Vasculitis in the Geriatric Population

Prevalence and pattern of geriatric emergencies in a teaching hospital of North India

Introduction

Changing demographic patterns worldwide and improvement in healthcarehas contributed to increasing visits to the emergency department byelderly patients. Geriatric patients usually have multiple co-morbidities and declining physiological functional status. This complex interplay of various factors requires a specific and curated approach from the emergency physicians. Our aim was to study the pattern and prevalence of geriatric emergencies and the profile of infectious and non-infectious causes of fever in geriatric population in our tertiary care center.

Materials and Methods

This retrospective descriptive study was carried out at a tertiary care hospital of north India and included all patients aged more than 18 years who visited the emergency department over a period of six months (July 2018 to December 2018). Detailed data regarding demographic, clinical and diagnosis was obtained retrospectively from the hospital records system. The patients were divided into two groups, age less than 60 years and elderly patients more than 60 years of age for comparison.

Results

A total of 24768 patients above the age of 18 years visited the emergency department over a period of six months. Out of which 5399 (27.5%) patients belonged to the geriatric age group more than 60 years of age. 2474 (45.8%) geriatric age group patientswere triaged to critical areas level one and level two as compared to 4668 (24.1%) patients aged less than 60 years. Ninety (1.8%) geriatric patients succumbed to death as compared to 77 (0.4%) patients aged less than 60 years. 651 (21.9%) geriatric patients were shifted to intensive care unit as opposed to 1038 (14.8%) patients of the younger age group.226 (4.2%) geriatric patients presented with fever in the emergency department.116 (73.4%) patients having underlying co-morbidities , had fever due to infectious causes whereas 42 ( 26.5%) patients had fever due to non-infectious causes.

Conclusion

The clinical presentation mortality and morbidity pattern of geriatric patients differs significantly from that of younger population and requires a customized approach and dedicated emergency setups.

Older patients with ANCA-associated vasculitis and dialysis dependent renal failure: a retrospective study

Background

ANCA-associated vasculitis (AAV) with renal involvement is not uncommon in older individuals. Unfortunately, this can be catastrophic requiring hemodialysis (HD) and may lead to end stage renal disease (ESRD). However, more than 50 % of patients with AAV who require HD initially have renal recovery and discontinue HD. The aim of this study was to describe a retrospective cohort of older patients with AAV and severe renal involvement which required hemodialysis.

Methods

Between 1995 and 2013 a total of 30 patients with histologic evidence of pauci-immune glomerulonephritis who required HD were evaluated at a single university center. The association of demographic and clinical parameters with age was assessed. Older age of disease onset was defined as age ≥60 years. The risk of developing ESRD at 3 months was examined using univariate logistic regression analysis.

Results

Among 30 patients with AAV who required HD, the mean age of disease onset was 59 ± 17 years (range 22-88 years). Twelve patients were in the older age group, and 18 were in the younger group. Three months after diagnosis, 43 % of the cohort had ESRD with a statistically similar proportion of older (n = 9, 50 %) versus younger (n = 4, 33 %) patients (p = 0.367). Most patients (93 %) received immunosuppressive therapy. There was not a statistically significant association between age and ESRD.

Conclusions

These data suggest that age alone does not predict renal recovery among individuals on HD due to AAV. Renal recovery is a realistic expectation and outcome, if patients are treated, even among older patients with AAV who require HD initially.

The causes of acute Fever requiring hospitalization in geriatric patients: comparison of infectious and noninfectious etiology

Introduction. Infectious diseases may present with atypical presentations in the geriatric patients. While fever is an important finding of infections, it may also be a sign of noninfectious etiology. Methods. Geriatric patients who were hospitalized for acute fever in our infectious diseases unit were included. Acute fever was defined as presentation within the first week of fever above 37.3°C. Results. 185 patients were included (82 males and 103 females). Mean age was 69.7 ± 7.5 years. The cause of fever was an infectious disease in 135 and noninfectious disease in 32 and unknown in 18 of the patients. The most common infectious etiologies were respiratory tract infections (n = 46), urinary tract infections (n = 26), and skin and soft tissue infections (n = 23). Noninfectious causes of fever were rheumatic diseases (n = 8), solid tumors (n = 7), hematological diseases (n = 10), and vasculitis (n = 7). A noninfectious cause of fever was present in one patient with no underlying diseases and in 31 of 130 patients with underlying diseases. Conclusion. Geriatric patients with no underlying diseases generally had infectious causes of fever while noninfectious causes were responsible from fever in an important proportion of patients with underlying diseases.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.

Vascular dendritic cells in giant cell arteritis

Giant cell arteritis (GCA) is a granulomatous vasculitis that selectively targets medium-sized and large arteries, especially the cranial branches of the aorta. The inflammatory activity of vascular lesions is driven by adaptive immune responses, with CD4 T cells undergoing clonal expansion in the vessel wall and releasing interferon gamma. Recent studies have described a distinctive population of dendritic cells (DCs) localized at the adventitia-media border of normal medium-sized arteries that appear to play a critical role in the initiation of vasculitis. Immune effector functions of this DC population are being examined in human artery-severe combined immunodeficient (SCID) mouse chimeras. In their constitutive form, CD11c+ fascin+ adventitial DCs are not recognized by alloreactive T cells. Triggering with Toll-like receptor (TLR) ligands is sufficient to break this state of tolerance and initiate DC activation, T-cell recruitment, T-cell activation, and T-cell retention in the arterial wall. Systemic administration of ligands for TLR2 or -4 in human artery-SCID chimeras drives differentiation of adventitial DCs into chemokine-producing effector cells with high-level expression of both CD83 and CD86 and mediates T-cell regulatory function through release of interleukin 18. In established vasculitis, fully matured DCs retain antigen-presenting function; antibody-mediated DC depletion disrupts T-cell and macrophage activation and has marked anti-inflammatory effects. We conclude that adventitial DCs, an indigenous cell population of the arterial wall, are responsive to pathogen-derived macromolecules and have gatekeeper function in regulating T-cell recruitment and retention to the arterial adventitia. A switch of adventitial DCs from being nonstimulatory to T-cell activating emerges as a critical event in the initiation of vasculitis.