The complications of vasculitis and its treatment

Antineutrophil cytoplasmic antibody‑associated vasculitis complicated with oral and maxillofacial space infection in a young woman: A case report

Antibody-associated vasculitis (AAV) is a systemic autoimmune disease, with hormones and immunosuppressants as its main treatment measures. However, during the treatment process, various infections such as lung infections and urinary tract infections are prone to occur, and patients with OMSI are relatively rare. The present case report describes the case of a young woman who received long-term oral glucocorticoids and immunosuppressive agents for the treatment of antineutrophil cytoplasmic (AAV). At hospital admission, the patient with a high fever and painful swelling of the left side of the mouth. The patient was diagnosed with an oral and maxillofacial space infection (OMSI). Therefore, the local incision, drainage and irrigation of abscesses were subsequently performed. Additionally, the immunosuppressive agents were discontinued, the glucocorticoid dose was reduced and intravenous antibiotic therapy was provided. The patient was discharged 1 week later in good condition. Notably, the incidence of AAV is extremely low. Although OMSI is not uncommon, the simultaneous occurrence of AAV in combination with OMSI has not been reported previously. To the best of our knowledge, this is the first reported case of AAV combined with OMSI.

Eosinophilic granulomatosis with polyangiitis - Advances in pathogenesis, diagnosis, and treatment

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease characterized by eosinophil-rich granulomatous inflammation and necrotizing vasculitis, pre-dominantly affecting small-to-medium-sized vessels. It is categorized as a primary antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) but also shares features of hypereosinophilic syndrome (HES); therefore, both vessel inflammation and eosinophilic infiltration are suggested to cause organ damage. This dual nature of the disease causes variable clinical presentation. As a result, careful differentiation from mimicking conditions is needed, especially from HES, given the overlapping clinical, radiologic, and histologic features, and biomarker profile. EGPA also remains a diagnostic challenge, in part because of asthma, which may pre-dominate for years, and often requires chronic corticosteroids (CS), which can mask other disease features. The pathogenesis is still not fully understood, however, the interaction between eosinophils and lymphocytes B and T seems to play an important role. Furthermore, the role of ANCA is not clear, and only up to 40% of patients are ANCA-positive. Moreover, two ANCA-dependent clinically and genetically distinct subgroups have been identified. However, a gold standard test for establishing a diagnosis is not available. In practice, the disease is mainly diagnosed based on the clinical symptoms and results of non-invasive tests. The unmet needs include uniform diagnostic criteria and biomarkers to help distinguish EGPA from HESs. Despite its rarity, notable progress has been made in understanding the disease and in its management. A better understanding of the pathophysiology has provided new insights into the pathogenesis and therapeutic targets, which are reflected in novel biological agents. However, there remains an ongoing reliance on corticosteroid therapy. Therefore, there is a significant need for more effective and better-tolerated steroid-sparing treatment schemes.

Relationship Between Gender and 1-Year Mortality in ANCA-Associated Vasculitis Patients: A Single-Center Retrospective Analysis and Meta-Analysis

Objective

The relationship between gender and short-term prognosis of patients with anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is unclear, hence single-center retrospective analysis and meta-analysis were conducted to determine the relationship.

Methods

Initially treated patients with AAV were retrospectively enrolled. Data of clinical manifestation, laboratory indicators, Birmingham vasculitis activity score (BVAS), therapeutic treatments, and the patients' situations within 1 year were recorded. First, we compared the basic characteristics between male and female patients. Second, the risk factors associated with a 1-year mortality rate of patients with AAV were evaluated. Finally, a meta-analysis was performed to explore the effect of gender on 1-year mortality in patients with AAV.

Results

The study involved 84 patients with AAV, including 33 female and 51 male participants. In total, 14 people died (12 males and 2 females) and 70 survived in the 1st year. Statistical differences were noted in the age of onset, the course of the disease, WBC, HB, N, ESR, CRP, BUN, ALT and ALB, BVAS, and 1-year mortality rate between male and female participants. In male patients, elevated Scr, NLR, PLT, and RDW-CV were associated with poor AAV (P < 0.05) prognosis. The meta-analysis verified that male gender was an independent risk factor for the 1-year mortality of patients with AAV(OR = 1.54).

Conclusion

Significant sex-specific differences were found in patients with AAV. Male patients contributed to 1.54-fold of 1-year mortality risk in patients with AAV by meta-analysis. More attention should be paid to the mortality risk of male patients with AAV in the early stage.

The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides

Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.

Predictive factors of mortality in granulomatosis with polyangiitis: A single-center study

Objectives

The aim of this study was to identify predictors of mortality in granulomatosis with polyangiitis (GPA) patients and to seek the ways of improving survival in GPA patients.

Patients and methods

Between January 2005 and June 2020, a total of 60 patients (26 males, 34 females; median age: 49 years; range, 19 to 75 years) who were diagnosed with GPA were retrospectively analyzed. Demographic, clinical, laboratory, and radiological findings of all patients were recorded. Survival rates were analyzed using the Kaplan-Meier plot.

Results

The median follow-up was 36 months, and 10 (16.7%) patients died during the study period. Univariate analysis showed that the prognostic values were attributed to high serum creatinine levels (>2.1 mg/dL; p=0.01), proteinuria (p=0.01), dialysis-requiring renal damage at the time of diagnosis (p=0.01) or at any time during follow-up (p=0.01), low lymphocyte levels (p=0.01), hypoalbuminemia (p=0.04), absence of upper respiratory tract involvement (p=0.01), presence of lung involvement with cavitary lesions (p=0.01), high Birmingham Vascular Activity Score (p=0.02), and history of serious infection (p=0.01). In the multivariate analysis, the presence of renal damage requiring dialysis at any time during follow-up (relative risk [95% confidence interval]: 21 [4.1-18.3]; p=0.01) was found to be an independent predictor of mortality. Immunosuppressive drugs exerted no effect on mortality, and the most common causes of death were infections (50%).

Conclusion

The presence of dialysis-requiring renal damage is the most important risk factor for mortality in GPA patients. These patients should be followed more closely and carefully to improve survival.

The impact of antineutrophil cytoplasmic antibody-associated vasculitis on employment and work disability in an Australian population

AIM

Although antineutrophil cytoplasmic antibody-associated vasculitis (AAV) most commonly affects older individuals, many patients develop the disease during their most productive working years. The aim of this study was to examine the effects of AAV on employment and work disability in a cohort of Australian patients of working age.

METHODS

Patients attending a vasculitis clinic located in Melbourne, Australia, completed an employment questionnaire in addition to the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem.

RESULTS

The average age of the 47 respondents was 47.8 ± 11.9 years (range 22-63 years), with a median disease duration of 60 months (range 10.2-318.5 months). There were 68.1% who were currently employed, but 20.6% of respondents employed at the time of diagnosis were no longer working and 10.6% had experienced a significant reduction in work hours since their diagnosis. There were 12.7% who were dependent on the disability support pension. The rate of work disability was 23.4%. Many participants considered themselves work impaired (41.9%), with 10.1% having missed work in the previous week. Furthermore, 44.7% of respondents reported that their financial stability had been negatively impacted by their vasculitis diagnosis. Fatigue was commonly reported. Work disabled patients were significantly more likely to be obese and less likely to have completed a tertiary education. Work disabled patients tended to be older, myeloperoxidase-antineutrophil cytoplasmic antibody positive, and have renal involvement and lung involvement.

CONCLUSION

A proportion of people living with AAV in Australia experience a decline in employment and an increase in work disability when living with this condition.

Multimorbidity in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results From a Longitudinal, Multicenter Data Linkage Study

OBJECTIVE

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is considered a chronic, relapsing condition. To date, no studies have investigated multimorbidity in AAV nationally. This study was undertaken to characterize temporal trends in multimorbidity and report excess health care expenditures associated with multimorbidities in a national AAV cohort from Scotland.

METHODS

Eligible patients with AAV were diagnosed between 1997 and 2017. Each patient was matched with up to 5 general population controls. Linked morbidity and health care expenditure data were retrieved from a Scottish national hospitalization repository and from published national cost data. Multimorbidity was defined as the development of ≥2 disorders. Prespecified morbidities, individually and together, were analyzed for risks and associations over time using modified Poisson regression, discrete interval analysis, and chi-square test for trend. The relationship between multimorbidities and health care expenditure was investigated using multivariate linear regression.

RESULTS

In total, 543 patients with AAV (median age 58.7 years [range 48.9-68.0 years]; 53.6% male) and 2,672 general population controls (median age 58.7 years [range 48.9-68.0 years]; 53.7% male) were matched and followed up for a median of 5.1 years. AAV patients were more likely to develop individual morbidities at all time points, but especially <2 years after diagnosis. The highest proportional risk observed was for osteoporosis (adjusted incidence rate ratio 8.0, 95% confidence interval [95% CI] 4.5-14.2). After 1 year, 23.0% of AAV patients and 9.3% of controls had developed multimorbidity (P < 0.0001). After 10 years, 37.0% of AAV patients and 17.3% of controls were reported to have multimorbidity (P < 0.0001). Multimorbidity was associated with disproportionate increases in health care expenditures in AAV patients. Health care expenditure was highest for AAV patients with ≥3 morbidities (3.89-fold increase in costs, 95% CI 2.83-5.31; P < 0.001 versus no morbidities).

CONCLUSION

These findings emphasize the importance of holistic care in patients with AAV, and may identify a potentially critical opportunity to consider early screening.

ANCA associated vasculitis

Vasculitis is characterized by inflammation of the vascular wall. It reaches vessels of different sizes and locations, conditioning multisystem and complex manifestations that require a holistic approach. Antineutrophil cytoplasmic antibody-associated vasculitis has an annual incidence rate of 20 per million inhabitants. It is the result of the interaction of infectious, genetic and environmental factors and manifest itself with varied and unspecific symptoms, often reaching the general state, respiratory and renal systems. The combination of clinical, laboratory, imaging and fundamentally histological changes allows the diagnosis and classification of the extent / severity of the disease necessary for the decision of the therapeutics to be taken. Glucocorticoids are generally used; with methotrexate being considered when localized disease and cyclophosphamide, rituximab or azathioprine when generalized disease. A systematized approach can increase survival rates from 12% to 70% over a 5-year span.