Steroid-responsive thromboangiitis obliterans

Development of Eosinophilic Temporal Arteritis and Digital Ischemia in a Patient with Hypereosinophilic Syndrome

We describe a case of eosinophilic temporal arteritis in a 61-year-old woman with hypereosinophilic syndrome, who developed subcutaneous nodules in the temporal areas and digital cyanosis with small nodules on the sides of her fingers. Ultrasound revealed occlusion and corkscrew-like changes of the temporal and digital arteries, respectively. Temporal artery biopsy revealed eosinophilic vasculitis without giant cell formation. Angiography showed occlusion of the ulnar and digital arteries. Administration of low-dose corticosteroid improved the temporal artery swelling and digital cyanosis. More reports of similar cases are required to characterize this type of non-giant cell eosinophilic vasculitis that affects the peripheral arteries.

"Idiopathic Eosinophilic Vasculitis": Another Side of Hypereosinophilic Syndrome? A Comprehensive Analysis of 117 Cases in Asthma-Free Patients

BACKGROUND

The absence of asthma may rule out a diagnosis of eosinophilic granulomatosis with polyangiitis in patients with hypereosinophilic syndrome (HES) and features of vasculitis.

OBJECTIVE

To describe eosinophilic vasculitis (EoV) as a possible manifestation of HES in asthma-free patients.

METHODS

We screened our hospital database and the literature for patients with HES who met the following 4 criteria: (1) histopathological or clinical features of EoV (biopsy-proven vasculitis with predominant eosinophilic infiltration of the vessel wall and/or features of vasculitis with tissue and/or blood hypereosinophilia [absolute eosinophil count >1.5 G/L]); (2) no other obvious causes of reactive eosinophilia, organ damage, and vasculitis; (3) the absence of antineutrophil cytoplasmic antibodies; and (4) the absence of current asthma.

RESULTS

Ten of our 83 (12%) asthma-free patients with HES and 107 additional cases in the literature met the criteria for EoV. After a critical analysis of the patients' clinical and laboratory characteristics and outcomes, we identified 41 cases of single-organ EoV (coronary arteritis, n = 29; temporal arteritis, n = 8; cerebral vasculitis, n = 4). Of the remaining 76 patients with EoV, the most frequent manifestations (>10%) were cutaneous vasculitis (56%), peripheral neuropathy (24%), thromboangiitis obliterans-like disease (16%), fever (13%), central nervous system involvement (13%), deep venous thrombosis (12%), and nonasthma lung manifestations (12%). Blood hypereosinophilia more than 1.5 G/L was observed in 79% of patients, and necrotizing vasculitis was observed in 44%.

CONCLUSIONS

Our results suggest that idiopathic EoV (HES-associated vasculitis) can be classified as an eosinophilic-rich, necrotizing, systemic form of vasculitis that affects vessels of various sizes in asthma-free patients.

Hypereosinophilic syndrome accompanied by Buerger's disease-like femoral arterial occlusions

A case of hypereosinophilic syndrome (HES) with a rare complication of Buerger's disease-like large arterial occlusion (AO) was successfully treated with emergent percutaneous transluminal angioplasty and anticoagulants plus corticosteroid. By reviewing 15 reported cases of HES with AO including the present case, we found man predominance but no other consistent characteristics in HES with AO, such as age, smoking history, eosinophil counts or previous treatments, thus, predicting AO in HES patients appears to be difficult. Vessel intervention should be considered as a treatment option, since treatment delay in some patients has resulted in the amputation of extremities.

Buerger's disease: What has the last decade taught us?

Thrombangiitis obliterans (TAO), or Buerger's disease, is most likely an endarteritis that is introduced by T-cell-mediated cellular immunity and B-cell-mediated humoral immunity associated with the activation of macrophages or dendritic cells in the intima. There is no specific marker of the disease, and the diagnosis is based on clinical and angiographic criteria. The disease spontaneously leads to tissue loss and major amputations and is self-limiting in the 5th to 6th decades of life. Patients should quit smoking and be offered treatment with prostaglandin or prostacyclin, modern wound management, and pain-relieving drugs. Surgical revascularization may be indicated in elective patients, and amputation should only be the last option. It has been suggested that environmental factors may play a major role in the modification of the disease process. TAO is a typical lower class disease, the social and psychological components of which are widely unexplored. Unfortunately, the last decade has not taught us anything to enable us to improve the treatment of TAO patients.

Enfermedad de Buerger (tromboangeítis obliterante)

Thromboangiitis obliterans (TAO) is a segmental, inflammatory, vasoocclusive disease that predominantly affects the small and medium-sized arteries and veins of the extremities. It most often occurs in young male smokers, especially those from Mediterranean and Asian countries. It is considered an autoimmune process related to the use of tobacco products. Clinically, it is characterized by the presence of painful, ischemic ulcers of the digits. Histopathological studies usually show an occlusive intraluminal thrombus with a predominantly acute inflammatory infiltrate. To make the diagnosis, it is important to exclude other causes of ischemia of the extremities, and different authors have proposed criteria to establish this diagnosis. Treatment is only effective if it is accompanied by abstention from tobacco. There are also different pharmacological and surgical strategies for its management.