features of these patients. All 3 patients with EGPA were men, with a mean age of 56 years. The length of resected intestine ranged from 10 to 60 cm. Histopathologic examination revealed ulcers and perforations of the small intestine associated with vasculitis, compatible with EGPA. All patients had an uneventful postoperative course. Patients with EGPA presenting with abdominal pain must be carefully evaluated for possible intestinal perforation, especially those receiving corticosteroid therapy.
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Abstract
Systemic and odontogenic etiologies of chronic rhinosinusitis, although rare, are an integral consideration in the comprehensive management of patients with sinonasal disease. Proper knowledge and timely recognition of each disease process, with referrals to appropriate consultants, will facilitate treatment, because many of these conditions require both local and systemic therapy. In some instances, medical therapy plays a pivotal role, with surgery being a supplemental treatment technique. We review the most commonly encountered systemic etiologies of chronic rhinosinusitis and odontogenic sinusitis, including clinical presentation, diagnosis, management, and treatment outcomes.
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Affiliation(s)
- Edward C Kuan
- Department of Head and Neck Surgery, University of California, Los Angeles (UCLA) Medical Center, 10833 Le Conte Avenue, 62-132 CHS, Los Angeles, CA 90095, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, University of California, Los Angeles (UCLA) Medical Center, 10833 Le Conte Avenue, 62-132 CHS, Los Angeles, CA 90095, USA.
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Santos YAP, Silva BRA, Lira PNZBA, Vaz LCA, Mafort TT, Bruno LP, Lopes AJ. Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome) as a differential diagnosis of hypereosinophilic syndromes. Respir Med Case Rep 2017; 21:1-6. [PMID: 28337408 PMCID: PMC5352719 DOI: 10.1016/j.rmcr.2017.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 01/01/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare systemic disease situated between primary small vessel vasculitides associated with antineutrophil cytoplasmic antibodies (ANCAs) and hypereosinophilic syndromes (HES). Here, we present a case of EGPA in a 38-year-old male, with a previous diagnosis of asthma, who presented with fever, migratory lung infiltrates and systemic eosinophilia that was refractory to previous courses of antibiotics. This case highlights the importance of the primary care physician understanding the differential diagnosis of pulmonary eosinophilic syndromes.
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Affiliation(s)
- Yuri Albuquerque Pessoa Santos
- Department of Clinical Medicine, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 3º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Bruno Rangel Antunes Silva
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil; Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
| | | | - Luiz Carlos Aguiar Vaz
- Department of Anatomic Pathology, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 3º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
| | - Thiago Thomaz Mafort
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Leonardo Palermo Bruno
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Department of Pneumology, University Hospital Pedro Ernesto, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, 2º andar, Vila Isabel, 20551-030, Rio de Janeiro, Brazil; Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Av. Prof. Manoel de Abreu, 444, 2º andar, Vila Isabel, 20550-170, Rio de Janeiro, Brazil
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Albreiki D, Al Belushi F, Patel V, Farmer J. When a temporal artery biopsy reveals a diagnosis other than temporal arteritis: eosinophilic granulomatosis with polyangiitis. Can J Ophthalmol 2017; 51:e108-9. [PMID: 27316282 DOI: 10.1016/j.jcjo.2016.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/15/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Danah Albreiki
- Department of Ophthalmology, University of Ottawa, Ottawa, Ont.
| | | | - Vivek Patel
- Department of Ophthalmology, University of Ottawa, Ottawa, Ont; Department of Ophthalmology, University of Southern California, Los Angeles, Calif
| | - James Farmer
- Department of Ophthalmology, University of Ottawa, Ottawa, Ont; Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ont
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Shimojima Y, Kishida D, Hineno A, Yazaki M, Sekijima Y, Ikeda SI. Hypertrophic pachymeningitis is a characteristic manifestation of granulomatosis with polyangiitis: A retrospective study of anti-neutrophil cytoplasmic antibody-associated vasculitis. Int J Rheum Dis 2017; 20:489-496. [PMID: 28217942 DOI: 10.1111/1756-185x.13046] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To elucidate the characteristics of patients with hypertrophic pachymeningitis (HP) in a population with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS We retrospectively investigated the clinical records of 39 patients who were diagnosed with AAV. To determine the characteristics of HP in AAV, the epidemiological and clinical data from patients with HP were statistically compared with those from patients without HP. RESULTS Of 39 patients with AAV, seven (17.9%) had associated HP. All patients with HP were classified as having granulomatosis with polyangiitis (GPA), whereas only five of 32 patients without HP were diagnosed as having GPA (P < 0.0001). The frequencies of myeloperoxidase (MPO)-ANCA and proteinase 3-ANCA positivity in patients with HP were equivalent, while MPO-ANCA positivity was obviously dominant in patients without HP. HP occurred as the initial clinical episode of AAV in three patients (7.7% of all AAV). Frequent significant characteristics of patients with HP were headache, cranial neuropathy and paranasal involvement (P < 0.05), and histopathological findings from paranasal involvement were useful for the diagnosis of GPA in some patients with HP. Combination therapy of corticosteroid and an immunosuppressant, such as methotrexate, cyclophosphamide or rituximab, was effective for achieving remission and improving radiographic findings of HP. CONCLUSION AAV is a common cause of HP; epidemiological features of AAV patients with HP are different from those of patients without HP. Additionally, HP impacts diagnosis because it may be an initial clinical sign of AAV.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Akiyo Hineno
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Intractable Disease Care Center, Shinshu University Hospital, Matsumoto, Japan
| | - Masahide Yazaki
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Shu-Ichi Ikeda
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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Pecoraro A, Crescenzi L, Carucci L, Genovese A, Spadaro G. Heart failure not responsive to standard immunosuppressive therapy is successfully treated with high dose intravenous immunoglobulin therapy in a patient with Eosinophilic Granulomatosis with Polyangiitis (EGPA). Int Immunopharmacol 2017; 45:13-15. [PMID: 28152445 DOI: 10.1016/j.intimp.2017.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/23/2022]
Abstract
Glucocorticoids and immunosuppressive drugs represent the first-line treatment of eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss syndrome), even though the combined therapy is not successful in achieving the disease remission in some patients with neurological or cardiac involvement. We describe a case of an EGPA male patient with impaired left ventricular function not responsive to glucocorticoid and immunosuppressive therapy. We observed that high-dose (2g/kg/4weeks) intravenous immunoglobulin (IVIG) therapy significantly improved cardiac function, which was deteriorated after reducing IVIG dose at 0.5g/kg/4weeks, and was restored increasing again IVIG dose to 2g/kg/4weeks. The finding highlights the relevance of IVIG as treatment of choice in EGPA patients with cardiac involvement not responsive to the standard glucocorticoid and immunosuppressive therapy. Moreover, at a follow-up of 24months, the continuance of high dose IVIG therapy was required to maintain a sustained remission of the heart failure.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy.
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Laura Carucci
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
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Pagnoux C. Updates in ANCA-associated vasculitis. Eur J Rheumatol 2016; 3:122-133. [PMID: 27733943 PMCID: PMC5058451 DOI: 10.5152/eurjrheum.2015.0043] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/13/2015] [Indexed: 12/15/2022] Open
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are small-vessel vasculitides that include granulomatosis with polyangiitis (formerly Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Renal-limited ANCA-associated vasculitides can be considered the fourth entity. Despite their rarity and still unknown cause(s), research pertaining to ANCA-associated vasculitides has been very active over the past decades. The pathogenic role of antimyeloperoxidase ANCA (MPO-ANCA) has been supported using several animal models, but that of antiproteinase 3 ANCA (PR3-ANCA) has not been as strongly demonstrated. Moreover, some MPO-ANCA subsets, which are directed against a few specific MPO epitopes, have recently been found to be better associated with disease activity, but a different method than the one presently used in routine detection is required to detect them. B cells possibly play a major role in the pathogenesis because they produce ANCAs, as well as neutrophil abnormalities and imbalances in different T-cell subtypes [T helper (Th)1, Th2, Th17, regulatory cluster of differentiation (CD)4+ CD25+ forkhead box P3 (FoxP3)+ T cells] and/or cytokine-chemokine networks. The alternative complement pathway is also involved, and its blockade has been shown to prevent renal disease in an MPO-ANCA murine model. Other recent studies suggested strongest genetic associations by ANCA type rather than by clinical diagnosis. The induction treatment for severe granulomatosis with polyangiitis and microscopic polyangiitis is relatively well codified but does not (yet) really differ by precise diagnosis or ANCA type. It comprises glucocorticoids combined with another immunosuppressant, cyclophosphamide or rituximab. The choice between the two immunosuppressants must consider the comorbidities, past exposure to cyclophosphamide for relapsers, plans for pregnancy, and also the cost of rituximab. Once remission is achieved, maintenance strategy following cyclophosphamide-based induction relies on less toxic agents such as azathioprine or methotrexate. The optimal maintenance strategy following rituximab-based induction therapy remains to be determined. Preliminary results on rituximab for maintenance therapy appear promising. Efforts are still under way to determine the optimal duration of maintenance therapy, ideally tailored according to the characteristics of each patient and the previous treatment received.
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Affiliation(s)
- Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital, University Health Network, University of Toronto, Ontario, Canada
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Seccia V, Fortunato S, Cristofani-Mencacci L, Dallan I, Casani AP, Latorre M, Paggiaro P, Bartoli ML, Sellari-Franceschini S, Baldini C. Focus on audiologic impairment in eosinophilic granulomatosis with polyangiitis. Laryngoscope 2016; 126:2792-2797. [PMID: 27075698 DOI: 10.1002/lary.25964] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the clinical features of audiologic impairment and its relationship with the nasal, vestibular, and rheumatologic profile in a cohort of patients with eosinophilic granulomatosis with polyangiitis (EGPA), formerly named Churg-Strauss syndrome. STUDY DESIGN Prospective cross-sectional study. METHODS Thirty-nine patients with EGPA, considered controlled according to the Birmingham Vasculitis Activity Score and the Vasculitis Damage Index, underwent a complete audiologic evalutaion with otomicroscopy, impedance audiometry, speech audiometry, and auditory brainstem responses; rhinologic evaluation was made by means of fiberoptic endoscopy and nasal cytology; the clinical evaluation was completed with analysis of the facial function and, in patients with referred vertigo, with videonystagmography (VNG). Data were compared to the rheumatologic profile (eosinophil count, antineutrophil cytoplasmic antibodies status). RESULTS Thirty-four of 39 patients fulfilled the inclusion criteria. Of those, 18 (52, 8%) were affected by variable degrees of hearing loss (sensorineural hearing loss [SNHL]) in four cases (11, 8%), mixed sensorineural and conductive hearing loss in two (5, 9%), presbycusis in six (17, 6%), and otitis media with effusion (OME) in six (17, 6%). Vestibular impairment was represented by benign paroxysmal positional vertigo and unspecific dizziness in three (8, 8%) and four cases (11, 8%), respectively, all with normal VNG. Ear involvement was statistically related to the EGPA vasculitic pattern and independent from the nasal impairment, cytology, and duration of nasal symptoms. No facial palsy was registered. CONCLUSION In our experience, the largest in the existing literature, the otological involvement in EGPA is common and may occur variably as SNHL or OME. Otological involvement occurs early in the course of the disease process, but is nonspecific in making the diagnosis of EGPA. Its recognition is therefore fundamental. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2792-2797, 2016.
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Affiliation(s)
- Veronica Seccia
- Otorhinolaryngology Unit, Department of Neuroscience, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Susanna Fortunato
- Otorhinolaryngology Unit, Department of Neuroscience, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Iacopo Dallan
- Otorhinolaryngology Unit, Department of Neuroscience, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Augusto P Casani
- Otorhinolaryngology Unit, Department of Neuroscience, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Manuela Latorre
- Respiratory Pathophysiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Pierluigi Paggiaro
- Respiratory Pathophysiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Maria Laura Bartoli
- Respiratory Pathophysiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Baikunje S, Vankalakunti M, Upadhyaya VS, Hosmane GB. Eosinophilic granulomatosis with polyangiitis with severe pulmonary hemorrhage treated with rituximab. Indian J Nephrol 2016; 26:142-4. [PMID: 27051141 PMCID: PMC4795432 DOI: 10.4103/0971-4065.161021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by systemic vasculitis, asthma and eosinophilia. Severe pulmonary hemorrhage is rare. Renal involvement is seen in approximately 25% and can vary from isolated urinary abnormality to rapidly progressive glomerulonephritis. There is limited evidence to support the use of rituximab in this condition. We present a patient with EGPA who had severe pulmonary hemorrhage and rapidly progressive glomerulonephritis. He responded to standard treatment including prednisolone, cyclophosphamide, and plasma exchange. He subsequently had a relapse of pulmonary hemorrhage that was treated successfully with rituximab.
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Affiliation(s)
- S Baikunje
- Department of Nephrology, K. S. Hegde Medical Academy, Deralakatte, Mangalore, India
| | - M Vankalakunti
- Department of Nephropathology, Manipal Hospital, Bengaluru, Karnataka, India
| | - V S Upadhyaya
- Department of Radiology, K. S. Hegde Medical Academy, Deralakatte, Mangalore, India
| | - G B Hosmane
- Department of Pulmonology, K. S. Hegde Medical Academy, Deralakatte, Mangalore, India
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Abstract
This review covers the histopathology and pathogenesis of non-infectious inflammatory diseases of the sinonasal tract, in particular, sarcoidosis, granulomatous vasculitides Wegener, Churg-Strauss), relapsing polychondritis, eosinophilic angiocentric fibrosis, chronic rhinosinusitis and nasal perforations. Molecular associations and mechanisms are emphasised to assist pathologists to put their observations into the context of clinical, genetic and environmental influences on patients' diseases.
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