ANCA-positive Churg-Strauss syndrome with renal failure

Axillary lymphadenopathy as the initial manifestation in ANCA-associated systemic vasculitis: A case report

BACKGROUND

The anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides are a collection of relatively rare autoimmune diseases characterized by the presence of ANCAs, predominantly against myeloperoxidase and proteinase 3. Multiple organs and systems are involved, but superficial lymph node involvement is rarely reported.

CASE PRESENTATION

A 31-year-old woman initially presented with bilateral axillary lymphadenopathy and that the hilums were not clear. We report the rare case of a patient who presented with an ANCA-associated systemic vasculitis whose initial manifestation was axillary lymphadenopathy. The axillary lymph node needle biopsy specimens had reactive hyperplasia. One year later, the bilateral inguinal lymph nodes had similar morphological and structural changes, and laboratory test results showed renal insufficiency. A renal biopsy revealed the presence of sclerotic glomeruli, crescentic glomeruli, and fibrous crescentic glomeruli, but no deposition of immunocomplex or complement. Finally, the patient was treated with prednisone and mycophenolate mofetil. As the laboratory indicators normalized, so did the sizes of the axillary lymph nodes. A subsequent laboratory examination showed that in addition to urine protein all indicators had normalized, ultrasonography showed slight enlargement of unilateral axillary lymph nodes and normal hilum structure.

CONCLUSIONS

Superficial lymphadenopathy is very rare in ANCA-associated systemic vasculitis. Studying this case improves our understanding of the initial manifestations of ANCA-associated vasculitis and may help provide accurate early diagnosis, thus allowing timely treatment and improved patient prognosis.

Churg-Strauss syndrome presenting with acute renal insufficiency accompanied by eosinophilic tubulointerstitial nephritis

We encountered an unusual and rare case of 59-year-old woman with Churg-Strauss syndrome (CSS) showing myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA)-related acute renal insufficiency accompanied by eosinophilic tubulointerstitial nephritis. To date, reports in English of CSS presenting with rapidly progressive/acute renal insufficiency and biopsy-proven renal lesions have been uncommon. Here, we discuss this unusual case and review the previously reported CSS cases. The complication of eosinophilic tubulointerstitial nephritis in CSS cases with acute renal insufficiency might be higher than generally thought. Furthermore, the presence of eosinophilic infiltration and eosinophilic tubulointerstitial nephritis might be associated with the good renal outcome in CSS patients.

A case of nephrotic syndrome in a patient with Churg-Strauss syndrome

Renal involvement in Churg-Strauss syndrome (CSS) is not uncommon, but nephrotic syndrome is rarely reported in patients with CSS. A 25-year-old woman with a long history of bronchial asthma presented to our hospital with a chief complaint of generalized edema. Laboratory studies revealed normocytic normochromic anemia, marked eosinophilia, positive anti-neutrophil cytoplasmic antibody, hypoalbuminemia, and hypercholesterolemia. Urinalysis showed heavy proteinuria (4+) without significant casts. The 24-hour urinary protein excretion was 6.5 g with a selective index of 0.35. Echocardiography and X-ray of the paranasal sinuses suggested restrictive cardiomyopathy and maxillary sinusitis, respectively. Diagnoses of CSS and nephrotic syndrome were made on the basis of clinical and laboratory findings. Renal biopsy was performed, and pathologic findings revealed focal segmental glomerulosclerosis with mesangiolysis. The patient's clinical symptoms and proteinuria improved markedly after combined treatment with corticosteroids and cyclophosphamide. Herein, we report a case of nephrotic syndrome in a patient with CSS.

Churg-Strauss syndrome

Churg-Strauss syndrome is a rare diffuse vasculitis that is almost invariably accompanied by severe asthma. Although overall prognosis is good, and treatment with prednisone alone or in combination with immunosuppressive drugs is usually successful, severe asthma typically persists. Diffuse organ involvement of Churg-Strauss syndrome, especially cardiovascular and rare involvement of the CNS and renal system, suggests a poorer prognosis than usual, and can be fatal. The cause of Churg-Strauss syndrome is unknown, but its characteristic histological findings and association with asthma distinguish it from other vasculitides. Controversy surrounds the use of asthma drugs-especially antileukotrienes--and development of the disorder. We review the epidemiological evidence for an association of drug treatment with Churg-Strauss syndrome, the diverse diagnostic and pathological criteria for this syndrome, and treatment options.

Diagnostic and pathogenetic role of antineutrophil cytoplasmic autoantibodies

Anti-neutrophil cytoplasmic antibodies (ANCA) are mostly known as a useful diagnostic tool in patients with small-vessel vasculitides. With the accumulating knowledge of these autoantibodies, however, it becomes clear that the role of ANCA may not be only limited to a diagnosis of such disorders. The current review addresses, in addition to classical diagnostic associations, other diseases connected with ANCA positivity, both in adults and in children. The etiology of ANCA remains unknown, but still, the importance of both genetic and environmental factors is undoubted. The role of infection and chemicals in the etiology of ANCA-associated diseases is stressed in particular. A pathogenetic role of ANCA is suggested because of clinical observations based on the correlation of the vasculitis activity and the titer of ANCA. Many experiments show the effects of ANCA in various steps of an inflammatory process, particularly on leukocyte microbicidal activity and oxidative burst. Recent findings are analyzed in the experimental field and they are correlated with clinical significance.

Churg-Strauss syndrome

OBJECTIVES

This article discusses the clinical manifestations and treatment protocols of Churg-Strauss syndrome (CSS). A review of the definition, pathophysiology, and prognosis of CSS is included, as well as more recent evidence of the presumed association between antileukotriene antagonists and CSS.

DATA SOURCES

Relevant articles in the medical literature derived from searching the MEDLINE database (1966 to present) with key terms Churg-Strauss syndrome, allergic granulomatosis, and allergic granulomatous angiitis. Sources included review articles, meta-analyses, randomized control trials, case reports, case series, and seminal articles, the majority of which had been published within the past decade.

STUDY SELECTION

Studies that described the clinical manifestations, pathophysiology, etiology, treatment, or prognosis of CSS.

RESULTS

CSS is a systemic vasculitic disorder with multiorgan involvement and diverse presentations.

CONCLUSIONS

Recognition of the multiorgan manifestations of CSS is crucial to clinical management. Whether a causal relationship exists between antileukotriene antagonists and onset of CSS remains unclear.

Disease of the month. The Churg Strauss Syndrome

The Churg Strauss Syndrome is an eosinophil-associated small vessel vasculitis. Although its pathogenesis may be distinctive and the association with severe late-onset asthma typical, the clinical features during the vasculitic phase widely overlap with those of the other forms of necrotizing vasculitis, and no single clinical or histologic feature is pathognomic of the condition. Renal involvement is common, although usually mild, and even when severe it tends to respond well to treatment. The prognosis for both patient and renal survival with adequate treatment is in general good. The optimal treatment strategy, however, is uncertain, and may differ from that for the other vasculitides. In particular, in contrast to Wegener's granulomatosis, the need for routine cyclophosphamide treatment is unconfirmed and requires further study.