1
|
Leleux C, Zerbib Y, Pommerolle P, Da Rocha A, Serpier M, Caillard P. Rare manifestations of cryoglobulinemic vasculitis: a case report. Front Immunol 2023; 14:1271584. [PMID: 37901234 PMCID: PMC10611471 DOI: 10.3389/fimmu.2023.1271584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Cryoglobulinemic vasculitis is a type of small vessel vasculitis diseases that can cause dysfunction in multiple organs. It is characterized by general symptoms, often accompanied by nonspecific cutaneous, articular, neurological, and renal manifestations. Diagnosing cryoglobulinemia through biological testing can be time-consuming and sometimes yields negative results, making diagnosis challenging. There are also other potentially life-threatening complications that can significantly impact prognosis and delay urgent treatment, including digestive manifestations and heart failure. Case presentation We report the case of a 60-year-old male patient with a medical history of rheumatoid arthritis. He was admitted to the Nephrology Department for investigation of necrotic vascular purpura, acute kidney injury, and pancytopenia. Laboratory tests revealed consumption of the C3 and C4 complement fractions and the presence of mixed-type III cryoglobulinemia. Despite the initiation of the treatment, the patient rapidly developed multiple severe organ failures, including renal, cardiac, respiratory, and finally digestive complications. Acute colic ischemia led to emergency surgery and the patient was transferred to the Intensive Care Unit. Despite surgical intervention and hemodynamic support, the patient experienced multi-visceral organ failure and died two hours after admission. Discussion Mixed cryoglobulinemia vasculitis may result in rare cases of acute and life-threatening organ damage, such as cardiac or respiratory failure with pulmonary hemorrhage, gastrointestinal ischemia, and neurological disorders. These severe manifestations are associated with a poor prognosis and it is crucial to promptly initiate an aggressive therapeutic strategy.
Collapse
Affiliation(s)
- Charlotte Leleux
- Department of Internal Medicine, Amiens University Hospital, Amiens, France
| | - Yoann Zerbib
- Department of Intensive Care Unit, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Pierre Pommerolle
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Audrey Da Rocha
- Department of Hematology, Amiens University Hospital, Amiens, France
| | - Marine Serpier
- Department of Internal Medicine, Amiens University Hospital, Amiens, France
| | - Pauline Caillard
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| |
Collapse
|
2
|
Yang X, Jiao C, Liu X, Zhang Y, Zhou H, Wang Y. Coexistence of cryoglobulinemia and ANCA-associated vasculitis in a chronic brucellosis patient -a case report and literature review. BMC Infect Dis 2023; 23:272. [PMID: 37131122 PMCID: PMC10152744 DOI: 10.1186/s12879-023-08232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The renal involvement of brucellosis is not common. Here we reported a rare case of chronic brucellosis accompanied by nephritic syndrome, acute kidney injury, the coexistence of cryoglobulinemia and antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) superimposed on iliac aortic stent implantation. The diagnosis and treatment of the case are instructive. CASE PRESENTATION A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up. CONCLUSIONS Here we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.
Collapse
Affiliation(s)
- Xu Yang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Congcong Jiao
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Xiaomei Liu
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yongzhe Zhang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Hua Zhou
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yanqiu Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China.
| |
Collapse
|
3
|
Altomare A, Corrado A, Maruotti N, Cici D, Cantatore FP. Hcv and Autoimmunity in Rheumatic Diseases. Curr Rheumatol Rev 2021; 18:101-107. [PMID: 34387165 DOI: 10.2174/1573397117666210812141524] [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: 12/29/2020] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
HCV is a global health problem affecting mainly the liver and often characterized by extrahepatic manifestions mediated by autoimmune reactions. Among these, arthritis and arthralgia are most frequent, as well as the presence of cryoglobulinemia that may induce vasculitis, and sicca syndrome. Thus, HCV appears to be a trigger for autoimmune response as demonstrated by the finding of autoantibody in a high percentage of serum of these patients. Therefore, it is important that clinicians recognize these autoimmune manifestations as symptoms due to an autoimmune activity triggered by HCV, in order to give the correct diagnosis and start an effective therapy strategy. Therefore, clinical examination, searching of markers of infection as well as autoantibody patterns should be performed to make a correct differential diagnosis. The treatment should be based on antiviral drugs associated to immunosuppressive drugs according to autoimmune manifestations.
Collapse
Affiliation(s)
- Alberto Altomare
- Rheumatology Clinic "Mario Carrozzo", Department of Medical and Surgical Sciences, University of Foggia, "Policlinico Riuniti" Universitary Hospital, Viale Pinto, 1 - 71121 Foggia. Italy
| | - Addolorata Corrado
- Rheumatology Clinic "Mario Carrozzo", Department of Medical and Surgical Sciences, University of Foggia, "Policlinico Riuniti" Universitary Hospital, Viale Pinto, 1 - 71121 Foggia. Italy
| | - Nicola Maruotti
- Rheumatology Clinic "Mario Carrozzo", Department of Medical and Surgical Sciences, University of Foggia, "Policlinico Riuniti" Universitary Hospital, Viale Pinto, 1 - 71121 Foggia. Italy
| | - Daniela Cici
- Rheumatology Clinic "Mario Carrozzo", Department of Medical and Surgical Sciences, University of Foggia, "Policlinico Riuniti" Universitary Hospital, Viale Pinto, 1 - 71121 Foggia. Italy
| | - Francesco Paolo Cantatore
- Rheumatology Clinic "Mario Carrozzo", Department of Medical and Surgical Sciences, University of Foggia, "Policlinico Riuniti" Universitary Hospital, Viale Pinto, 1 - 71121 Foggia. Italy
| |
Collapse
|
4
|
Hasegawa J, Wakai S, Kono M, Imaizumi Y, Masuda S, Ishizu A, Honda K. An Autopsy Case of Myeloperoxidase-anti-neutrophil Cytoplasmic Antibody (MPO-ANCA)-associated Vasculitis Accompanied by Cryoglobulinemic Vasculitis Affecting the Kidneys, Skin, and Gastrointestinal Tract. Intern Med 2018; 57:2739-2745. [PMID: 29709950 PMCID: PMC6191583 DOI: 10.2169/internalmedicine.0720-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and cryoglobulinemic vasculitis (CV) rarely coexist. An 83-year-old woman was admitted with rapidly progressive renal failure, gastrointestinal hemorrhage and purpura with myeloperoxidase (MPO)-ANCA positivity and cryoglobulinemia. Despite intensive immunosuppressive treatment, she died of aspergillus pneumonia. Autopsy revealed necrotizing crescentic glomerulitis in the majority of the glomeruli, accompanied by partially membranoproliferative-like glomerular changes. Immunofluorescence staining revealed the presence of neutrophil extracellular trap (NET) formation in the glomeruli and cutaneous arteries. These pathological findings suggested that MPO-AAV and/or CV caused NET formation, leading to lethal systemic vasculitis.
Collapse
Affiliation(s)
- Jumpei Hasegawa
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Japan
- Department of Urology, Tokyo Women's Medical University, Japan
| | - Sachiko Wakai
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Japan
| | - Momoko Kono
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Japan
| | - Yusuke Imaizumi
- Department of Nephrology, Tokyo Metropolitan Health and Medical Treatment Corporation Okubo Hospital, Japan
| | - Sakiko Masuda
- Faculty of Health Sciences, Hokkaido University, Japan
| | | | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Japan
| |
Collapse
|
5
|
Hanna RM, So N, Kaldas M, Hou J, Arman F, Sangalang M, Yanny B, Selamet U, Saab S, Nobakht N, Rastogi A. Case Report: Patient with Hepatitis C, p-ANCA, and Cryoglobulin Antibodies Presenting with Necrotizing Crescentic p-ANCA Glomerulonephritis. Case Rep Nephrol Dial 2018; 8:161-170. [PMID: 30197905 PMCID: PMC6120379 DOI: 10.1159/000491629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 01/21/2023] Open
Abstract
Hepatitis C (HCV) infection has a prevalence of 3 million infected individuals in the United States, according to recent Center for Disease Control reports, and can have various renal manifestations. Cryoglobulins, antibodies that precipitate at colder temperatures in vitro, are a relatively common cause of renal disease in HCV infection. The cryoglobulin proteins can form occlusive aggregates in small glomerular capillary lumina or deposit in other areas of the glomerulus, resulting in hypocomplementemia, proteinuria, hematuria, and renal injury. The typical biopsy pattern is that of membranoproliferative glomerulonephritis (MPGN). There are, however, other HCV-related patterns of glomerular injury. Anti-neutrophil cytoplasmic antibodies (ANCA) are known to exist in HCV-infected patients. In many reported cases, ANCA serologic testing may appear positive due to cross-reactivity of the immune assays; however, the biopsy findings do not support ANCA-associated crescentic glomerulonephritis (GN)/vasculitis as the primary cause of glomerular injury. There are rare reports of microscopic polyangiitis (MPA) p-ANCA vasculitis, in patients with HCV infection. In comparison with the MPGN pattern of cryoglobulinemic glomerular injury, biopsies from these HCV-infected patients with concomitant MPA revealed a crescentic GN, associated with normal serum complement levels. We present a case of HCV-associated glomerular disease with the surprising biopsy finding of necrotizing and crescentic p-ANCA GN, with a background, low-grade mesangial immune complex GN. Thus, p-ANCA disease should also be considered in HCV-infected patients, in addition to the more typical lesions of MPGN or cryoglobulinemic GN.
Collapse
Affiliation(s)
- Ramy M Hanna
- UCLA-Southbay Nephrology, Rancho Palos Verdes, California, USA.,UCLA David Geffen School of Medicine, Westwood, California, USA
| | - Naomi So
- UCLA David Geffen School of Medicine, Westwood, California, USA
| | - Marian Kaldas
- UCLA David Geffen School of Medicine, Westwood, California, USA.,UCLA Health-Southbay Rheumatology, Torrance, California, USA
| | - Jean Hou
- Cedars Sinai Medical Center, Renal Pathology, Los Angeles, California, USA
| | - Farid Arman
- UCLA David Geffen School of Medicine, Westwood, California, USA
| | - Michelle Sangalang
- UCLA David Geffen School of Medicine, Westwood, California, USA.,UCLA Southbay Family Medicine, Rancho Palos Verdes, California, USA
| | - Bishoy Yanny
- UCLA-Southbay Nephrology, Rancho Palos Verdes, California, USA.,UCLA David Geffen School of Medicine, Westwood, California, USA
| | - Umut Selamet
- UCLA-Southbay Nephrology, Rancho Palos Verdes, California, USA.,UCLA David Geffen School of Medicine, Westwood, California, USA
| | - Sammy Saab
- UCLA David Geffen School of Medicine, Westwood, California, USA.,UCLA Ronald Regan Medical Center, Department of Medicine, Division of Hepatology, Westwood, California, USA
| | | | - Anjay Rastogi
- UCLA David Geffen School of Medicine, Westwood, California, USA
| |
Collapse
|
6
|
Antineutrophil Cytoplasmic Antibody Induction due to Infection: A Patient with Infective Endocarditis and Chronic Hepatitis C. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:3585860. [PMID: 27366166 PMCID: PMC4904576 DOI: 10.1155/2016/3585860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 12/21/2015] [Indexed: 11/17/2022]
Abstract
While antineutrophil cytoplasmic antibody (ANCA) is often used as a diagnostic marker for certain vasculitides, ANCA induction in the setting of infection is much less common. In the case of infective endocarditis, patients may present with multisystem disturbances resembling an autoimmune process, cases that may be rendered even trickier to diagnose in the face of a positive ANCA. Though not always straightforward, distinguishing an infective from an inflammatory process is pivotal in order to guide appropriate therapy. We describe an encounter with a 43-year-old male with chronically untreated hepatitis C virus infection who featured ANCA positivity while hospitalized with acute bacterial endocarditis. His case serves as a reminder of two of the few infections known to uncommonly generate ANCA positivity. We also summarize previously reported cases of ANCA positivity in the context of endocarditis and hepatitis C infections.
Collapse
|
7
|
Retamozo S, Díaz-Lagares C, Bosch X, Bové A, Brito-Zerón P, Gómez ME, Yagüe J, Forns X, Cid MC, Ramos-Casals M. Life-Threatening Cryoglobulinemic Patients With Hepatitis C: Clinical Description and Outcome of 279 Patients. Medicine (Baltimore) 2013; 92:273-284. [PMID: 23974248 PMCID: PMC4553974 DOI: 10.1097/md.0b013e3182a5cf71] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cryoglobulinemia is characterized by a wide range of causes, symptoms, and outcomes. Hepatitis C virus (HCV) infection is detected in 30%-100% of patients with cryoglobulins. Although more than half the patients with cryoglobulinemic vasculitis present a relatively benign clinical course, some may present with potentially life-threatening situations. We conducted the current study to analyze the clinical characteristics and outcomes of HCV patients presenting with life-threatening cryoglobulinemic vasculitis. We evaluated 181 admissions from 89 HCV patients diagnosed with cryoglobulinemic vasculitis consecutively admitted to our department between 1995 and 2010. In addition, we performed a systematic analysis of cases reported to date through a MEDLINE search.The following organ involvements were considered to be potentially life-threatening in HCV patients with cryoglobulinemic vasculitis: cryoglobulinemic, biopsy-proven glomerulonephritis presenting with renal failure; gastrointestinal vasculitis; pulmonary hemorrhage; central nervous system (CNS) involvement; and myocardial involvement. A total of 279 patients (30 from our department and 249 from the literature search) fulfilled the inclusion criteria: 205 presented with renal failure, 45 with gastrointestinal vasculitis, 38 with CNS involvement, 18 with pulmonary hemorrhage, and 3 with myocardial involvement; 30 patients presented with more than 1 life-threatening cryoglobulinemic manifestation. There were 146 (52%) women and 133 (48%) men, with a mean age at diagnosis of cryoglobulinemia of 54 years (range, 25-87 yr) and a mean age at life-threatening involvement of 55 years (range, 25-87 yr). In 232 (83%) patients, life-threatening involvement was the first clinical manifestation of cryoglobulinemia. Severe involvement appeared a mean of 1.2 years (range, 1-11 yr) after the diagnosis of cryoglobulinemic vasculitis. Patients were followed for a mean of 14 months (range, 3-120 mo) after the diagnosis of life-threatening cryoglobulinemia. Sixty-three patients (22%) died. The main cause of death was sepsis (42%) in patients with glomerulonephritis, and cryoglobulinemic vasculitis itself in patients with gastrointestinal, pulmonary, and CNS involvement (60%, 57%, and 62%, respectively). In conclusion, HCV-related cryoglobulinemia may result in progressive (renal involvement) or acute (pulmonary hemorrhage, gastrointestinal ischemia, CNS involvement) life-threatening organ damage. The mortality rate of these manifestations ranges between 20% and 80%. Unfortunately, this may be the first cryoglobulinemic involvement in almost two-thirds of cases, highlighting the complex management and very elevated mortality of these cases.
Collapse
Affiliation(s)
- Soledad Retamozo
- From Josep Font Laboratory of Autoimmune Diseases (SR, CDL, AB, PBZ, MEG, MRC) and Vasculitis Research Unit (MCC), Department of Autoimmune Diseases; Department of Internal Medicine (XB); Department of Immunology (JY); and Viral Hepatitis Unit (XF), Department of Hepatology; CIBERehd, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Konstantinov KN, Emil SN, Barry M, Kellie S, Tzamaloukas AH. Glomerular disease in patients with infectious processes developing antineutrophil cytoplasmic antibodies. ISRN NEPHROLOGY 2013; 2013:324315. [PMID: 24959541 PMCID: PMC4045435 DOI: 10.5402/2013/324315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/06/2012] [Indexed: 12/21/2022]
Abstract
To identify differences in treatment and outcome of various types of glomerulonephritis developing in the course of infections triggering antineutrophil cytoplasmic antibody (ANCA) formation, we analyzed published reports of 50 patients. Immunosuppressives were added to antibiotics in 22 of 23 patients with pauci-immune glomerulonephritis. Improvement was noted in 85% of 20 patients with information on outcomes. Death rate was 13%. Corticosteroids were added to antibiotics in about 50% of 19 patients with postinfectious glomerulonephritis. Improvement rate was 74%, and death rate was 26%. Two patients with mixed histological features were analyzed under both pauci-immune and post-infectious glomerulonephritis categories. In 9 patients with other renal histology, treatment consisted of antibiotics alone (7 patients), antibiotics plus immunosuppressives (1 patient), or immunosuppressives alone (1 patient). Improvement rate was 67%, permanent renal failure rate was 22%, and death rate was 11%. One patient with antiglomerular basement disease glomerulonephritis required maintenance hemodialysis. Glomerulonephritis developing in patients who became ANCA-positive during the course of an infection is associated with significant mortality. The histological type of the glomerulonephritis guides the choice of treatment. Pauci-immune glomerulonephritis is usually treated with addition of immunosuppressives to antibiotics.
Collapse
Affiliation(s)
- Konstantin N. Konstantinov
- Division of Rheumatology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Suzanne N. Emil
- Division of Rheumatology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Marc Barry
- Department of Pathology, University of New Mexico School of Medicine, MSC08 4640, BMSB, Room 335, University of New Mexico, Albuquerque, NM 87131, USA
| | - Susan Kellie
- Division of Infectious Diseases, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Antonios H. Tzamaloukas
- Division of Nephrology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, VA Medical Center (111C), 1501 San Pedro, SE, Albuquerque, NM 87131, USA
| |
Collapse
|
9
|
Morizane R, Konishi K, Hashiguchi A, Tokuyama H, Wakino S, Kawabe H, Hayashi M, Hayashi K, Itoh H. MPO-ANCA associated crescentic glomerulonephritis with numerous immune complexes: case report. BMC Nephrol 2012; 13:32. [PMID: 22656245 PMCID: PMC3470990 DOI: 10.1186/1471-2369-13-32] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/17/2012] [Indexed: 11/30/2022] Open
Abstract
Background Antineutrophil cytoplasmic antibody (ANCA)-associated crescentic glomerulonephritis (CGN) is a major cause of rapidly progressive glomerulonephritis (RPGN). ANCA-associated CGN is generally classified into pauci-immune RPGN, in which there are few or no immune complexes. Case Presentation A 78-year-old man presented with RPGN after a 7-year course of chronic proteinuria and hematuria with stable renal function. A blood examination showed a high titer of myeloperoxidase (MPO)-ANCA. A renal biopsy showed crescentic glomerulonephritis with abundant subepithelial, intramenbranous and subendothelial deposits by electron microscopy, leading to the diagnosis of ANCA-associated CGN superimposed on type 3 membranoproliferative glomerulonephritis (MPGN). Conclusions This case is unique in that type 3 MPGN and MPO-ANCA-associated CGN coexisted, and no similar case has been reported to date. Because ANCA-associated CGN has a predilection for elderly individuals and primary type 3 MPGN is rarely seen in this age group, coincidental existence appears less likely. This case may confer valuable information regarding the link between immune complex and ANCA-associated CGN.
Collapse
Affiliation(s)
- Ryuji Morizane
- Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Hanf W, Serre JE, Salmon JH, Fabien N, Ginon I, Dijoud F, Trolliet P. Glomérulonéphrite rapidement progressive à ANCA révélant une endocardite infectieuse subaiguë. Rev Med Interne 2011; 32:e116-8. [PMID: 21277658 DOI: 10.1016/j.revmed.2010.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 12/20/2010] [Accepted: 12/22/2010] [Indexed: 11/19/2022]
Affiliation(s)
- W Hanf
- Service de néphrologie-dialyse et transplantation, centre hospitalier Lyon-Sud, chemin du Grand-Revoyet, Pierre-Bénite cedex, France.
| | | | | | | | | | | | | |
Collapse
|
11
|
Palazzi C, Buskila D, D'Angelo S, D'Amico E, Olivieri I. Autoantibodies in patients with chronic hepatitis C virus infection: pitfalls for the diagnosis of rheumatic diseases. Autoimmun Rev 2011; 11:659-63. [PMID: 22155016 DOI: 10.1016/j.autrev.2011.11.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 11/22/2011] [Indexed: 12/29/2022]
Abstract
Hepatitis C virus infection (HCV) is one of the best mimes in medicine. About 40-70% of patients suffering from this disorder develop at least one extra-hepatic disorder that can have a rheumatic nature (arthralgias, arthritis, vasculitis and sicca syndrome) and must be differentiated from the primitive rheumatic diseases. In addition, HCV infection can also alter the laboratory tests. Several alterations of first line laboratory tests can be usually found in both chronic HCV infection and chronic inflammatory rheumatic disorders. In the present review we analyze the interference of HCV in tests more specifically used in rheumatology: rheumatoid factor and other autoantibodies (ANA, anti-ENA, ANCA, anti-DNA, antiphospholipid, anti-CCP). In patients suffering from HCV infection, the diagnosis of connective tissue diseases (CTD) or rheumatoid arthritis (RA) should be made only when the detected symptoms or laboratory data are not inducible by HCV, otherwise only a diagnosis of "possible CTD" or "possible RA" should be considered.
Collapse
Affiliation(s)
- Carlo Palazzi
- Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Italy.
| | | | | | | | | |
Collapse
|
12
|
Retamozo S, Díaz-Lagares C, Bosch X, de Vita S, Ramos-Casals M. Life-Threatening Cryoglobulinemia. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
13
|
Prolonged infections associated with antineutrophil cytoplasmic antibodies specific to proteinase 3 and myeloperoxidase: diagnostic and therapeutic challenge. Clin Rheumatol 2010; 29:893-904. [PMID: 20306213 DOI: 10.1007/s10067-010-1424-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 02/13/2010] [Accepted: 02/23/2010] [Indexed: 12/12/2022]
Abstract
Chronic infections may mimic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). We investigated which markers may help in the diagnosis and the prognosis of infections associated with proteinase 3 (PR3) and myeloperoxidase (MPO)-ANCA. In this study (1993-2008)--with an average follow-up of 5.1 years--we compared 66 AAV patients with 17 PR3 and/or MPO-ANCA-positive patients with protracted bacterial (11/17) or viral (6/17) infections. Seven of 17 patients had subacute bacterial endocarditis (SBE), while six of 17 patients had various autoimmune manifestations of chronic hepatitis C virus (HCV) infection. We determined ANCA, antinuclear antibodies, anti-PR3, anti-MPO, anticardiolipin (aCL), antibeta 2 glycoprotein I (beta2-GP I), cryoglobulins, C3, and C4. Patients with infections were younger than AAV patients (p < 0.01). There was no difference in frequency of renal and skin lesions. AAV patients more frequently had pulmonary and nervous system manifestations (p < 0.01). Patients with infections more frequently had dual ANCA (high PR3, low MPO), aCL, anti-beta2-GP I, cryoglobulins, and hypocomplementemia (p < 0.001). Immunosuppressive therapy (IST) was used in five 17 patients who had persistently high ANCA, cryoglobulinemia, and hypocomplementemia. There was no difference in frequency of lethality and renal failure in the two study groups. In patients who are PR3- and/or MPO-ANCA positive, SBE and HCV infection should be excluded. Although similar in renal and skin manifestations in comparison to AAV, only patients with infections developed multiple serological abnormalities. In patients with infections, concomitant presence of ANCA, cryoglobulins, and hypocomplementemia was associated with severe glomerulonephritis. The serological profile should be repeated after specific antimicrobial or surgical therapy, since some cases might require IST.
Collapse
|
14
|
Guilpain P, Servettaz A, Tamby MC, Chanseaud Y, Le Guern V, Guillevin L, Mouthon L. Pathogénie des vascularites systémiques primitives (II): vascularites ANCA-négatives. Presse Med 2005; 34:1023-33. [PMID: 16225258 DOI: 10.1016/s0755-4982(05)84105-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The pathogenesis of different types of systemic vasculitis negative for antineutrophil cytoplasm antibodies (ANCA) and involving small or medium-sized vessels is not very well documented. During polyarteritis nodosa (PAN), which is related to hepatitis B virus (HBV) infection, as well as during cryoglobulinemic vasculitides, associated with hepatitis C virus (HCV), and probably during Henoch Schönlein purpura, histological lesions may result from the deposition of immune complexes formed from viral antigens and from antibodies responsible for the activation of the classic complement pathway and for recruitment of polymorphonuclear neutrophils. Two other mechanisms are discussed for other types of ANCA-negative systemic vasculitis: immune complex deposition and sheer stress at arterial bifurcation points. A bacterial superantigen is suspected in Kawasaki disease but remains unproved.
Collapse
Affiliation(s)
- P Guilpain
- Université Paris-Descartes, Faculté de médecine, UPRES EA 1833, site Cochin, Paris
| | | | | | | | | | | | | |
Collapse
|
15
|
Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, Kobrynski LJ, Levinson AI, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol 2005; 94:S1-63. [PMID: 15945566 DOI: 10.1016/s1081-1206(10)61142-8] [Citation(s) in RCA: 311] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Francisco A Bonilla
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Iwata Y, Ohta S, Kawai K, Yamahana J, Sugimori H, Ishida YI, Saito K, Miyamori T, Futami K, Arakawa Y, Hirota YI, Wada T, Yokoyama H, Yoshida K. Shunt nephritis with positive titers for ANCA specific for proteinase 3. Am J Kidney Dis 2004; 43:e11-6. [PMID: 15112193 DOI: 10.1053/j.ajkd.2004.01.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The authors report a case of shunt nephritis with antineutrophil cytoplasmic autoantibody (ANCA) and review 2 similar cases. A 55-year-old man was admitted to our hospital for continuous fever and foot edema in 2002. A ventriculoperitoneal shunt was implanted because of a brain abscess and subsequent hydrocephalus in 1987; it was changed to a ventriculoatrial (VA) shunt in 1995. Urinary analysis showed proteinuria (5.4 g/d) and microscopic hematuria. Laboratory data showed renal dysfunction and hypocomplementemia. ANCA specific for proteinase 3 (PR3-ANCA) was positive in his serum, and blood culture grew Propionibacterium acnes. Renal biopsy results showed membranoproliferative glomerulonephritis type I. Therefore, the VA shunt was replaced, and antibiotics were administered. Oral prednisolone was initiated at a dose of 50 mg/d. Proteinuria and the serum levels of creatinine were improved concomitant with normalization of the serum complement levels and the decrease in serum PR3-ANCA titer. Similarly, another 2 cases reported in the literature of PR3-ANCA-positive shunt nephritis caused by P acnes and Gemella morbillorum showed good outcomes after removal of the shunt and administration of antibiotics with or without steroid therapy.
Collapse
Affiliation(s)
- Yasunori Iwata
- Department of Internal Medicine, Toyama City Hospital, Toyama, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
UNLABELLED Vasculitis can range in severity from a self-limited single-organ disorder to a life-threatening disease with the prospect of multiple-organ failure. This condition presents many challenges to the physician, including classification and diagnosis, appropriate laboratory workup, treatment, and the need for careful follow-up. The physician must not only be able to recognize vasculitis but also be able to provide a specific diagnosis (if possible) as well as recognize and treat any underlying etiologic condition. Most diagnostic criteria are based on the size of vessel involvement, which often correlates with specific dermatologic findings. This may allow the dermatologist to provide an initial diagnosis and direct the medical evaluation. This article reviews the classification and diagnosis of cutaneous vasculitic syndromes and current treatment options; it also presents a comprehensive approach to diagnosing and treating the patient with suspected cutaneous vasculitis. (J Am Acad Dermatol 2003;48:311-40.) LEARNING OBJECTIVE At the completion of this learning activity, participants should be familiar with the classification and clinical features of the various forms of cutaneous vasculitis. They should also have a rational approach to diagnosing and treating a patient with vasculitis.
Collapse
MESH Headings
- Drug Therapy, Combination
- Female
- Humans
- Incidence
- Male
- Prognosis
- Risk Factors
- Severity of Illness Index
- Skin Diseases, Vascular/diagnosis
- Skin Diseases, Vascular/drug therapy
- Skin Diseases, Vascular/epidemiology
- Vasculitis/diagnosis
- Vasculitis/drug therapy
- Vasculitis/epidemiology
- Vasculitis, Leukocytoclastic, Cutaneous/diagnosis
- Vasculitis, Leukocytoclastic, Cutaneous/drug therapy
- Vasculitis, Leukocytoclastic, Cutaneous/epidemiology
Collapse
Affiliation(s)
- David F Fiorentino
- Department of Dermatology, Stanford University School of Medicine, CA 94305, USA.
| |
Collapse
|
18
|
Hirahashi J, Kuramochi S, Konishi K, Chikaraishi A, Takase O, Hayashi M, Saruta T. Glomerulonephritis with microtubular deposits associated with cryoglobulinemia and chronic active hepatitis. Pathol Int 2002; 52:483-7. [PMID: 12167108 DOI: 10.1046/j.1440-1827.2002.01376.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 65-year-old-woman presented with edema, ascites, proteinuria and abnormal liver function tests. A small amount of mixed cryoglobulin was detected in her serum. Liver biopsy revealed mild chronic active hepatitis, but tests for hepatotropic viral infection were negative. Electron microscopy of the renal biopsy revealed glomerular electron-dense deposits that contained numerous tubular structures. Renal amyloidosis and light chain deposition disease were ruled out by appropriate histological techniques. The ultrastructural findings of renal biopsy suggested either cryoglobulinemic glomerulonephritis or immunotactoid glomerulopathy. Although the exact interrelationship among the peculiar glomerulopathy, cryoglobulinemia and chronic active hepatitis in the present case remains undetermined, this report enlarges the spectrum of glomerulopathy characterized by extracellular deposition of microtubules.
Collapse
|
19
|
Dominguez JH, Sha E. Apheresis in cryoglobulinemia complicating hepatitis C and in other renal diseases. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:69-76. [PMID: 11886579 DOI: 10.1046/j.1526-0968.2002.00400.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Removal of cryoglobulins by plasma exchange is now an accepted therapy. Cryoglobulins are circulating complexes that can deposit on small vessels and cause limited or extensive tissue injury. There are 3 major classes of cryoglobulins. Type I cryoglobulins are monoclonal and are detected in a variety of lymphoproliferative disorders. Type II cryoglobulins are mixed containing monoclonal and polyclonal IgG or IgM molecules. Type III cryoglobulins are also mixed and contain polyclonal IgG. Type II cryoglobulins are largely caused by hepatitis C virus infection; hence, they are the most common of the 3 types. In hepatitis C, cryoglobulins are linked to glomerular immune complex injury, often times accompanied by vasculitis of the skin, nerves, and other vital organs. Immediate removal of cryoglobulins by plasma exchange is an effective short-term treatment that can complement more-specific therapies. Plasma exchange has also been used to remove other circulating nephrotoxic agents such as antiglomerular basement antibodies that cause Goodpasture's syndrome, protease inhibitor autoantibodies that cause thrombotic thrombocytopenic purpura, and antiglomerular factors that cause some types of focal glomerulosclerosis.
Collapse
Affiliation(s)
- Jesus H Dominguez
- Department of Medicine, Indiana University and Veterans Administration Medical Center, Indianapolis, Indiana, USA.
| | | |
Collapse
|
20
|
KURUSU A, HORIKOSHI S, UEYAMA-SAKODA S, TAKEDA Y, MAEDA K, SUZUKI S, FUNABIKI K, SHIRATO I, TOMINO Y. Monitoring of serum hepatitis C virus RNA level during steroid therapy for hepatitis C virus-positive antineutrophil cytoplasmic antibody-related glomerulonephritis: report of two cases. Int J Organ Transplant Med 2001. [DOI: 10.1016/s1561-5413(09)60066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
21
|
Affiliation(s)
- P Lamprecht
- Medical University Lübeck, and Rheumaclinic Bad Bramstedt, Germany
| | | | | |
Collapse
|
22
|
Vassilopoulos D, Hoffman GS. Clinical utility of testing for antineutrophil cytoplasmic antibodies. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 1999; 6:645-51. [PMID: 10473510 PMCID: PMC95747 DOI: 10.1128/cdli.6.5.645-651.1999] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- D Vassilopoulos
- Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | |
Collapse
|