Aortitis syndrome associated with positive perinuclear antineutrophil cytoplasmic antibody: report of three cases

Two-Stage Surgery Using FROZENIX Partial ET for Frozen Elephant Trunk Technique and Open Descending Aortic Replacement in a Patient With Recurrent Type B Aortic Dissection and Microscopic Polyangiitis: A Case Report

The frozen elephant trunk (FET) technique, initially developed as a one-stage procedure to treat extensive thoracic aortic aneurysms, has since been adapted to address acute and chronic aortic dissections by closing entry tears and expanding the true lumen. It has become widely adopted due to its effectiveness in managing aortic diseases. We present the case of a 39-year-old female with microscopic polyangiitis (MPA) who developed recurrent type B aortic dissection accompanied by rapid expansion. The patient, a compromised host with multiple comorbidities such as glomerulonephritis, chronic renal failure, alveolar hemorrhage, and acute pancreatitis, required urgent surgical intervention. Given the complexity of her condition and the high risks associated with direct surgery, a staged approach was selected. The first stage involved using a novel FET prosthesis, the FROZENIX Partial ET (FPET), inserted via median sternotomy, followed by a left thoracotomy for non-deep hypothermic circulatory arrest (non-DHCA) descending aortic replacement. The surgery led to favorable outcomes without any major complications or sequelae. FPET offers distinct advantages in this complex scenario. Its design features a 2 cm stent-free distal section, which reduces the risk of distal stent graft-induced new entries (dSINEs) and simplifies anastomosis during the second stage of surgery. For patients with severe comorbidities and anatomical challenges that make the thoracic endovascular aortic repair (TEVAR) unsuitable, a staged open surgical approach is a viable alternative, mitigating the risks linked to DHCA. This case underscores the utility of a staged surgical approach using FPET in managing complicated chronic type B aortic dissection in patients with significant comorbidities. The FPET prosthesis facilitates effective lesion control while minimizing the risk of dSINEs and streamlining subsequent surgical procedures, presenting a promising strategy for similar complex cases.

More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia

We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.

More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia

We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.

Predominant Involvement of the Aortic Root in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Congestive Heart Failure due to Subacute Severe Aortic Regurgitation and Reversible Conduction Disturbance

A 72-year-old woman was referred to our institution with decompensated congestive heart failure owing to subacute severe aortic regurgitation and mitral regurgitation. Her blood sample tested positive for myeloperoxidase anti-neutrophil cytoplasmic antibody (ANCA). Cardiac computed tomography revealed abnormal thickening and shortening of the aortic valvar leaflets as well as wall thickening of the sinuses of Valsalva. Based on the diagnosis of ANCA-associated vasculitis, predominantly involving the aortic root, prednisolone administration was initiated, which failed to improve the valvar dysfunction. The patient underwent aortic root replacement and mitral annuloplasty. Histopathology confirmed severe inflammation involving both the aortic valvar sinuses and leaflets.

Aortitis caused by antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis: a case-based review

Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a systemic necrotizing small vessel vasculitis primarily affecting elderly patients. Neutrophil apoptosis and release of pro-inflammatory mediators promote small vessel inflammation and hence multi-organ disease. It rarely affects larger vessels with extremely rare aortic involvement. Diagnosis is made based on clinical presentation, tissue biopsy of affected organ, as well as immunofluorescence and ELISA assays for ANCA. Management includes immunosuppression (e.g., glucocorticoids, cyclophosphamide and rituximab) and supportive therapy. We present a rare case of a younger patient with AAV involving the aorta. The patient's diagnosis was supported by clinical presentation, systemic organ involvement, strongly positive c-ANCA, and skin as well as aortic tissue biopsy results. After failing multiple immunosuppressants, he responded well to rituximab with improved symptoms, inflammatory markers, and imaging findings. Based on our literature review, we were only able to find ten cases of ANCA-related vasculitis involving the aorta. This is the first reported case of successful treatment of AAV-related aortitis using rituximab. Our case report and literature review provide insight into treatment of severe cases of AAV with aortic involvement.

Aortitis and pachymeningitis: an unusual combination in granulomatosis with polyangiitis (myeloperoxidase-associated vasculitis)

Aortitis and pachymeningitis are uncommon manifestations of the antineutrophil cytoplasmic antibody-associated vasculitides, a group of systemic autoimmune diseases mainly affecting small vessels. We present a case of a 71-year-old woman with a remote history of idiopathic chronic granulomatous pachymeningitis complicated with aortic thickening due to autoimmune aortitis.

Surgical Treatment of Symptomatic Aortic Aneurysm in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Case Report and Review of the Literature

Vasculitis is an heterogeneous group of syndromes, which shares inflammation of blood vessel wall as the main feature. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, with few or no immune deposits, predominantly affecting small vessels (i.e., capillaries, venules, arterioles, and small arteries), associated with ANCAs specific for myeloperoxidase or proteinase 3. Clinical manifestations may be heterogeneous but an involvement of lungs and kidneys frequently occurs. AAV of large vessels is a very rare condition whose standard therapy is medical approach. Surgical revascularization has been described in selected patients after medical failure or in emergent settings. We report the case of a patient affected by symptomatic infrarenal aortic aneurysm related to AAV, who underwent in-situ reconstruction by means of cryopreserved homograft.

IgG4-Related Disease: Beyond Glucocorticoids

IgG4-related disease is a heterogeneous immune-mediated fibroinflammatory condition that can affect every single organ. This disease is more prevalent in the elderly (the mean age of patients is above 60 years) and the prevalence rate is estimated to be over 4.6 per 100,000 population. Before making a diagnosis, the exclusion of malignancies, lymphoma, anti-neutrophil cytoplasmic antibody-associated vasculitis, multicentric Castleman disease, and other mimickers is crucial for appropriate treatment. Broad management guidelines have been published emphasizing the need for prompt treatment and the use of glucocorticoids as first-line drug therapy for induction of remission. However, the toxic effects of glucocorticoids are problematic because IgG4-related disease is more prevalent in patients above 60 years of age, a population with frequent comorbid conditions and polypharmacy. Immunosuppressants (cyclophosphamide, methotrexate, leflunomide, and tacrolimus) and targeted immunomodulators (rituximab, XmAb5871, and abatacept) are appealing to overcome potential toxic effects of glucocorticoids and as emerging glucocorticoid-sparing and/or maintenance treatments. In this review, we provide an overview of our understanding of the pathophysiology of the disease (T follicular helper cells, CD4⁺ cytotoxic T cells, plasmablasts, and alternatively activated M2 macrophages) and clinical characteristics, and highlight the potential targets for treatment intervention.

Antineutrophil Cytoplasmic Antibody-Associated Multiple Giant Saccular Aortic Aneurysms

We describe a very rare case of a 67-year-old man with multiple saccular aortic aneurysms throughout the entire aorta due to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The patient underwent staged aortic surgical procedures, including stent-graft insertion for a left iliac artery aneurysm, thoracic endovascular aortic repair for a descending aortic aneurysm, and total replacement of the ascending aorta and aortic arch with the use of high-dose steroids to control inflammation. The histologic findings demonstrated that the damage to the vasa vasorum of the adventitia resulting from AAV caused ischemia of the media, resulting in the formation of saccular aneurysmal changes.

cANCA-associated aortitis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is traditionally viewed as a small vessel disease. We report a patient with cANCA antibodies directed against proteinase-3 with asymptomatic aortic involvement, in combination with diffuse alveolar haemorrhage and pauci-immune, necrotizing crescentic glomerulonephritis. A review of the literature is discussed.

Churg-Strauss syndrome complicated by chronic periaortitis: a case report and review of the literature

We present a case of Churg-Strauss syndrome complicated by chronic periaortitis. A 68-year-old man presented with wheezing, dyspnea, purpurae, and numbness of the extremities. Antineutrophil cytoplasmic antibodies were absent; however, eosinophilia, a pulmonary infiltrative shadow on chest X-ray, eosinophilic vasculitis on histologic examination of skin and kidney, and mononeuritis multiplex were detected. Churg-Strauss syndrome was diagnosed. Contrast-enhanced abdominal computed tomography revealed a periaortic soft tissue mass extending from the subphrenic abdominal aorta to the proximal area of the bilateral iliac arteries. This indicated chronic periaortitis, probably caused by vasculitic activities. Both disorders improved with steroid therapy.

Hydronephrosis caused by a relapse of granulomatosis with polyangiitis (Wegener's)

We describe a case of relapsed granulomatosis with polyangiitis (Wegener's) (GPA) that presented with abdominal pain. (18)F-fluoro-2-deoxy-D: -glucose positron emission tomography (FDG-PET)/computed tomography (CT) clearly depicted an inflammation of the left peri-iliac arterial soft tissue, which was thought to be the cause of the ureteral obstruction and hydronephrosis. Our case shows that peri-iliac arterial inflammation occurs in GPA and causes hydronephrosis. In addition, FDG-PET/CT is a useful tool for management of this systemic inflammatory disease.

More than meets the eye

A 27-year-old woman was hospitalized with fever and visual changes. She had been well until nine months earlier when she developed unilateral blurry vision in the left eye. Ophthalmologic examination revealed bilateral acute anterior uveitis. She was treated with topical steroids and her vision returned to baseline. However, over the next few months, she developed debilitating fatigue and experienced an unintentional fifteen pound weight loss. One month prior to presentation, she noted the onset of daily low grade fevers and chills. On the day of admission, she developed a temperature of 103°F and a severe frontal headache. Here we describe a case where the overlap of clinical features led to an initially broad differential diagnosis of seemingly unrelated diseases. Ultimately, the discovery of a key radiographic finding allowed us to more clearly define the diagnosis.

Microscopic polyangitis presenting with temporal arteritis and multiple cranial neuropathies

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis affects vessels of various diameters in various tissues or organs, sometimes associated with neurological complications. A 77-year-old man developed dysphagia, hoarseness, dysgeusia, gait unsteadiness, and right temporalgia; neurological examination revealed multiple cranial neuropathies. Laboratory studies demonstrated severe inflammatory responses, elevation of perinuclear ANCA, and mild proteinuria. Magnetic resonance imaging of the brain showed dural enhancement in the cerebellar tentorium. Biopsy revealed necrotizing glomerulonephritis in the kidney, and temporal arteritis without giant cells in the temporal artery. The patient was diagnosed with microscopic polyangitis presenting with temporal arteritis and multiple cranial nerve involvement, and was treated with predonisolone, after which the symptoms and laboratory data showed improvement. This is the first case of ANCA-associated vasculitis with pathologically verified lesions in the temporal artery as well as in the kidney. Thus, ANCA-associated vasculitis may simultaneously affect large vessels such as temporal artery, as well as microvessels in the kidney, nerves and other organs.

Wegener's granulomatosis overlapping with Takayasu's arteritis revealed by FDG-PET scan

We report the case of a 23-year-old woman who initially presented with Wegener's granulomatosis (WG) limited to the lungs, diagnosed on the basis of a biopsy of an upper left lobe nodule and elevated ANCA titers. Remission occurred under treatment with methylprednisolone and intravenous immunoglobulins. Later in the course of the disease, findings highly suggestive of Takayasu's arteritis (TA) appeared: murmur at the level of the left subclavian artery, thickening of the arterial wall of the aorta and pulmonary arteries on tomodensidometry, and abnormal uptake of the aortic arch and ascending aorta on FDG-PET scan. This latter exam also showed an increased uptake of an already known pulmonary nodule, due to WG. Although five cases of WG occurring together with TA have previously been reported, this is the only one in which TA was revealed by FDG-PET scan. In the specific setting of overlapping vasculitides, FDG-PET scan may be helpful in simultaneously evaluating the activity of the two diseases.

p-ANCA-associated periaortitis with histological proof of Wegener's granulomatosis: case report

We describe a 63-year-old man who presented with an inflammatory aortic aneurysm. The patient had p-ANCA antibodies directed against myeloperoxidase. A diagnosis of idiopathic periaortitis was made. Seven years later, he was rehospitalized because of fever, weight loss, and polyneuropathy. After revision of the aortic biopsy, which showed necrotizing vasculitis with palisading granuloma, a diagnosis of Wegener's granulomatosis (WG) was made. This case report illustrates an unusual disease course in WG, resembling large vessel vasculitis, and we discuss the possible mechanisms of large vessel involvement in this form of vasculitis.

Large vessel involvement in ANCA-associated vasculitides: report of a case and review of the literature

Vasculitides are currently classified according to the size of the vessels involved and characteristic clinical and histopathologic findings. Antineutrophil cytoplasmic antibodies (ANCA) and other serologic tests have been used to further characterize small vessel vasculitides. Large vessel involvement in ANCA-associated small vessel vasculitides has been overlooked in the medical literature. Here, we report a case of fatal aortitis and aortic dissection in a patient with microscopic polyangiitis and review reported cases of large vessel involvement in ANCA-associated vasculitides since 1990. We have attempted to characterize this subgroup of patients. Large vessel disease in ANCA-associated vasculitis may present as stenosing large vessel arteritis, aneurysmal disease, aortic dissection, aortic rupture, aortic regurgitation, and death. Prominent perivascular inflammation may present as mediastinal, cervical or abdominal soft tissue masses. ANCA-associated large vessel disease should be considered in the differential diagnosis of these disorders. The epidemiologic, clinical and pathologic characteristics of these patients differ from those of the well-defined large vessel vasculitides such as giant cell (temporal) arteritis or Takayasu's arteritis. We suggest that large vessel involvement is part of the spectrum of ANCA-associated vasculitis rather than an overlap with other large vessel vasculitides. It occurs in both myeloperoxidase- and proteinase 3-positive patients with either Wegener's granulomatosis or microscopic polyangiitis, but has not been reported in Churg-Strauss syndrome. Large vessel vasculitis can precede small vessel vasculitis or occur in the absence of small vessel involvement. We hope this report will contribute to the ongoing development of classification systems for the vasculitic syndromes.

Necrotizing Vasculitis: A Cause of Aortic Insufficiency and Conduction System Disturbance

Cardiac involvement in vasculitis syndromes is uncommon. We describe a 50-year-old male who presented with progressive dyspnea and myalgies. Echocardiogram revealed significant thickening of aortic root, aortic cusps, and anterior mitral valve leaflet, with severe aortic regurgitation that required aortic valve replacement. Furthermore, this patient suffered progressive atrioventricular block that needed implantation of a pacemaker. The study performed disclosed the presence of necrotizing vasculitis positive for perinuclear antineutrophil cytoplasmic antibody.

Atypical manifestation of a cytoplasmic antineutrophil cytoplasmic antibody (PR3-ANCA)-associated vasculitis with involvement of aortic intima and parietal endocardium

The traditional classification of vasculitis, based on the size of affected vessels, has meanwhile been extended by using antineutrophil cytoplasmic antibodies (ANCAs) as seromarkers in the differential diagnosis of different types of vasculitis. We report an autopsy case of fulminant generalized vasculitis positive for C-ANCA (1:320) and anti-proteinase 3 (PR3) antibodies (>100 U/mL) in a 63-year-old man. The unusually broad histologic spectrum included periarteritis nodosa-like lesions in medium-sized vessels and leucocytoclastic vasculitis in small vessels, as well as capillaritis. In addition, the left atrial and ventricular endocardium and the intima of the aorta thoracalis were patchily involved in the inflammatory process. Glomerulonephritis and/or immune complexes were not detectable by electron microscopy or immunohistochemistry. To the best of our knowledge, involvement of the aortic intima ("intimitis") and the parietal endocardium has not been described in PR3-ANCA-positive vasculitis to date.