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Yan XX, Huang J, Lin J. Demyelinating neuropathy in patients with hepatitis B virus: A case report. World J Clin Cases 2024; 12:1766-1771. [PMID: 38660079 PMCID: PMC11036481 DOI: 10.12998/wjcc.v12.i10.1766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/17/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Hepatitis B rarely leads to demyelinating neuropathy, despite peripheral neuropathy being the first symptom of hepatitis B infection. CASE SUMMARY A 64-year-old man presented with sensorimotor symptoms in multiple peripheral nerves. Serological testing showed that these symptoms were due to hepatitis B. After undergoing treatment involving intravenous immunoglobulin and an antiviral agent, there was a notable improvement in his symptoms. CONCLUSION Although hepatitis B virus (HBV) infection is known to affect hepatocytes, it is crucial to recognize the range of additional manifestations linked to this infection. The connection between long-term HBV infection and demyelinating neuropathy has seldom been documented; hence, prompt diagnostic and treatment are essential. The patient's positive reaction to immunoglobulin seems to be associated with production of the antigen-antibody immune complex.
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Affiliation(s)
- Xiao-Xiao Yan
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Ruian 325000, Zhejiang Province, China
| | - Jin Huang
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Ruian 325000, Zhejiang Province, China
| | - Jing Lin
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Ruian 325000, Zhejiang Province, China
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Gill H, Trinh D, Anderson DJ, Li N, Madenberg D. Cocaine and Levamisole Induced Vasculitis. Cureus 2021; 13:e17192. [PMID: 34548986 PMCID: PMC8439268 DOI: 10.7759/cureus.17192] [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] [Accepted: 08/15/2021] [Indexed: 12/03/2022] Open
Abstract
Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn’s Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed.
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Affiliation(s)
- Harpreet Gill
- Hospital Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Dylan Trinh
- School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | | | - Nathan Li
- School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Devin Madenberg
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
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Ortu E, Pietropaoli D, Baldi M, Marzo G, Giannoni M, Monaco A. Polyarteritis nodosa involving the hard palate: a case report. J Med Case Rep 2013; 7:79. [PMID: 23506354 PMCID: PMC3607961 DOI: 10.1186/1752-1947-7-79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 02/12/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Polyarteritis nodosa is a rare disease resulting from blood vessel inflammation (vasculitis), causing damage to organ systems and featuring an extended range of possible symptoms. The cause of polyarteritis nodosa is unknown. Case presentation In the present report we describe the presentation and treatment of polyarteritis nodosa involving the hard palate in an 88-year-old Caucasian woman. Clinical and laboratory analyses showed stenosis of the greater palatine artery, which led to necrosis of the affected area. At one year after pharmacological treatment, the lesion has regressed completely. Conclusions We successfully treated a case of polyarteritis nodosa via a pharmacological approach, which we describe here.
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Affiliation(s)
- Eleonora Ortu
- Unit of Dentistry; Building Delta 6, Department of Life, Health and Environmental Sciences, University of L'Aquila; San Salvatore Hospital, Via Vetoio, L'Aquila, 67100, Italy.
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Ebert EC, Hagspiel KD, Nagar M, Schlesinger N. Gastrointestinal involvement in polyarteritis nodosa. Clin Gastroenterol Hepatol 2008; 6:960-6. [PMID: 18585977 DOI: 10.1016/j.cgh.2008.04.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 03/06/2008] [Accepted: 04/02/2008] [Indexed: 02/07/2023]
Abstract
Polyarteritis nodosa (PAN) is a necrotizing, focal segmental vasculitis that affects predominantly medium-sized arteries in many different organ systems. It is associated with hepatitis B virus (HBV) in about 7% of cases, a decline from about 30% before the mandatory testing of blood products and the widespread vaccination programs. HBV PAN is an early postinfectious process. The hepatitis is silent in most cases, with mild transaminase level increases in 50% of patients. Gastrointestinal involvement occurs in 14% to 65% of patients with PAN. Postprandial abdominal pain from ischemia is the most common symptom. When transmural ischemia develops, there may be necrosis of the bowel wall with perforation, associated with a poor prognosis. Liver involvement occurs in 16% to 56% of patients, although clinical manifestations related to liver disease are quite rare. Acalculous gangrenous cholecystitis may develop owing to arteritis involving the wall of the gallbladder. Microaneurysms on arteriography or computed tomography angiography are characteristic of PAN, but are seen in other conditions. Tissue biopsy may confirm the diagnosis, although involvement is segmental. Corticosteroids are used for non-HBV PAN with cyclophosphamide added for severe disease. For PAN related to HBV, a 2-week course of corticosteroids is begun, with plasma exchanges and an antiviral agent. Corticosteroids and cyclophosphamide have improved patient outcome so that the 1-year survival rate is now about 85%.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA.
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Abstract
The classification of vasculitis and the clinical features of vasculitic neuropathy are reviewed. Vasculitic neuropathy usually presents with painful mononeuropathies or an asymmetric polyneuropathy of acute or subacute onset. Neurologists should categorize vasculitic neuropathy in terms of clinical features (eg, systemic or non systemic) and in terms of histopathology (eg, nerve large arteriole vasculitis or nerve microvasculitis). Systemic vasculitis should be classified further into one of the primary and secondary forms. Steroids and cytotoxic agents have been the mainstay of therapy for most forms of vasculitic neuropathy. Dosing, potential side effects, and management recommendations of conventional therapies are provided.
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Affiliation(s)
- Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA
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Abstract
Palpable purpura, the inflammation of blood vessels is the hallmark of vasculitis. It can be observed in a variety of settings, where vessels can be affected primarily or as a secondary event. Every patient with vasculitis should be considered to have a systemic disease unless proven otherwise. One or more systemic symptoms occur in at least 50% of patients and there is no way to predict systemic involvement. Patients may demonstrate mild systemic involvement like arthralgia and arthritis, fever and malaise or more severe symptoms such as massive proteinuria and raised creatinine leading to chronic renal failure, severe intestinal bleeding or perforation with a fatal outcome. In this article we will review the life-threatening aspects of purpura and vasculitis.
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Affiliation(s)
- Andreas Katsambas
- Department of Dermatology, Andreas Sygros Hospital, University of Athens, Greece.
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Semple D, Keogh J, Forni L, Venn R. Clinical review: Vasculitis on the intensive care unit -- part 2: treatment and prognosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:193-7. [PMID: 15774077 PMCID: PMC1175906 DOI: 10.1186/cc2937] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The second part of this review addresses the treatment and prognosis of the vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg–Strauss syndrome and polyarteritis nodosa. Treatment regimens consist of an initial remission phase with aggressive immunosuppression, followed by a more prolonged maintenance phase using less toxic agents and doses. This review focuses on the initial treatment of fulminant vasculitis, the mainstay of which remains immunosuppression with steroids and cyclophosphamide. For Wegener's granulomatosis and microscopic polyangiitis plasma exchange can be considered for first-line therapy in patients with acute renal failure and/or pulmonary haemorrhage. Refractory disease is rare and is usually due to inadequate treatment. The vasculitides provide a particular challenge for the critical care team. Particular aspects of major organ support related to these conditions are discussed. Effective treatment has revolutionized the prognosis of these conditions. However, mortality is still approximately 50% for those requiring admission to intensive care unit. Furthermore, there is a high morbidity associated with both the diseases themselves and the treatment.
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Affiliation(s)
- David Semple
- Specialist Registrar Renal Medicine, Worthing Hospital, Worthing, UK
| | - James Keogh
- Specialist Registrar Anaesthetics, Worthing Hospital, Worthing, UK
| | - Luigi Forni
- Consultant Physician, Worthing Hospital, Worthing, UK
| | - Richard Venn
- Consultant Anaesthetist, Worthing Hospital, Worthing, UK
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Abstract
Several extrahepatic manifestations are associated with chronic HBV infection, many with significant morbidity and mortality. The cause of these extrahepatic manifestations is generally believed to be immune mediated. PAN is a rare, but serious, systemic complication of chronic HBV affecting the small- and medium-sized vessels. PAN is seen more frequently in North American and European patients and rarely in Asian patients. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. The optimal treatment of HBV-associated PAN is thought to include a combination of antiviral and immunosuppressive therapies. HBV-associated GN occurs mainly in children, predominantly males, in HBV endemic areas of the world, but is only occasionally reported in the United States. In children, GN is usually self-limited with only rare progression to renal failure. In adults, the natural disease course of GN may be more relentless, slowly progressing to renal failure. Immunosuppressive therapy in HBV-related GN is not recommended, but antiviral therapy with alpha-interferon has shown promise. The serum-sickness like "arthritis-dermatitis" prodrome is seen in approximately one third of patients acquiring HBV. The joint and skin manifestations are varied, but the syndrome spontaneously resolves at the onset of clinical hepatitis with few significant sequelae. Occasionally, arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial; but a triad of purpura, arthralgias, and weakness, which can progress to nephritis, pulmonary disease, and generalized vasculitis, has characterized the syndrome. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.
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Affiliation(s)
- Steven-Huy B Han
- Division of Digestive Diseases, Pfleger Liver Institute, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095-7302, USA.
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Abstract
Monoclonal antibody and recombinant DNA technologies have led to the development of biologic therapies capable of directly targeting selected components of the immune response. With the steady expansion of knowledge regarding the mechanisms of vascular inflammation, the safety and efficacy of biologic agents in the vasculitic diseases are being increasingly investigated. By targeting specific effector mechanisms involved in the pathogenesis of vasculitis, these agents may provide a less toxic means of inducing remission and lessening relapse. However, the study of biologic therapies in the vasculitides must be approached with caution, as unanticipated effects on disease activity and disease-specific toxicities can occur. Studies to examine these agents must recognize the potential for active vasculitis to be organ- or life-threatening as well as the current existence of effective therapies. In the research setting, investigation of biologic agents in the treatment of vasculitic diseases may also provide important insights into pathogenesis of these syndromes.
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Affiliation(s)
- Carol A Langford
- Immunologic Diseases Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Abstract
The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Room 220, 9th Floor, Eaton Wing, M5G 2C4, ON, Canada.
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