1
|
Junek ML, Zhao L, Garner S, Cuthbertson D, Pagnoux C, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland LW, Rhee RL, Seo P, Specks U, Sreih AG, Warrington K, Wechsler ME, Merkel PA, Khalidi NA. Ocular manifestations of ANCA-associated vasculitis. Rheumatology (Oxford) 2023; 62:2517-2524. [PMID: 36440847 PMCID: PMC10321114 DOI: 10.1093/rheumatology/keac663] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/12/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) is a group of multisystem diseases that can have several ocular manifestations. There are published data on ocular manifestations of granulomatosis with polyangiitis (GPA), but few for eosinophilic granulomatosis with polyangiitis (EGPA) or microscopic polyangiitis (MPA). There is little information concerning chronicity, complications, and association with other cranial manifestations of AAV. METHODS This study retrospectively analysed longitudinal multicentre cohorts of individuals with AAV followed between 2006 and 2022. Data included diagnosis, demographics, cranial manifestations of disease, presence of manifestations at onset of disease and/or follow-up, and ocular complications of disease. Univariate and multivariable logistic regression analysis assessed associations across disease manifestations. RESULTS Data from 1441 patients were analysed, including 395 with EGPA, 876 with GPA, and 170 with MPA. Ocular manifestations were seen within 23.1% of patients: 39 (9.9%) with EGPA, 287 (32.7%) with GPA, and 12 (7.1%) with MPA at any time in the disease course. There were more ocular manifestations at onset (n = 224) than during follow-up (n = 120). The most common disease-related manifestations were conjunctivitis/episcleritis and scleritis. In multivariable analysis, dacryocystitis, lacrimal duct obstruction, and retro-orbital disease were associated with sinonasal manifestations of GPA; ocular manifestations were associated with hearing loss in MPA. The most common ocular complications and/or damage seen were cataracts (n = 168) and visual impairment (n = 195). CONCLUSION Ocular manifestations occur in all forms of AAV, especially in GPA. Clinicians should be mindful of the wide spectrum of ocular disease in AAV, caused by active vasculitis, disease-associated damage, and toxicities of therapy.
Collapse
Affiliation(s)
- Mats L Junek
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Lily Zhao
- Division of Ophthalmology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | - Stephanie Garner
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | - Paul A Monach
- Rheumatology Section, Veteran’s Affairs Boston Healthcare System, Boston, MA, USA
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | - Nader A Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
2
|
Baca V, Barragán-García AA, García-Vega D, Vázquez-Lara Y, Siordia-Reyes G, Yañez-Gutierrez L. Limited granulomatosis with polyangiitis in children with idiopathic orbital inflammation: a case series and literature review. Rheumatol Int 2023:10.1007/s00296-023-05366-7. [PMID: 37322355 DOI: 10.1007/s00296-023-05366-7] [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: 04/16/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
Idiopathic orbital inflammation (IOI) is a diagnosis of exclusion, but the exclusion of other inflammatory diseases of the orbit is broad and relies on clinician experience, response to corticosteroid, or biopsy. This study aimed to investigate the presence of granulomatosis with polyangiitis (GPA) in patients initially diagnosed as IOI and describe its clinicopathological features, ANCA status, treatment, and outcome. We performed a retrospective case series study of children diagnosed with limited GPA (L-GPA) in patients with IOI. A systematic review of the literature was performed in children with GPA and orbital mass. Eleven of 13 (85%) patients with IOI had L-GPA. Two additional patients with orbital mass and L-GPA were included in this analysis. The median age was 10 years, and 75% were female. Twelve cases were ANCA positive and 77% were MPO-pANCA positive. Most patients had a poor response to treatment and had a high relapse rate. Based on literature review, 28 cases were found. Most (78.6%) were female with a median age of 9 years. Three patients were misdiagnosed as IOI. Patients with L-GPA more frequently had MPO-pANCA positivity (35%) than children with systemic GPA (18%) and were less often PR3-cANCA positive than patients with systemic GPA (18% vs. 46%). L-GPA accounts for a high prevalence of children diagnosed as IOI. The high prevalence of MPO-pANCA observed in our study may be related to L-GPA rather than with the orbital mass. Long-term follow-up, orbital biopsy, and serial ANCA testing are necessary to exclude GPA in patients with IOI.
Collapse
Affiliation(s)
- Vicente Baca
- Department of Rheumatology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Av. Cuauhtémoc # 330, Col. Doctores, CP 06720, Mexico City, Mexico.
| | - Alejandro A Barragán-García
- Department of Rheumatology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Av. Cuauhtémoc # 330, Col. Doctores, CP 06720, Mexico City, Mexico
- Department of Pediatrics, Hospital Gabriel Mancera IMSS, Mexico City, Mexico
| | - Daphne García-Vega
- Department of Ophthalmology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Yolanda Vázquez-Lara
- Department of Ophthalmology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Georgina Siordia-Reyes
- Department of Pathology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Lucelli Yañez-Gutierrez
- Department of Congenital Heart Diseases, Hospital de Cardiología Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| |
Collapse
|
3
|
Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
Collapse
Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
| |
Collapse
|
4
|
Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
Collapse
Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| |
Collapse
|
5
|
Ang T, Juniat V, Selva D. Autoimmune markers in screening for orbital inflammatory disease. Eye (Lond) 2022; 37:1088-1093. [PMID: 35440697 PMCID: PMC10102185 DOI: 10.1038/s41433-022-02068-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Immunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody). METHODS A retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson's Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy. RESULTS 79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI. CONCLUSION Serological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.
Collapse
Affiliation(s)
- Terence Ang
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide, Adelaide, SA, Australia.
| | - Valerie Juniat
- Department of Ophthalmology, The Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dinesh Selva
- Department of Ophthalmology, The Royal Adelaide Hospital, Adelaide, SA, Australia
| |
Collapse
|
6
|
Bayrashevskaya AV, Degtyareva ND, Radenska-Lopovok SG. [ANCA-associated small-vessel vasculitides]. Arkh Patol 2022; 84:50-58. [PMID: 35166479 DOI: 10.17116/patol20228401150] [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: 06/14/2023]
Abstract
ANCA-associated vasculitides refer to systemic small-vessel vasculitides. The paper shows the role of antineutrophil cytoplasmic antibodies in the development of immune inflammation of blood vessels and tissues. It considers the pathogenesis of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis and presents the clinical and morphological manifestations of the diseases.
Collapse
Affiliation(s)
- A V Bayrashevskaya
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - N D Degtyareva
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - S G Radenska-Lopovok
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
- Russian Medical Academy of Continuious Professional Education of the Ministry of Health of Russia, Moscow, Russia
| |
Collapse
|
7
|
Abstract
This article provides an overview of rare orbital diseases. Congenital
malformations, inflammatory diseases, benign and malignant neoplasias are
described. Although it represents a relatively small area of the body the
orbit contains multiple different tissues. Therefore, a great variety of
diseases can be found within the orbital space. That is the reason, why both
the completeness and the level of detail in the description of particular
diseases must be somewhat limited. Nevertheless, clinical manifestations,
important aspects of diagnosis, treatment strategies, and, when specific
data are available, the prognosis are described. The authors tried to
highlight the most characteristic aspects of the different diseases to
describe their relevant aspects in spite of the brevity of the
subsections.
Collapse
Affiliation(s)
- Ulrich Kisser
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
| | - Jens Heichel
- Universitätsklinik und Poliklinik für Augenheilkunde, Halle/S. (Klinikdirektor: Prof. Dr. med. A. Viestenz)
| | - Alexander Glien
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
| |
Collapse
|
8
|
Andrada-Elena M, Ioana TT, Mihaela FM, Irina-Elena C, Andrei TI, Florian B. Wegener's granulomatosis with orbital involvement: case report and literature review. Rom J Ophthalmol 2021; 65:93-97. [PMID: 33817443 PMCID: PMC7995507 DOI: 10.22336/rjo.2021.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: To describe the chronology and the extent of orbital involvement in a case of granulomatosis with polyangiitis. Methods: Descriptive case report and literature review. Results: A 45-year-old patient, formerly diagnosed with granulomatosis with polyangiitis due to otorhinolaryngologic manifestations, pulmonary lesions, renal impairment, left knee arthritis and high blood levels of antineutrophil cytoplasmic antibodies, addressed the Ophthalmology Department in November 2020, having the following complaints: left eye mild retro-orbital discomfort, proptosis and epiphora. On examination, Snellen’s best corrected visual acuity was 6/ 6 in both eyes. The anterior segment of the left eye displayed significant changes: proptosis, upper lid swelling, ptosis, slightly decreased ocular motility, mild conjunctival hyperemia and chemosis, thinning of sclera in the upper quadrant and mild posterior subcapsular cataract. Left eye funduscopy revealed a slightly elevated optic disc, with indistinct margins in the nasal quadrant. Spectral-domain optical coherence tomography (OCT) of the optic nerve confirmed the clinical findings, illustrating an increase in the retinal nerve fiber layers thickness in the nasal quadrant, with no corresponding visual field defect. The orbit magnetic resonance imaging (MRI) unveiled an intraconal mass surrounding the optic nerve on its entire intra-orbital path, confirming the diagnosis of left orbital granuloma. Conclusion: Considering the relapsing disease and the orbital involvement, the patient is currently a candidate for rituximab, a monoclonal antibody against CD20. Abbreviations: AAV = ANCA associated vasculitides, ANCA = antineutrophil cytoplasmic antibody, AOM = acute otitis media, BCVA = best corrected visual acuity, CRP = C-reactive protein, CT = computerized tomography, EGPA = eosinophilic granulomatosis with polyangiitis, ENT = otorhinolaryngology/ ear-nose-throat, ESR = erythrocyte sedimentation rate, GPA = granulomatosis with polyangiitis, LE = left eye, MPA = microscopic polyangiitis, MRI = magnetic resonance imaging, OCT = optical coherence tomography, RE = right eye, RNFL = retinal nerve fiber layers, TNF = tumor necrosis factor, WG = Wegener’s granulomatosis
Collapse
Affiliation(s)
| | - Teodora Tofolean Ioana
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Retina" Clinic, Bucharest, Romania
| | - Florica Milicescu Mihaela
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Rheumatology Department, "Dr. Ioan Cantacuzino" Clinical Hospital, Bucharest, Romania
| | | | | | - Baltă Florian
- Emergency Eye Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Retina" Clinic, Bucharest, Romania
| |
Collapse
|
9
|
Krishna R, De Giacomi F, Kumar N, Kalina P, Specks U, Baqir M. Rituximab Versus Cyclophosphamide for Central Nervous System Involvement of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Series. J Clin Rheumatol 2021; 27:64-72. [PMID: 31567753 DOI: 10.1097/rhu.0000000000001169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effectiveness of rituximab (RTX) with cyclophosphamide (CYC) in patients who have central nervous system (CNS) involvement in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS A computer-assisted search was conducted to identify all adults who received a diagnosis of AAV with CNS involvement from January 1, 1997, through July 1, 2017, at our institution. RESULTS Of the 17 patients identified, 11 had received RTX, and 6 had received CYC. Age at diagnosis of CNS involvement was similar in both groups. In the RTX group, 91% of the patients were women; in the CYC group, 33% were women (p = 0.03). At the time of CNS presentation, orbital involvement had occurred in 6 patients in the RTX group and in none of the patients in the CYC group. Initial remission of induction was achieved in all patients (100%) in the CYC group and in 10 patients (91%) in the RTX group. Two patients had no response to RTX: 1 patient when RTX was used for remission induction at the time of diagnosis and the second patient when RTX was used for remission induction after relapse. The median follow-up was 38 months (range, 9-127 months). Central nervous system relapse occurred in 4 patients in the RTX group and in 1 patient in the CYC group. Of the 4 patients in the RTX group with relapse, 3 had marked ocular involvement. Both nonresponder patients in the RTX group had ocular involvement. CONCLUSION Rituximab is as effective as CYC in remission induction in patients with CNS involvement in AAV.
Collapse
Affiliation(s)
- Rachana Krishna
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Federica De Giacomi
- Cardio-Thoracic-Vascular Department, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | | | | | - Ulrich Specks
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
10
|
Wei J, Zhao Q, Yao M, Meng L, Xin Y, Jiang X. Radiotherapy of granulomatosis with polyangiitis occurring in the eyelid: A case report and literature review. Medicine (Baltimore) 2021; 100:e22794. [PMID: 33545922 PMCID: PMC7837942 DOI: 10.1097/md.0000000000022794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is a chronic systemic vasculitis characterized by necrotizing granulomatous vasculitis. The disease mainly affects the middle and small blood vessels and mainly occurs in the upper respiratory tract (nose and paranasal sinuses), lower respiratory tract (lungs), and kidneys. Disease occurrence in the eyelid area is relatively rare. The standard GPA treatment is combination therapy with adrenocortical hormone and immunosuppressants. Radiotherapy as a treatment option for GPA has not been widely investigated. PATIENT CONCERNS A 29-year-old man presented with a 1.0 × 1.0 cm mass without exophthalmos and decreased vision in the left lower eyelid. Computed tomography revealed a mass-like high-density shadow below the left eye with a computed tomography value of 80-108 U. DIAGNOSIS The laboratory investigations revealed positive cytoplasmic antineutrophil cytoplasmic antibodies (titer = 1:40). Biopsy of the lower left eyelid mass revealed necrosis and granulomatous reaction with a large number of inflammatory cell infiltration. After consultation with the pathology department, the diagnosis was determined as left lower eyelid GPA. INTERVENTIONS The patient received 9MeV electron beam radiation therapy in the area of the left lower eyelid lesion. OUTCOMES The lesion in the patient was significantly reduced and the symptom relieved obviously. No symptom recurrence or significant toxicity occurred during or after the treatment. The patient remains under routine follow-up. CONCLUSION We present a case of a male patient with GPA located exclusively in the eyelid area, who underwent successful radiotherapy and achieved a complete response. The lesson we learned from this case study is that for GPA patients, when the standard treatment model fails to achieve good results, novel treatments such as radiotherapy should be considered according to the situation.
Collapse
Affiliation(s)
- Jinlong Wei
- Department of Radiation Oncology
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University
| | - Qin Zhao
- Department of Radiation Oncology
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University
| | - Min Yao
- Department of pathology, the Second Hospital of Jilin University, Changchun, China
| | - Lingbin Meng
- Department of Internal Medicine, Florida Hospital, Orlando, FL 32803, USA
| | - Ying Xin
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun, China
| | - Xin Jiang
- Department of Radiation Oncology
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University
| |
Collapse
|
11
|
Mitsuhashi M, Yoshimi R, Kishimoto D, Hidekawa C, Iizuka Y, Sakurai N, Kamiyama R, Kirino Y, Kondo Y, Mizuki N, Nakajima H. Refractory optic perineuritis related to granulomatosis with polyangiitis treated with intensive immunosuppressive therapy combined with plasma exchange. Mod Rheumatol Case Rep 2020; 4:84-89. [PMID: 33086977 DOI: 10.1080/24725625.2019.1649857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/25/2019] [Indexed: 06/11/2023]
Abstract
Optic perineuritis (OPN), which is an inflammatory disorder affecting the optic nerve sheath, is one of the rare complications in granulomatosis with polyangiitis (GPA). Although several groups have reported that immunosuppressive therapies are generally effective against GPA-associated OPN, so far, there is little information as to other options for refractory cases. Here we demonstrate a case of GPA-associated OPN, which is refractory to potent immunosuppressive therapy including high-dose glucocorticoid, intravenous cyclophosphamide and rituximab therapy, and effective application of therapeutic plasma exchange. We also report here that CSF IL-6 levels may serve as a new biomarker for GPA-associated OPN.
Collapse
Affiliation(s)
- Masaki Mitsuhashi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Daiga Kishimoto
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Chiharu Hidekawa
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yuki Iizuka
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Natsuki Sakurai
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Reikou Kamiyama
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yukiho Kondo
- Department of Ophthalmology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| |
Collapse
|
12
|
TNF-α Inhibitors for the Management of Orbital Inflammatory Conditions. Clin Ophthalmol 2020; 60:103-109. [DOI: 10.1097/iio.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
13
|
Orbital Nasal-Type Extranodal Natural Killer/T-Cell Lymphoma: An Ongoing Diagnostic Challenge Further Confounded by Small-Cell Predominance. Ophthalmic Plast Reconstr Surg 2019; 35:478-483. [DOI: 10.1097/iop.0000000000001333] [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]
|
14
|
Durel CA, Hot A, Trefond L, Aumaitre O, Pugnet G, Samson M, Abad S, Belot A, Blanchard-Delaunay C, Cohen P, Cohen-Aubard F, Cottin V, Crestani B, Moreuil CD, Durupt S, Garzaro M, Girszyn N, Godeau B, Hachulla E, Jamilloux Y, Jego P, Killian M, Lazaro E, Le Gallou T, Liozon E, Martin T, Papo T, Perlat A, Pillet P, Guillevin L, Terrier B. Orbital mass in ANCA-associated vasculitides: data on clinical, biological, radiological and histological presentation, therapeutic management, and outcome from 59 patients. Rheumatology (Oxford) 2019; 58:1565-1573. [DOI: 10.1093/rheumatology/kez071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Objective
Orbital mass is a rare and sight-threatening manifestation of ANCA-associated vasculitides, which remains a therapeutic challenge. We aimed to describe the presentation, therapeutic management and outcome of ANCA-associated vasculitides-related orbital mass.
Methods
We conducted a French nationwide retrospective study of patients with orbital mass in the setting of ANCA-associated vasculitides according to ACR criteria and/or Chapel Hill Consensus Conference definitions.
Results
Fifty-nine patients [33 women, median age 46 (range 7–90) years] were included. Fifty-six (95%) patients had granulomatosis with polyangiitis, two eosinophilic granulomatosis with polyangiitis and one microscopic polyangiitis. Orbital mass was unilateral in 47 (80%) cases, and seemed to develop from ENT involvement in most cases. Orbital mass biopsy was available in 32 (54%) patients, showing lymphoplasmacytic infiltration in 65%, fibrosis in 55%, granulomas in 48% and vasculitis in 36%. All patients but one received glucocorticoids as first-line therapy associated with immunosuppressive agents in 82%, mainly cyclophosphamide. Response to therapy was noted in 52% of patients treated with cyclophosphamide compared with 91% of those treated with rituximab. Twenty-seven (46%) patients required a second-line therapy because of relapse (59%) or refractory course (41%). Sequelae included visual impairment in 28%, with definitive blindness in 17%. Refractory course was associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
Conclusion
Orbital mass is associated with refractory course and high frequency of sequelae, especially blindness. Refractory course is associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
Collapse
Affiliation(s)
| | - Arnaud Hot
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon
| | - Ludovic Trefond
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Olivier Aumaitre
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Gregory Pugnet
- Department of Internal Medicine, Hôpital Purpan, Toulouse
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon
| | - Sébastien Abad
- AP-HP, Hôpital Avicennes, Department of Internal Medicine, Université Paris 13, Sorbonne, Paris Cité, Faculté de Médecine Bobigny, Paris
| | - Alexandre Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, National Referral Center for Inflammatory Rheumatism and Autoimmune Diseases, Hôpital Femme Mère Enfant, Bron
| | | | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris
| | - Fleur Cohen-Aubard
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Lyon
| | | | - Claire De Moreuil
- Department of Internal Medicine, Hôpital de la Cavale Blanche, Brest
| | - Stéphane Durupt
- Department of Internal Medicine, Centre Hospitalier Lyon Sud, Lyon
| | | | - Nicolas Girszyn
- Department of Internal Medicine, Hôpital Charles Nicolle, Rouen
| | - Bertrand Godeau
- Department of Internal Medicine, Referral Center for Adult Autoimmune Cytopenias, Hôpital Henri Mondor, Créteil
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, National Referral Center for Systemic Autoimmune Diseases North and North-West of France, Université de Lille, Lille
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Lyon
| | - Patrick Jego
- Department of Internal Medicine, Hôpital Sud, Rennes
| | - Martin Killian
- Department of Internal Medicine, Hôpital Nord, Saint-Etienne
| | - Estibaliz Lazaro
- Department of Internal Medicine, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac
| | | | - Eric Liozon
- Department of Internal Medicine, Hôpital de Limoges, Limoges
| | - Thierry Martin
- Department of Clinical Immunology, HIV, and Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases RESO, Nouvel Hôpital Civil, Strasbourg
| | - Thomas Papo
- Department of Internal Medicine, Hôpital Bichat, Paris
| | | | - Pascal Pillet
- Department of Medical Pediatrics, CHU de Bordeaux – GH Pellegrin, Bordeaux
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| |
Collapse
|
15
|
Lefebvre DR, Reinshagen KL, Yoon MK, Stone JH, Stagner AM. Case 39-2018: An 18-Year-Old Man with Diplopia and Proptosis of the Left Eye. N Engl J Med 2018; 379:2452-2461. [PMID: 30575493 DOI: 10.1056/nejmcpc1807503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel R Lefebvre
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Katherine L Reinshagen
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Michael K Yoon
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - John H Stone
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Anna M Stagner
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| |
Collapse
|
16
|
|
17
|
Xu D, Lin SR, Bonelli L, Glasgow BJ, Goldberg RA. Orbital granulomatosis with polyangiitis masquerading as invasive fungal sinusitis. Orbit 2018; 37:309-312. [PMID: 29303390 DOI: 10.1080/01676830.2017.1423339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 55-year-old man presented with unilateral orbital inflammation and no light perception vision. Imaging revealed infiltrative enhancement of the optic nerve, orbit, and intracranial tissue. The case was suspicious for invasive fungal disease, but ultimate workup and orbital biopsy revealed granulomatosis with polyangiitis. The patient's inflammation resolved with corticosteroid and rituximab therapy. Granulomatosis with polyangiitis is a systemic vasculitis that can mimic a number of orbital pathologies.
Collapse
Affiliation(s)
- David Xu
- a Stein Eye Institute, University of California , Los Angeles , CA , USA
| | - Shawn R Lin
- a Stein Eye Institute, University of California , Los Angeles , CA , USA
| | - Laura Bonelli
- a Stein Eye Institute, University of California , Los Angeles , CA , USA
| | - Ben J Glasgow
- a Stein Eye Institute, University of California , Los Angeles , CA , USA
| | - Robert A Goldberg
- a Stein Eye Institute, University of California , Los Angeles , CA , USA
| |
Collapse
|
18
|
Drobysheva A, Fuller J, Pfeifer CM, Rakheja D. Orbital Granulomatosis With Polyangiitis Mimicking IgG4-Related Disease in a 12-Year-Old Male. Int J Surg Pathol 2018; 26:453-458. [PMID: 29366363 DOI: 10.1177/1066896917754252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Granulomatosis with polyangiitis is rare in children. We report a case of a 12-year-old male who presented with new symptoms of left eyelid swelling and ptosis. Magnetic resonance imaging showed an enhancing orbital mass suspicious for a neoplasm. Excisional biopsy was performed. Microscopic examination revealed fibrovascular tissue with dense collagenous fibrosis and mixed inflammatory infiltrate that included many plasma cells. Many small and medium-sized blood vessels showed granulomatous and necrotizing vasculitis with disruption of the vessel walls and fibrinoid necrosis. Immunostain for IgG highlighted the numerous plasma cells, approximately 50% of which were positive for IgG4 immunostain. A diagnosis of granulomatosis with polyangiitis was suggested, with recommendation of serologic testing for anti-neutrophil cytoplasmic antibodies. Serum anti-neutrophil cytoplasmic antibodies were borderline high with a cytoplasmic staining pattern. The patient improved with steroid and methotrexate therapy. Granulomatosis with polyangiitis can present as an orbital mass in up to 30% of children. It may be misdiagnosed as IgG4-related disease since the inflammatory background in both conditions may be rich in plasma cells with a high proportion of IgG4+ plasma cells, and accompanied by fibrosis and obliterated blood vessels. The differential diagnosis in this location should also include inflammatory pseudotumor and inflammatory myofibroblastic tumor. Knowledge of this unusual manifestation of granulomatosis with polyangiitis and its diagnostic pitfalls can facilitate early diagnosis and treatment.
Collapse
Affiliation(s)
- Anastasia Drobysheva
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Julie Fuller
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Cory M Pfeifer
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| | - Dinesh Rakheja
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Health, Dallas, TX, USA
| |
Collapse
|
19
|
Ungprasert P, Crowson CS, Cartin-Ceba R, Garrity JA, Smith WM, Specks U, Matteson EL, Makol A. Clinical characteristics of inflammatory ocular disease in anti-neutrophil cytoplasmic antibody associated vasculitis: a retrospective cohort study. Rheumatology (Oxford) 2017; 56:1763-1770. [PMID: 28957561 PMCID: PMC6251565 DOI: 10.1093/rheumatology/kex261] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/06/2017] [Indexed: 11/14/2022] Open
Abstract
Objective To characterize the clinical correlates and outcome of inflammatory ocular disease (IOD) among patients with ANCA-associated vasculitides (AAV). Methods Medical records of potential cases of AAV seen at Mayo Clinic from 2003 to 2013, inclusive, were reviewed to identify confirmed cases meeting the diagnosis of AAV using the Chapel Hill Consensus Conference 2012 descriptors. Records of confirmed cases of AAV were then further reviewed for IOD, and clinical characteristics, treatment and outcomes abstracted. Results A total of 1171 confirmed cases of AAV were identified of which 183 patients (mean age 49.0 years; 51% female; 95% Caucasian) had IOD. The most common manifestation of IOD was injection of the eye (57%) followed by eye pain (46%) and visual acuity loss (18%). Scleritis was the most common type of IOD (22%) followed by episcleritis (21%), orbital inflammation (18%), lacrimal duct stenosis (10%) and uveitis (9%). Oral glucocorticoids were used to treat IOD in the majority of patients (96%). CYC and rituximab were the most frequently used immunosuppressive agents (54 and 36%, respectively). Of those with orbital inflammation, 52% underwent therapeutic surgical intervention. Clinical remission of IOD was achieved in 91% of patients but relapses were seen in 23%. Significant visual acuity loss was observed in only six patients. Conclusion IOD is a common manifestation of AAV and seen in about 16% of patients with AAV. Scleritis, episcleritis and orbital inflammation are the most common subtypes. Most patients respond well to glucocorticoids and immunosuppression, but relapse of IOD is common.
Collapse
Affiliation(s)
| | - Cynthia S. Crowson
- Division of Rheumatology, Department of Internal Medicine
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | | | | | - Ulrich Specks
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine
| | - Eric L. Matteson
- Division of Rheumatology, Department of Internal Medicine
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ashima Makol
- Division of Rheumatology, Department of Internal Medicine
| |
Collapse
|
20
|
Luemsamran P, Rootman J, White VA, Nassiri N, Heran MKS. The role of biopsy in lacrimal gland inflammation: A clinicopathologic study. Orbit 2017; 36:411-418. [PMID: 28816552 DOI: 10.1080/01676830.2017.1352608] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the causes of lacrimal gland inflammation based on histopathology and systemic evaluation. METHODS This is a retrospective case series study. From the University of British Columbia Orbit Clinic between January 1976 and December 2008, we reviewed the medical records of 60 patients who presented with inflammatory features of the lacrimal gland (i.e., erythema, edema, or tenderness) in which the diagnoses were not possible clinically and on imaging alone. As was our routine practice, all these patients underwent lacrimal gland biopsy before starting any treatment. RESULTS The histopathologic findings of the 60 patients showed that 37 (61.7%) had identifiable types of lacrimal inflammation including 10 with Sjogren's syndrome, seven with sarcoidal reaction, six with feature of granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis), five with lymphoma, two with sclerosing inflammation, two with IgG4-related dacryoadenitis, and one patient each with infectious dacryoadenitis, myoepithelial carcinoma, xanthogranuloma, eosinophilic angiocentric fibrosis, and eosinophilic allergic granulomatous nodule. The histopathologic findings of the remaining 23 (38.3%) patients showed nonspecific inflammation of the lacrimal gland. 23 patients (38.3%) had associated systemic diseases. 48 patients (80%) were treated successfully and 10 (16.7%) had recurrence of inflammation. CONCLUSIONS We recommend that in patients presenting with lacrimal gland inflammation (i.e., erythema, edema, tenderness) in which the specific diagnosis cannot be made clinically and on imaging, biopsy is warranted for accurate diagnosis and appropriate treatment. We found that the majority of these patients (61.7%) had specific histopathology, and 38% had systemic diseases.
Collapse
Affiliation(s)
- Panitee Luemsamran
- a Department of Ophthalmology, Siriraj Hospital , Mahidol University , Bangkok , Thailand
| | - Jack Rootman
- b Department of Ophthalmology and Visual Sciences , University of British Columbia and the Vancouver General Hospital , Vancouver , BC , Canada.,c Department of Pathology and Laboratory Medicine , University of British Columbia and the Vancouver General Hospital , Vancouver , BC , Canada.,d Jules Stein Eye Institute , University of California at Los Angeles , USA
| | - Valerie A White
- c Department of Pathology and Laboratory Medicine , University of British Columbia and the Vancouver General Hospital , Vancouver , BC , Canada
| | - Nariman Nassiri
- d Jules Stein Eye Institute , University of California at Los Angeles , USA
| | - Manraj K S Heran
- e Department of Radiology , University of British Columbia and the Vancouver General Hospital , Vancouver , BC , Canada
| |
Collapse
|
21
|
|
22
|
Kubaisi B, Abu Samra K, Foster CS. Granulomatosis with polyangiitis (Wegener's disease): An updated review of ocular disease manifestations. Intractable Rare Dis Res 2016; 5:61-9. [PMID: 27195187 PMCID: PMC4869584 DOI: 10.5582/irdr.2016.01014] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a potentially lethal systemic disorder that is characterized by necrotizing vasculitis of small arteries and veins. The respiratory system is most commonly affected in limited forms of the disease, however upper and lower respiratory system, systemic vasculitis, and necrotizing glomerulonephritis are the characteristic components of the disease triad. The peak incidence is observed at 64-75 years of age, with a prevalence of 8-10 per million depending on geographic location. In this review we focus on the ocular manifestations of the disease which occur in nearly in one third of the patients. In addition we describe the neuro-ophthalmic complications which occur in up to half of cases. We also discuss the current systemic treatment options including corticosteroids, cyclophosphamide, azathioprine, and the available biologic response modifiers including rituximab. The disease remains difficult to diagnose due to the generalized symptomatic presentation of patients with GPA. As a result, several sets of diagnostic criteria have been developed which include clinical, serological, and histopathological findings to varying extents. Early diagnosis and multi-specialty collaboration among physicians is necessary to adequately manage the disease and the potential complications that may result from drugs used in the treatment of the disease. Despite recent advances, more research is necessary to prevent the high rates of mortality from the disease itself and from therapeutic side effects.
Collapse
Affiliation(s)
- Buraa Kubaisi
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Khawla Abu Samra
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C. Stephen Foster
- Massachusetts Eye Research and Surgery institution, Waltham, MA, USA
- Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Harvard Medical School, Boston, MA, USA
- Address correspondence to: Dr. C. Stephen Foster, Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, USA. E-mail:
| |
Collapse
|
23
|
Taylan A, Karakas B, Gulcu A, Birlik M. Bilateral orbital pseudotumor in a patient with Takayasu arteritis: a case report and review of the literature. Rheumatol Int 2016; 36:743-6. [DOI: 10.1007/s00296-016-3432-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
|
24
|
Abstract
PURPOSE OF REVIEW To review the spectrum of lacrimal gland inflammation, with particular reference to the old condition, idiopathic dacryoadenitis, and the new, immunoglobulin G4 (IgG4)-related dacryoadenitis. RECENT FINDINGS Idiopathic dacryoadenitis remains the most common inflammatory lesion of the lacrimal gland, for which surgical treatment is successful. There is mounting evidence that the presence of IgG4-positive plasma cells in a lacrimal gland specimen is nonspecific, for being found in other inflammatory lacrimal gland lesions, even lymphoproliferative ones. To identify IgG4-related dacryoadenitis, particularly when there is no documented disease elsewhere, the criteria have been strengthened toward abundant IgG4-positive plasma cell counting. SUMMARY The gold standard of diagnosis of noninfectious lacrimal gland inflammation is tissue biopsying, which is commonly therapeutic in the case of idiopathic dacryoadenitis. Although it was initially suggested that IgG4-related dacryoadenitis is a possible cause of idiopathic dacryoadenitis, it becomes obvious that it has more resemblance to the lymphoproliferative tumors.
Collapse
|
25
|
Abstract
Fevers are relatively common in rheumatic disease, largely due to the fact that the inflammatory process is driven by inflammatory mediators that function as endogenous pyrogens. Since the immune system's sensors cannot accurately distinguish between endogenous and exogenous (pathogen-derived) pyrogens a major challenge for physicians and rheumatologists has been to decipher patterns of clinical signs and symptoms to inform clinical decision making. Here we describe some of the common pitfalls and clinical challenges, and highlight the importance of a systematic approach to investigating the rheumatic disease patient presenting with fever.
Collapse
Affiliation(s)
- James Galloway
- Academic Department of Rheumatology, King's College London, London, UK
| | - Andrew P Cope
- Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, King's College London, London, UK
| |
Collapse
|
26
|
Muller K, Lin JH. Orbital granulomatosis with polyangiitis (Wegener granulomatosis): clinical and pathologic findings. Arch Pathol Lab Med 2014; 138:1110-4. [PMID: 25076302 DOI: 10.5858/arpa.2013-0006-rs] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The pathology of granulomatosis with polyangiitis (GPA), formerly Wegener granulomatosis, typically features a granulomatous and sometimes necrotizing vasculitis targeting the respiratory tract and kidneys. However, orbital involvement occurs in up to 60% of patients and is frequently the first or only clinical presentation in patients with systemic or limited forms of GPA. Orbital GPA can cause significant morbidity and potentially lead to complete loss of vision and permanent facial deformity. Fortunately, GPA is highly responsive to medical treatment with corticosteroids combined with cyclophosphamide or, more recently, rituximab. Therefore, it is imperative for this disease to be accurately diagnosed on orbital biopsy and distinguished from other histologically similar orbital lesions. Herein, we review the clinical and pathologic findings of orbital GPA, focusing on the differentiation of this disease from other inflammatory orbital lesions.
Collapse
Affiliation(s)
- Karra Muller
- From the Department of Pathology, UC San Diego, San Diego (Dr Muller), and the Department of Pathology, UC San Diego, La Jolla (Dr Lin), California
| | | |
Collapse
|
27
|
Comarmond C, Cacoub P. Granulomatosis with polyangiitis (Wegener): clinical aspects and treatment. Autoimmun Rev 2014; 13:1121-5. [PMID: 25149391 DOI: 10.1016/j.autrev.2014.08.017] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/22/2014] [Indexed: 11/17/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis, which affects small- and medium-sized blood vessels and is often associated with cytoplasmic ANCA. GPA occurs in patients between 45 and 60 years old of both genders, and is rarely observed in blacks. The prevalence of GPA increases along a south-north gradient in Europe (20 to 150/million). The main clinical characteristics involve the upper and/or lower respiratory tract and kidneys. Ear, nose and throat manifestations with recurrent sinusitis and crusting rhinorrhea are usually severe. Lung nodules are frequently seen, sometimes excavated. Renal involvement is characterized by rapidly progressive necrotizing glomerulonephritis with extracapillary crescents. Limited forms of GPA predominantly affect the upper respiratory tract, whereas generalized forms of GPA include renal manifestations and/or alveolar hemorrhage and/or vital organ involvement with an altered general condition. The combination of immunosuppressant drugs and corticosteroids has converted this typically fatal illness into one in which 80% of patients achieve remission. However, despite considerable therapeutic progress over the last decades, relapses remain frequent (50% at 5 years), and maintenance treatment is now the main therapeutic challenge.
Collapse
Affiliation(s)
- Cloé Comarmond
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Unviversitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France
| | - Patrice Cacoub
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Unviversitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France.
| |
Collapse
|
28
|
Taylor SRJ, Salama AD, Pusey CD, Lightman S. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.1.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
29
|
Isse N, Nagamatsu Y, Yoshimatsu N, Obata T, Takahara N. Granulomatosis with polyangiitis presenting as an orbital inflammatory pseudotumor: a case report. J Med Case Rep 2013; 7:110. [PMID: 23617946 PMCID: PMC3639886 DOI: 10.1186/1752-1947-7-110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/04/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Granulomatosis with polyangiitis is a systemic inflammatory disease that often presents with necrosis, granuloma formation and vasculitis of small- to medium-sized vessels. Affected patients usually present with disease of the upper respiratory tract, lungs and kidneys, but this disease has been reported to involve almost any organ. We report the case of a patient with ocular manifestations of granulomatosis with polyangiitis after the remission of renal and auditory manifestations. CASE PRESENTATION An 81-year-old Japanese woman had a four-year history of biopsy-proven antineutrophil cytoplasmic antibody-related glomerulonephritis that had been treated with oral prednisolone and was in serological remission. She had also recovered from a one-year history of complete hearing loss immediately following the steroid treatment for glomerulonephritis. She gradually experienced right eye visual disturbance and exophthalmos over a two-month period. Radiographic and histopathological findings revealed an orbital inflammatory pseudotumor. The administration of prednisolone completely restored her right eye visual acuity and eye movement after two weeks. Considering this case retrospectively, our patient had an orbital inflammatory pseudotumor caused by granulomatosis with polyangiitis including a medical history of reversible hearing loss, although her glomerulonephritis had remitted with an undetectable level of specific antineutrophil cytoplasmic antibody. CONCLUSIONS In this patient, hearing loss and visual loss occurred at different times during the course of treatment of granulomatosis with polyangiitis. Clinicians should consider a differential diagnosis of granulomatosis with polyangiitis in patients with treatable hearing and visual loss.
Collapse
Affiliation(s)
- Naohi Isse
- Department of Internal Medicine, Ako City Hospital, 1090 Nakahiro, Ako, Hyogo, 6780-232, Japan.
| | | | | | | | | |
Collapse
|
30
|
Abstract
Non-infectious vasculitides comprise a large number of diseases. Many of these diseases can cause inflammation within the orbit and a clinical presentation, which mimics numerous other processes. Orbital disease can often be the initial presentation of a systemic process and early diagnosis can help prevent long-term, potentially fatal consequences. The evaluation and treatment of non-infectious orbital vasculitides are often complicated and require a thorough understanding of the disease and underlying systemic associations. The long-term prognosis visually and systemically must be weighed against the risks and benefits of the treatment regimen. A large variety of corticosteroid formulations currently exist and are the mainstay of initial treatment. Traditional steroid-sparing immunosuppressive agents are also an important arsenal against these vasculitides. Recently, a new class of drugs called biologics, which target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. This review aims to synthesize the current literature on non-infectious orbital vasculitides.
Collapse
|
31
|
Santiago YM, Fay A. Wegener’s Granulomatosis of the Orbit: A Review of Clinical Features and Updates in Diagnosis and Treatment. Semin Ophthalmol 2011; 26:349-55. [DOI: 10.3109/08820538.2011.588662] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
32
|
Platnick J, Crum AV, Soohoo S, Cedeño PA, Johnson MH. The globe: infection, inflammation, and systemic disease. Semin Ultrasound CT MR 2011; 32:38-50. [PMID: 21277490 DOI: 10.1053/j.sult.2010.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infection, inflammation, and systemic diseases affecting the globe encompass a broad range of pathologies which may ultimately lead to progressive vision loss. Clinical symptomatology varies from the inexorably silent progressive visual loss to an acute presentation of ocular pain and/or red eye. Most are diagnosed by clinical ophthalmologic examination with selective use of ultrasound, computed tomography, and magnetic resonance imaging for confirmation of the diagnosis, assessment of disease extent, and signs of associated systemic disease. Knowledge of the differential diagnoses of vision loss, ocular pain, and redness makes imaging analysis of this diverse group of processes more precise.
Collapse
Affiliation(s)
- Joseph Platnick
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | |
Collapse
|
33
|
Shunmugam M, Morley AMS, Graham E, D'Cruz D, O'Sullivan E, Malhotra R. Primary Wegener's granulomatosis of the orbital apex with initial optic nerve infiltration. Orbit 2011; 30:24-26. [PMID: 21281075 DOI: 10.3109/01676830.2010.542872] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Wegener's granulomatosis can involve the orbit and sometimes the optic nerve. This usually occurs as a result of contiguous spread from affected sinuses or extraocular muscles, or from a vasculitic posterior optic neuropathy. However, we present an unusual case of isolated orbital apex infiltrative disease in a patient with known Wegener's granulomatosis. This initially caused painless optic neuropathy and progressed to painful ophthalmoplegia and blindness. Optic nerve biopsy, performed to exclude methotrexate-induced lymphoma, confirmed optic nerve infiltration. The condition was refractory to high-dose pulsed methylprednisolone but the patient gained symptomatic relief from rituximab. Wegener's granulomatosis should be considered in cases of isolated posterior optic neuropathy, and close attention should be placed on imaging the orbital apex.
Collapse
|
34
|
Abstract
The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides-Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome-can present with various ophthalmic manifestations. In a subset of patients, these findings may be the earliest indicators of systemic disease. Orbital and anterior segment findings are most common, whereas posterior segment complications such as retinal vasculitis and optic neuropathy occur much less frequently. This article describes the distinguishing features of associated ophthalmic disease, focusing on the manifestations clinicians are most likely to encounter and those with the most significant ocular morbidity. Although the ANCA-associated vasculitides require systemic workup and treatment, this article discusses diagnostic and therapeutic modalities often used concurrently for ophthalmic disease.
Collapse
Affiliation(s)
- Anup A Kubal
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | | |
Collapse
|
35
|
Abstract
Sensory innervation to the eye and periocular area arises from the ophthalmic branch of the trigeminal nerve. Thus, ocular, orbital, and systemic disorders may produce head pain with ocular signs and symptoms. Whereas some of these entities have characteristic diagnostic features, others mimic primary headache disorders such as migraine and cluster headache. This article reviews common ocular and neuro-ophthalmic conditions that are accompanied by pain in or near the eye.
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW This review discusses the use of interventional procedures to treat manifestations of Wegener's granulomatosis caused by tissue damage and scarring. These manifestations include nasal and paranasal sinus disease, middle ear inflammation, nasolacrimal duct obstruction, orbital inflammatory masses, subglottic stenosis, tracheobronchial disease, and end-stage renal disease. RECENT FINDINGS Tissue damage caused by inflammation or a cicatricial process represents one of the major sources of morbidity for patients with Wegener's granulomatosis. Some of these manifestations require special interventions used alone or in combination with conventional medical treatment. These interventional procedures may include surgical or endoscopic repair of altered tissue, replacement of damaged organs, or the delivery of topical or injectable medications directly to the site of disease. Distinguishing symptoms caused by active disease from symptoms caused by tissue scarring is challenging and may play a critical role regarding the use of systemic immunosuppressive medications in combination with interventional therapy. SUMMARY Interventional procedures are indicated in certain manifestations of Wegener's granulomatosis. Distinguishing active Wegener's granulomatosis from inactive Wegener's granulomatosis and recognizing disease manifestations that may be amenable to local interventions can greatly improve the quality of life of patients. However, the evidence supporting the use of many of these interventions is based on small case series or individual reports.
Collapse
|
37
|
|
38
|
Wang Y, Kang L, Xiao L. Infrequent bilateral orbital tumors and simulating lesions: the experience of a Chinese institute. Jpn J Ophthalmol 2009; 53:629-634. [PMID: 20020243 DOI: 10.1007/s10384-009-0736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 06/18/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine the types, frequency, and clinical features of infrequent bilateral orbital lesions. METHODS We reviewed 41 cases of either histopathologically or radiologically verified bilateral orbital lesions. The number and entities in each category were recorded. Clinical data and imaging findings were reviewed. RESULTS The number and percentage of lesions in each general category were leukemia lesions in eight patients (19.5%), metastatic tumors in seven (17%), optic nerve and meningeal tumors in six (14.6%), secondary tumors in six (14.6%), peripheral nerve lesions in four (9.8%), inflammatory lesions in four (9.8%), and vasculogenic, histiocytic, and miscellaneous lesions, each in two patients (4.9%). These lesions occurred in both childhood and adulthood, but were infrequent in people over 60 years old. Of all cases, 51.2% were benign and 48.8% were malignant. The ocular symptoms and signs presented unilaterally in 18 (43.9%) cases and bilaterally in 23 (56.1%). Of the 15 patients with either metastatic tumors or blood disorders, two (13.3%) had a history of primary neoplasm at presentation. In 19 (46.3%) cases, the configuration of the bilateral lesions was symmetrical, and they were of equal size. Computed tomography scans revealed bone changes in 13 patients (31.7%), while magnetic resonance imaging revealed intracranial extension in nine (22%). CONCLUSIONS Varied lesions can involve the bilateral orbits simultaneously or on follow-up. Through the combination of history, bilateral ocular manifestations, radiologic findings, and systemic examinations, the correct diagnosis can be made, which is valuable for early identification of both metastasis and blood disorders.
Collapse
Affiliation(s)
- Yi Wang
- Institute of Orbital Diseases, Armed Police General Hospital, Beijing, China. .,Institute of Orbital Diseases, Armed Police General Hospital, No.69 Yongding Road, Haidian District, Beijing, China.
| | - Li Kang
- Institute of Orbital Diseases, Armed Police General Hospital, Beijing, China
| | - LiHua Xiao
- Institute of Orbital Diseases, Armed Police General Hospital, Beijing, China
| |
Collapse
|
39
|
Watkins AS, Kempen JH, Choi D, Liesegang TL, Pujari SS, Newcomb C, Nussenblatt RB, Rosenbaum JT, Thorne JE, Foster CS, Jabs DA, Levy-Clarke GA, Suhler EB, Smith JR. Ocular disease in patients with ANCA-positive vasculitis. J Ocul Biol Dis Infor 2009; 3:12-19. [PMID: 20835396 PMCID: PMC2933008 DOI: 10.1007/s12177-009-9044-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 11/09/2009] [Indexed: 10/26/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis-the term recently applied to Wegener's granulomatosis-is a rare multi-system inflammation characterized by necrotizing granulomas and vasculitis. We investigated the ocular manifestations of this disease in a group of patients drawn from five inflammatory eye disease clinics across the United States. Of 8,562 persons with ocular inflammation, 59 individuals were diagnosed with ANCA-positive vasculitis; 35 males and 21 females, aged 16 to 96 years, were included in this study. Ocular diagnoses were scleritis (75.0%), uveitis (17.9%), and other ocular inflammatory conditions (33.9%) including peripheral ulcerative keratitis and orbital pseudotumor. Mean duration of ocular disease was 4.6 years. Oral corticosteroids and other systemic immunosuppressive agents were used by 85.7% and 78.5% of patients, respectively. Over time, patients with ANCA-positive vasculitis experienced 2.75-fold higher mortality than other patients with inflammatory eye disease.
Collapse
|
40
|
Manifestations ophtalmologiques de la granulomatose de Wegener. Revue de la littérature à propos d’une observation. Nephrol Ther 2009; 5:603-13. [DOI: 10.1016/j.nephro.2009.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 05/11/2009] [Accepted: 05/12/2009] [Indexed: 11/23/2022]
|
41
|
|
42
|
Abstract
PURPOSE To report three cases of sclerosing Wegener's granulomatosis in the orbit and to compare the histopathological morphology with those of other types of sclerosing orbital inflammation. METHODS We analysed the clinical data along with histopathological specimens from orbital biopsies and from two enucleated eyes. RESULTS All three patients had longstanding inflammation in the orbit and involvement of the paranasal sinuses. Proptosis, impaired ocular motility and reduced visual acuity dominated the clinical picture. All histopathological specimens featured granulomatous inflammation, tissue necrosis, vasculitis and widespread dense fibrosis. In certain areas of all specimens the fibrous tissue was arranged in characteristic concentric, onionskin-like whorls of collagen around obliterated small blood vessels. CONCLUSIONS Wegener's granulomatosis may lead to orbital fibrosis and sclerosis. The stromal changes and cellular infiltrate resemble the non-specific orbital inflammation previously termed orbital pseudotumour. We present the first 'onionskin' lesions in association with Wegener's granulomatosis in the orbit. This latter morphology may represent an abnormal fibrotic reaction in inflammatory tissue.
Collapse
Affiliation(s)
- Christoffer Ostri
- Department of Neuroscience and Pharmacology, Eye Pathology Section, University of Copenhagen, Copenhagen, Denmark
| | | | | |
Collapse
|
43
|
Abstract
Wegener's Granulomatosis (WG) in its limited form can be a challenging diagnosis. ANCA, radiological investigations and histology should be interpreted in light of clinical findings. A delay in diagnosis can have profound visual consequences. Immunosuppressive therapy and co-morbidities can mask signs of orbital sepsis. A low threshold for further exploration and biopsy should be maintained if an orbital abscess is suspected. This report describes a complex case of WG that illustrates the diagnostic and therapeutic challenges inherent in this form of orbital inflammatory disease.
Collapse
Affiliation(s)
- D Gupta
- James Paget University Hospital, Gorelston, United Kingdom.
| | | | | |
Collapse
|
44
|
Vischio JA, McCrary CT. Orbital Wegener’s granulomatosis: a case report and review of the literature. Clin Rheumatol 2008; 27:1333-6. [DOI: 10.1007/s10067-008-0949-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 05/12/2008] [Accepted: 06/04/2008] [Indexed: 11/28/2022]
|
45
|
Abstract
Enophthalmos can be defined as a relative, posterior displacement of a normal-sized globe in relation to the bony orbital margin. Non-traumatic enophthalmos has a wide variety of clinical presentations and may be the first manifestation of a number of local or systemic conditions. It may present with cosmetic problems such as deep superior sulcus, pseudoptosis or eyelid retraction; or functional problems such as diplopia or exposure keratopathy. There are three main pathogenic mechanisms: structural alterations in the bony orbit; orbital fat atrophy; and retraction. Evaluation of enophthalmos patients includes orbital imaging and a thorough ophthalmic and systemic examination. In this review, we discuss the presenting features of non-traumatic enophthalmos and include a brief description of the more important causes. An approach to the clinical evaluation of these patients is also discussed together with a brief overview of the principles of management.
Collapse
Affiliation(s)
- Paul A Athanasiov
- Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia.
| | | | | |
Collapse
|
46
|
Levi M, Kodsi SR, Rubin SE, Lyons C, Golden R, Olitsky SE, Christiansen S, Alcorn DM. Ocular involvement as the initial manifestation of Wegener's granulomatosis in children. J AAPOS 2008; 12:94-6. [PMID: 18083587 DOI: 10.1016/j.jaapos.2007.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Revised: 09/06/2007] [Accepted: 09/11/2007] [Indexed: 11/29/2022]
Abstract
Ophthalmic manifestations are noted in about 50% of adults with Wegener's granulomatosis. Wegener's granulomatosis is a rare disease in the pediatric age group. The disease may present initially with ocular manifestations. We report the largest series to date of children whose ocular findings were the initial presenting signs of Wegener's granulomatosis.
Collapse
Affiliation(s)
- Michelle Levi
- North Shore Long Island Jewish Health System, Great Neck, New York, USA
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Lutt JR, Lim LL, Phal PM, Rosenbaum JT. Orbital Inflammatory Disease. Semin Arthritis Rheum 2008; 37:207-22. [PMID: 17765951 DOI: 10.1016/j.semarthrit.2007.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 06/05/2007] [Accepted: 06/17/2007] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To familiarize rheumatologists and internists with the signs, symptoms, and management of orbital inflammatory disease (OID). METHODS A comprehensive literature review related to OID was performed and reported from the perspectives of rheumatology, ophthalmology, and radiology. RESULTS OID is a general term encompassing inflammatory diseases that affect some or all of the structures contained within the orbit external to the globe. Orbital involvement as a part of the initial symptom complex is not uncommon for systemic diseases such as Graves' disease, Wegener's granulomatosis, and sarcoidosis. The management of these and other causes of OID, such as idiopathic orbital inflammation (formerly known as "orbital pseudotumor"), orbital myositis, and Tolosa-Hunt syndrome frequently involves systemic immunosuppression. Before immunosuppression is considered, however, infectious and malignant causes of inflammation must be ruled out. DISCUSSION Rheumatologists should be familiar with the differential diagnosis of OID and often need to assist colleagues in ophthalmology and internal medicine with the management of this group of diseases.
Collapse
Affiliation(s)
- Joseph R Lutt
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
| | | | | | | |
Collapse
|
48
|
Chapter 7 Inflammatory Optic Neuropathies Not Associated with Multiple Sclerosis. Neuroophthalmology 2008. [DOI: 10.1016/s1877-184x(09)70037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
|
49
|
Ahmed M, Niffenegger JH, Jakobiec FA, Ben-Arie-Weintrob Y, Gion N, Androudi S, Folberg R, Raizman MB, Margo CE, Smith ME, McLean IW, Caya JG, Foster CS. Diagnosis of limited ophthalmic wegener granulomatosis: distinctive pathologic features with ANCA test confirmation. Int Ophthalmol 2007; 28:35-46. [PMID: 17589807 DOI: 10.1007/s10792-007-9109-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2007] [Accepted: 05/14/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE To describe the clinical and histopathologic finding of very limited ophthalmic Wegener granulomatosis (WG). METHODS Thirteen patients with scleritis, orbitopathy, episcleritis, and panuveitis were studied. They presented without evidence of lung or kidney disease, though eight had sinus involvement. We reviewed the biopsies for histopathologic findings consistent with WG, and tested for antineutrophil cytoplasmic antibodies antineutrophil cytoplasmic antibody (ANCA). RESULTS WG was suggested by granulomatous foci, collagen necrosis, neutrophils/nuclear dust, plasma cells and infiltrating eosinophils. Granular degeneration of the interstitial collagen; mummification of the collagen with disappearance of fibroblastic nuclei; and a polymorphous infiltrate exhibiting plasma cells, lymphocytes, neutrophils, and eosinophils within the epithelioid granulomas should suggest the diagnosis. ANCA test results supported the diagnosis of WG in all cases. CONCLUSION The described histologic characteristics are highly suggestive of WG. These findings along with clinical or laboratory findings, allow the diagnosis of very limited ophthalmic WG in the absence of systemic involvement.
Collapse
Affiliation(s)
- Muna Ahmed
- Massachusetts Eye Research & Surgery Institute, Harvard Medical School, 8th Floor, 5 Cambridge Center, Cambridge, MA 02142, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Ismail AR, Theaker JM, Manners RM. Wegener's granulomatosis masquerading as upper lid chalazion. Eye (Lond) 2007; 21:883-4. [PMID: 17304252 DOI: 10.1038/sj.eye.6702758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|