Multiple ulcerations and perforation in the small intestine after steroid treatment in eosinophilic granulomatosis with polyangiitis: a case report and literature review

Similarities and differences of clinical manifestations and prognosis between eosinophilic gastroenteritis and eosinophilic granulomatosis with polyangiitis complicating gastrointestinal involvement

OBJECTIVE

To investigate the similarities and differences of clinical manifestations and long-term prognosis between eosinophilic gastroenteritis (EGE) and eosinophilic granulomatosis with polyangiitis (EGPA) complicating GI involvement (EGPA-GI).

METHODS

Sixty-two EGE and 30 EGPA-GI patients were retrospectively enrolled in PUMCH from 2008 to 2023. Baseline clinical records were collected. Kaplan-Meier curves and log-rank tests were used to analyzed the relapse-free and non-adverse-outcome survival rate. Logistic regression was used to construct a predictive model for diagnosing EGE and EGPA-GI.

RESULTS

Both diseases had a middle age onset. EGE had a shorter disease duration (3.5 vs. 11.0 months, p = 0.023), higher prevalence of distension (50.0% vs 20.0%, p = 0.007) and intestinal obstruction (32.3% vs 3.3%, p = 0.001), and lower prevalence of fever (6.5% vs 50.0%, p < 0.001) than EGPA-GI. EGPA-GI had higher prevalence of allergic diseases (86.7% vs 46.8%, p < 0.001) and higher IgE level (445.0 KU/L vs 153.0 KU/L, p = 0.003). Meanwhile, in EGPA-GI, higher ESR (25.0 mm/h vs 4.0 mm/h, p = 0.001) and hsCRP (48.9 mg/L vs 1.8 mg/L, p < 0.001) were observed. Asthma (OR 572.043, 95% CI 21.729-176,210.429, p = 0.0043), fever (OR 25.221, 95% CI 2.334-585.159, p = 0.0157), rash (OR 28.671, 95% CI 1.898-2274.543, p = 0.454), intestinal obstruction (OR 0.015, 95% CI 0.000-0.357, p = 0.0318), higher ESR (OR 1.101, 95% CI 1.035-1.208, p = 0.0099), and hsCRP (OR 1.038, 95% CI 1.010-1.081, p = 0.0208) were found to be independent discriminating factors for EGPA-GI. Both diseases presented recurrent courses. Adverse outcomes including GI perforation, organ failure, and all-cause death occurred in seven EGPA-GI patients while none in EGE (p = 0.00011).

CONCLUSION

Both diseases have chronic and recurrent disease courses. Clinical manifestations and laboratory tests help to discriminate them. EGPA-GI have more unfavorable prognosis compared with EGE during long-term follow-up. Key Points •Baseline characteristics and long-term prognosis of 62 EGE and 30 EGPA patients with GI involvement (EGPA-GI) were compared in this study. •Both diseases had chronic and recurrent disease duration, eosinophilia, and increased IgE level. •EGPA-GI had higher prevalence of asthma, fever, rash, higher IgE, ESR, and CRP compared with EGE. •EGPA-GI had higher risk for severe adverse outcomes.

Heterogeneity and individualized therapy for eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA), as a heterogeneous component of antineutrophil cytoplasmic antibody-associated vasculitis, may be induced by a series of environmental and genetic factors, involved with a variety of immune cells and immune components, and presented with various clinical manifestations, with multiple organs and systems (respiratory, skin, heart, kidney, nerve, etc.) involved. The choice of glucocorticoid (GC) dosage and immunosuppressant in traditional treatment strategies varies greatly from individual to individual and is not universally applicable in all the EGPA phenotype spectrum, especially in relapsing or refractory diseases. With the understanding of the heterogeneity of EGPA, a variety of therapeutic approaches are emerging and improving the traditional treatment model. In this review, we summarized the heterogeneity of EGPA etiology and pathogenesis. Clinical and pathological manifestations of the same organ involved also show significant differences and there are even gender differences. Biological treatments that mainly target type 2 inflammatory pathways are widely used in clinical practice for remission induction and maintenance of EGPA. Targeted biological therapy has shown excellent performance in reducing GC dosage and controlling symptoms and recurrence. However, a large number of high-quality randomized controlled studies are still under research for relapsing or refractory EGPA with special organ involvement. We believe that EGPA has a highly heterogeneous phenotype spectrum, and the treatment patterns targeting key molecules in the pathogenesis are of great value for individual treatment of EGPA.

Eosinophilic Granulomatosis with Polyangiitis: Latest Findings and Updated Treatment Recommendations

Eosinophilic granulomatosis with polyangiitis (EGPA) causes necrotizing vasculitis and eosinophil-rich granulomatous inflammation in small- to medium-sized vessels, resulting in multiple organ damage. EGPA is classified as an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, with myeloperoxidase-ANCA detected in approximately one-third of the patients. Conventional treatment of EGPA relies on systemic glucocorticoids (GCs) in combination with cyclophosphamide when poor prognostic factors are present; however, the dilemma between disease control and drug-related adverse effects has long been a challenge. Recent studies have revealed that the genetic background, pathophysiology, and clinical manifestations differ between ANCA-positive and ANCA-negative patients; however, mepolizumab, an interleukin (IL)-5 inhibitor, is effective in both groups, suggesting that the IL-5-eosinophil axis is deeply involved in the pathogenesis of both ANCA-positive and ANCA-negative EGPA. This review summarizes the latest knowledge on the pathophysiology of EGPA and focuses on the roles of eosinophils and ANCA. We then introduce the current treatment recommendations and accumulated evidence for mepolizumab on EGPA. Based on current unmet clinical needs, we discuss potential future therapeutic strategies for EGPA.

Eosinophilic gastroenteritis: Pathogenesis, diagnosis, and treatment

ABSTRACT

Eosinophilic gastroenteritis (EGE) is a gastrointestinal disorder of unclear etiology that is characterized by eosinophilic infiltration of the stomach and small intestine, and consists of mucosal, muscular, and serosal subtypes. Eosinophilic infiltration of the gastrointestinal tract is a fundamental histopathological characteristic of EGE and is driven by several T-helper type 2 (Th2)-dependent cytokines and induced by food allergy. Due to the lack of a diagnostic gold standard, EGE has a high rate of delayed diagnosis or misdiagnosis. However, several new diagnostic strategies have been developed, such as novel genetic biomarkers and imaging tests. Although dietary therapy and corticosteroids remain the common choices for EGE treatment, recent decades have seen the emergence of novel treatment alternatives, such as biologics that target particular molecules involved in the pathogenic process. Preliminary investigations and clinical trials have demonstrated the efficacy of biologics and provided additional insights for the era of refractory or corticosteroid-dependent EGE biologics.

Clinical characteristics and long-term outcome of patients with gastrointestinal involvement in eosinophilic granulomatosis with polyangiitis

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.

Gastrointestinal Eosinophilic Granulomatosis with Polyangiitis following a Clostridium difficile Infection

Eosinophilic granulomatosis with polyangiitis (EGPA), historically named Churg-Strauss syndrome, is a rare vasculitis affecting small- and medium-sized blood vessels. The disease has a predilection for numerous organs including the lungs, sinuses, kidneys, heart, nerves, and gastrointestinal tract but is prominently associated with asthma, rhinosinusitis, and eosinophilia. Gastrointestinal involvement is common; however, a gastrointestinal manifestation as the cardinal symptom following an infection is atypical. Here, we present a case of a 61-year-old male who presented with persistent diarrhea following a toxigenic Clostridium difficile infection despite multiple antibiotic courses. Repeat testing confirmed eradication of the infection, and further evaluation with colon biopsy revealed small and medium-sized vasculitis with eosinophilic infiltration and granulomas. Treatment with prednisone and cyclophosphamide resulted in rapid improvement of his diarrhea. Gastrointestinal symptoms in EGPA are associated with worse prognosis, so prompt identification and treatment of the disease is crucial. EGPA is rarely documented in histopathological samples from the gastrointestinal tract as endoscopic biopsies are typically too superficial to sample the submucosal layer containing the affected vessels. Additionally, the link between EGPA and infections as a potential trigger has not been clearly established, but gastrointestinal EGPA manifesting after a colonic infection raises concerns that this may have been a triggering event. Ultimately, further study is needed to understand, diagnose, and treat gastrointestinal and postinfection EGPA.

Severe eosinophilic granulomatosis with polyangiitis responding to a combination of rituximab and mepolizumab

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss Syndrome, is a multisystem antineutrophil cytoplasmic antibody (ANCA) positive vasculitis, characterized by the presence of chronic rhinosinusitis, asthma and prominent peripheral blood eosinophilia. Although the most commonly involved organ is the lung, followed by the skin, EGPA can affect any organ system. Herein, we present the complicated case of an 18-year-old male patient with severe life-threatening EGPA, with central nervous system, cardiac and gasterointestinal involvement, which was resistant to initial treatment with glucocorticoids and cyclophosphamide. The patient responded well, achieving complete remission after the addition of rituximab and mepolizumab to glucocorticoids and cyclophosphamide.

Manifestations of the gastrointestinal tract in systemic rheumatic diseases: A narrative review

Gastrointestinal disorders are important place among the visceral manifestations of systemic autoimmune and immunoinflammatory rheumatic diseases (RD). Pathology of the esophagus, stomach, small and large intestine can vary from moderate functional disorders to the development of severe chronic inflammation with metaplasia and dysplasia of the mucous membrane, the formation of multiple erosions, hemorrhages and deep ulcers. Complications of gastrointestinal pathology in RD, such as bleeding, perforations and strictures, can cause death. This review examines the main clinical manifestations, possibilities of diagnosis and treatment of gastrointestinal lesions in systemic scleroderma, idiopathic inflammatory myopathies, systemic vasculitis, Sjogren’s syndrome and disease, as well as systemic lupus erythematosus.

Imaging of intestinal vasculitis focusing on MR and CT enterography: a two-way street between radiologic findings and clinical data

Diagnosis of intestinal vasculitis is often challenging due to the non-specific clinical and imaging findings. Vasculitides with gastrointestinal (GI) manifestations are rare, but their diagnosis holds immense significance as late or missed recognition can result in high mortality rates. Given the resemblance of radiologic findings with some other entities, GI vasculitis is often overlooked on small bowel studies done using computed tomography/magnetic resonance enterography (CTE/MRE). Hereon, we reviewed radiologic findings of vasculitis with gastrointestinal involvement on CTE and MRE. The variety of findings on MRE/CTE depend upon the size of the involved vessels. Signs of intestinal ischemia, e.g., mural thickening, submucosal edema, mural hyperenhancement, and restricted diffusion on diffusion-weighted imaging, are common in intestinal vasculitis. Involvement of the abdominal aorta and the major visceral arteries is presented as concentric mural thickening, transmural calcification, luminal stenosis, occlusion, aneurysmal changes, and collateral vessels. Such findings can be observed particularly in large- and medium-vessel vasculitis. The presence of extra-intestinal findings, including within the liver, kidneys, or spleen in the form of focal areas of infarction or heterogeneous enhancement due to microvascular involvement, can be another radiologic clue in diagnosis of vasculitis. The link between the clinical/laboratory findings and MRE/CTE abnormalities needs to be corresponded when it comes to the diagnosis of intestinal vasculitis.

Acute eosinophilic pneumonia with sepsis-like symptoms of arthralgia, joint stiffness and lymph node enlargement: A case report

Background

Acute eosinophilic pneumonia (AEP) is an acute febrile disease with good prognosis. It is often manifested as cough, dyspnea and fever, and sometimes may also as myalgia. However, there are no reports of AEP with sepsis-like symptoms of arthralgia, joint stiffness, lymph node enlargement, transient rashes and abnormal liver function in the literature.

Case summary

A male patient with AEP was admitted to our hospital. He presented with fever, cough, arthralgia and joint stiffness, and also had transient rashes, lymph node enlargement and mild abnormal liver function. The counts of white blood cells and eosinophils were increased in peripheral blood. It seemed like sepsis, but his percutaneous lung biopsy suggested eosinophil inflammation, which had a good response to corticosteroids instead of antibiotics.

Discussion

AEP is easily misdiagnosed as bacterial pneumonia with sepsis when it presents with lung infiltration on CT and atypical manifestations such as arthralgia, joint stiffness, lymph node enlargement, transient rashes and abnormal liver function. In this case, if a lot more antibiotics do not work, some of possible diseases including AEP may be considered. Increased eosinophils in peripheral blood and lung biopsy are helpful for the diagnosis of the disease.