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Moroni L, Giudice L, Lanzillotta M, Cariddi A, Ramirez GA, Bozzolo EP, Germinario B, Gallina G, Viscardi S, Carretta A, Dagna L. Role of systemic immunosuppression on subglottic stenosis in granulomatosis with polyangiitis: Analysis of a single-centre cohort. Eur J Intern Med 2023; 114:108-112. [PMID: 37156712 DOI: 10.1016/j.ejim.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Subglottic stenosis (SGS) is a potentially life-threatening manifestation of granulomatosis with polyangiitis (GPA). Endoscopic dilation is effective, but relapses are frequent and the benefit of systemic immunosuppression in this setting is still controversial. We aimed to investigate the role of immunosuppressive treatment on SGS relapse risk. METHODS This is a retrospective observational study based on review of medical charts among our cohort of patients with GPA. RESULTS Twenty-one patients with SGS-GPA were identified, with a prevalence of 20% among our entire GPA cohort (n = 105). Compared to patients without SGS, patients with SGS-GPA had an earlier disease onset (mean age 30.2 vs. 47.3 years, p<0.001), and lower BVAS (mean 10.5 vs 13.5; p = 0.018). Five patients didn't receive systemic immunosuppression for SGS and they all (100%) relapsed after the first procedure, while among medical treatment group relapse rate was 44% (p = 0.045). When single treatment regimens are considered, rituximab (RTX) and cyclophosphamide (CYC) yielded a protective role towards the need of subsequent dilation procedure after the first if compared with absence of medical treatment. Patients with SGS and generalized disease, who initially received either a RTX- or a CYC-based induction treatment, and higher cumulative doses of glucocorticoids, showed a delayed median time to SGS relapse (36 vs. 12 months, p = 0.024). CONCLUSIONS Subglottic stenosis is highly prevalent in patients with GPA and may define a milder systemic disease subset occurring more frequently in younger patients. Systemic immunosuppression provides benefit in preventing recurrence of SGS in GPA patients and regimens based on cyclophosphamide or rituximab might have a non-redundant role in this setting.
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Affiliation(s)
- Luca Moroni
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy.
| | - Laura Giudice
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Marco Lanzillotta
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Adriana Cariddi
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giuseppe A Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Enrica P Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Bruno Germinario
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Gabriele Gallina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Stefano Viscardi
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy; Unit of Thoracic Surgery, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Angelo Carretta
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy; Unit of Thoracic Surgery, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
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2
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Karpishchenko SA, Zubareva AA, Bolozneva EV, Savchenko EM, Zueva EA. [Possibilities of differential diagnosis of chronic diseases of the nasal cavity after surgical treatment and topical antibiotic therapy]. Vestn Otorinolaringol 2023; 88:44-50. [PMID: 37184554 DOI: 10.17116/otorino20228802144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The study was performed to assess the endoscopic state of the nasal mucosa after the use of local anti-inflammatory and antibacterial therapy, in particular, Polydexa nasal spray with phenylephrine containing Dexamethasone sodium metasulfobenzoate + Neomycin + Polymyxin B + Phenylephrine, and for the treatment of granulomatosis with polyangiitis. MATERIAL AND METHODS The study included 940 patients who underwent examination and treatment for chronic rhinosinusitis in the clinic of otorhinolaryngology of I.P. Pavlov SPbSMU surgical treatment of the paranasal sinuses underwent 907 patients. In the postoperative period, the first group (211 patients) underwent toileting of the nasal cavity. The second group (307 patients) received irrigation therapy. The third group (389 patients) received a topical treatment combined of Polydexa with phenylephrine. The dynamics of the condition was assessed on the 1st, 3rd and 7th days of treatment, the evaluation of the effectiveness of the treatment was carried out on the 3rd and 7th days. Differential diagnosis with granulomatosis with polyangiitis was carried out in 33 patients. All patients with granulomatosis with polyangiitis showed signs of chronic rhinosinusitis. Patients were prescribed local anti-inflammatory and antibacterial therapy with Polydexa with phenylephrine for 7 days with endoscopic control of the nasal cavity. CONCLUSION The use of the combined topical drug Polydexa with phenylephrine in patients with chronic rhinosinusitis and in patients with granulomatosis with polyangiitis has a positive effect, which reduces the clinical manifestations of chronic rhinosinusitis.
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Affiliation(s)
- S A Karpishchenko
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A A Zubareva
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E V Bolozneva
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E M Savchenko
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E A Zueva
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
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3
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Missed Otological Presentation of Wegener’s Granulomatosis: A Case. Indian J Otolaryngol Head Neck Surg 2022; 74:492-494. [PMID: 36032906 PMCID: PMC9411451 DOI: 10.1007/s12070-020-02328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022] Open
Abstract
Wegener's granulomatosis is a rare systemic autoimmune disease of unknown etiology. Typically, it affects the upper respiratory tract, lungs, and kidneys. Sometimes localized form of the disease in head and neck region is also seen. These often go unrecognized till the patient develops systemic signs and symptoms leading to significant complications affecting the quality of life of patient. If timely diagnosed, such potentially life altering sequelae can be avoided with treatment. We present here a case report of a female who presented with breathing difficulty along with Otological symptoms but remained undiagnosed for a long time leading to permanent morbidity because of facial nerve damage and hearing loss.
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4
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Dirikgil E, Tas SW, Verburgh CA, Soonawala D, Hak AE, Remmelts HHF, IJpelaar D, Laverman GD, Rutgers A, van Laar JM, Moens HJB, Verhoeven PMJ, Rabelink TJ, Bos WJW, Teng YKO. Identifying relevant determinants of in-hospital time to diagnosis for ANCA-associated vasculitis patients. Rheumatol Adv Pract 2022; 6:rkac045. [PMID: 35784016 PMCID: PMC9245319 DOI: 10.1093/rap/rkac045] [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: 02/16/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Diagnosing patients with ANCA-associated vasculitis (AAV) can be challenging owing to
its rarity and complexity. Diagnostic delay can have severe consequences, such as
chronic organ damage or even death. Given that few studies have addressed diagnostic
pathways to identify opportunities to improve, we performed a clinical audit to evaluate
the diagnostic phase. Methods This retrospective, observational study of electronic medical records data in hospitals
focused on diagnostic procedures during the first assessment until diagnosis. Results We included 230 AAV patients from nine hospitals. First assessments were mainly
performed by a specialist in internal medicine (52%), pulmonology (14%), ENT (13%) or
rheumatology (10%). The overall median time to diagnosis was 13 [interquartile range:
2–49] days, and in patients primarily examined by a specialist in internal medicine it
was 6 [1–25] days, rheumatology 14 [4–45] days, pulmonology 15 [5–70] days and ENT 57
[16–176] days (P = 0.004). Twenty-two of 31 (71%) patients primarily
assessed by a specialist in ENT had non-generalized disease, of whom 14 (64%) had
ENT-limited activity. Two hundred and nineteen biopsies were performed in 187 patients
(81%). Histopathological support for AAV was observed in 86% of kidney biopsies, 64% of
lung biopsies and 34% of ENT biopsies. Conclusion In The Netherlands, AAV is diagnosed and managed predominantly by internal medicine
specialists. Diagnostic delay was associated with non-generalized disease and ENT
involvement at presentation. Additionally, ENT biopsies had a low diagnostic yield, in
contrast to kidney and lung biopsies. Awareness of this should lead to more frequent
consideration of AAV and early referral for a multidisciplinary approach when AAV is
suspected.
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Affiliation(s)
- Ebru Dirikgil
- Department of Nephrology, Leiden University Medical Center , Leiden
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers , Amsterdam
| | | | | | - A Elisabeth Hak
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers , Amsterdam
| | | | | | | | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen , Groningen
| | - Jaap M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht , Utrecht
| | - Hein J Bernelot Moens
- Department of Rheumatology and Clinical Immunology, Ziekenhuisgroep Twente , Almelo/Hengelo
| | | | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center , Leiden
| | - Willem Jan W Bos
- Department of Nephrology, Leiden University Medical Center , Leiden
- Department of Internal Medicine, St. Antonius Hospital , Nieuwegein, The Netherlands
| | - Y K Onno Teng
- Department of Nephrology, Leiden University Medical Center , Leiden
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Ekbote G, Gupta R, Negalur N, Tanna D. Severe tracheobronchial stenosis in granulomatosis with polyangiitis and type 2 respiratory failure. Arch Rheumatol 2022; 36:611-614. [PMID: 35382373 PMCID: PMC8957777 DOI: 10.46497/archrheumatol.2021.7709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/02/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Gayatri Ekbote
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Rajiva Gupta
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Natasha Negalur
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
| | - Dhaval Tanna
- Medanta The Medicity, Rheumatology & Clinical Immunology, Gurgaon, India
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6
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Verma A, Rajbhar S, Thakur P, Agrawal S, Pradhan S. Favorable Pregnancy Outcome in a Granulomatosis With Polyangiitis Patient With Renal Insufficiency. J Med Cases 2021; 12:27-31. [PMID: 34434424 PMCID: PMC8383638 DOI: 10.14740/jmc3610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/04/2020] [Indexed: 12/02/2022] Open
Abstract
To present a case of successful pregnancy outcome in a granulomatosis with polyangiitis (GPA) patient with renal insufficiency. GPA, formerly known as Wegener’s granulomatosis, is a rare necrotizing systemic vasculitis, presenting with classical clinical triad of manifestations involving upper and lower airway and glomerulonephritis. An association of Antineutrophil cytoplasmic antibodies with GPA has been established and the antibodies are present in most patients with active disease. Pregnancy with GPA is burdened with the risk of possible maternal and fetal complications, further leading to higher morbidity and mortality rate. Due to sparsity of studies of GPA in pregnancy, management needs to be individualised. Diagnostic workup should include serological markers, radiological and histopathological examination. Cyclophosphamide combined with prednisolone is the standard induction regimen. A 22-year-old woman, multigravida at 35 weeks of gestation was referred to our department owing to 1-year diagnosis of GPA. During active phase, the disease manifested as pneumonia and acute kidney injury and perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCAs) were positive. She received pulse therapy of injection cyclophosphamide and methylprednisolone as induction regimen, followed by tapering doses of oral prednisolone and azathioprine for maintenance therapy. The disease was in remission at the onset of pregnancy but had flare up at 34 - 35 weeks of gestation and she presented with renal dysfunction. Neither the disease nor the treatment adversely affected the pregnancy and she delivered a healthy baby at 37 weeks. The unpredictable disease course and complications at unexpected gestation appears to be a major variable to take into account when assessing the risk of pregnancy with GPA. Early diagnosis, monitoring and timely intervention resulted in favourable pregnancy outcome in our patient.
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Affiliation(s)
- Arpana Verma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sarita Rajbhar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Pushpawati Thakur
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sarita Agrawal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
| | - Sangeeta Pradhan
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India
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Sorin SM, Răzvan-Marian M, Daniela MM, Dan-Alexandru T. Therapy of ocular complications in ANCA+ associated vasculitis. Rom J Ophthalmol 2021; 65:10-14. [PMID: 33817427 PMCID: PMC7995502 DOI: 10.22336/rjo.2021.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ANCA+ associated vasculitis (AAV) is a group of rare diseases with potentially vision-threatening complications. Ocular and orbital complications of these diseases are caused by vasculitis of the small vessels of the eye or by granulomatous mass formation. ANCA (anti-neutrophil cytoplasmic antibodies) represent a key component of pathophysiological pathways as well as a diagnostic marker. Various manifestations are reported in literature, scleritis and episcleritis being the most common, followed by pseudotumor orbitae. In vision-threatening orbital or ocular disease, aggressive systemic treatment with a combination of high-dose glucocorticoids and either cyclophosphamide or rituximab is needed. Certain cases require locoregional surgical management to preserve ocular integrity or vision. Ocular involvement of AAV remains a challenge in clinical practice, requiring multi-specialty cooperation in order to ensure the best possible visual outcome. Abbreviations: AAV = ANCA+ associated vasculitis, ANCA = anti-neutrophil cytoplasmic antibodies, GPA = granulomatosis with polyangiitis, EGPA = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis
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8
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Hayashi K, Watanabe H, Yamamura Y, Asano Y, Katayama Y, Hiramatsu-Asano S, Ohashi K, Morishita M, Narazaki M, Matsumoto Y, Sada KE, Wada J. Granulomatosis with polyangiitis with obstructive pneumonia progressing to hypertrophic pachymeningitis: A case report. Medicine (Baltimore) 2021; 100:e24028. [PMID: 33546000 PMCID: PMC7837910 DOI: 10.1097/md.0000000000024028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Bronchial involvement alone is a rare initial manifestation of granulomatosis with polyangiitis (GPA). Herein, we report a case of refractory GPA with obstructive pneumonia caused by bronchial involvement. PATIENT CONCERNS A 65-year-old man complained of a 2-week cough and fever. DIAGNOSES Considering the presence of opacities and multiple consolidations in both lungs due to obstruction or stenosis on the bronchus, which did not respond to antibiotics, and proteinase-3-antineutrophil cytoplasmic autoantibody positivity, he was diagnosed with GPA. Positron emission tomography- computed tomography scan revealed no abnormal findings in the upper respiratory tract. INTERVENTIONS He was treated with prednisolone (PSL, 50 mg/d) and intravenous cyclophosphamide. OUTCOMES His general and respiratory symptoms improved. However, 8 weeks after PSL treatment at 20 mg/d, he developed a relapse of vasculitis along with sinusitis and hypertrophic pachymeningitis. Hence, PSL treatment was resumed to 50 mg/d, and weekly administration of rituximab was initiated. Consequently, the symptoms gradually mitigated. LESSONS GPA with bronchial involvement is often intractable and requires careful follow-up, which should include upper respiratory tract and hypertrophic pachymeningitis assessment.
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Pendolino AL, Unadkat S, Zhang H, Pendolino M, Bianchi G, Randhawa PS, Andrews PJ. The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review. SAGE Open Med 2020; 8:2050312120936731. [PMID: 32676189 PMCID: PMC7340348 DOI: 10.1177/2050312120936731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/29/2020] [Indexed: 01/28/2023] Open
Abstract
Background: The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission. Purpose: The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement. Materials and methods: A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020. Conclusion: Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.
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Affiliation(s)
- Alfonso Luca Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
| | - Samit Unadkat
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Henry Zhang
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Monica Pendolino
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Premjit S Randhawa
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Peter J Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
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10
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Holme SS, Moen JM, Kilian K, Eggesbø HB, Molberg Ø. Impact of Paranasal Sinus Surgery in Granulomatosis With Polyangiitis: A Longitudinal Computed Tomography Study. Laryngoscope 2020; 130:E460-E468. [PMID: 32243590 DOI: 10.1002/lary.28639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/04/2020] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Severe chronic rhinosinusitis (CRS) in patients with granulomatosis with polyangiitis (GPA) failing medical therapies can be treated with paranasal sinus surgery. Whether this surgery protects from progressive sinonasal damage remains unknown. Here, we aimed to analyze time-dependent relations between sinus surgeries and computed tomography (CT) imaging features in the CRS of GPA. STUDY DESIGN Longitudinal observational study. METHODS We assessed CRS features including bone thickening by global osteitis scoring scale, bone erosions, and mucosal thickening by Lund-Mackay scores in serial paranasal sinus CT scans (742 CT scans in total) from a cohort of 127 well-characterized GPA patients. Data on sinonasal surgical procedures were from a mandatory national registry and from chart review. We defined the time from baseline CT to last CT as the study observation period in each patient. Datasets were analyzed by linear mixed models. RESULTS We found that 23/127 cohort patients had one or more paranasal sinus surgical procedures, and 96% of these (22/23) had osteitis by CT after surgery. In patients with nasal surgery alone or no surgery, we identified osteitis in 7/11 (64%) and 45/93 (48%), respectively. During the observation period of a median of 5 years, 38 patients had progression of their sinus osteitis, with the highest annual osteitis progression rates observed around the time of surgery. CONCLUSIONS In this cohort, paranasal sinus surgery was associated with prevalence, severity, and progression rate of sinus osteitis, indicating that sinus surgery does not reduce the bone damage development in the CRS of GPA. LEVEL OF EVIDENCE 4 Laryngoscope, 130: E460-E468, 2020.
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Affiliation(s)
- Sigrun S Holme
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jon M Moen
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Karin Kilian
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Rheumatology, Dermatology, and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Heidi B Eggesbø
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Øyvind Molberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Rheumatology, Dermatology, and Infectious Diseases, Oslo University Hospital, Oslo, Norway
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11
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Ear, nose and throat involvement in granulomatosis with polyangiitis: how it presents and how it determines disease severity and long-term outcomes. Clin Rheumatol 2018; 37:1075-1083. [DOI: 10.1007/s10067-018-4019-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/27/2018] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
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12
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Abstract
PURPOSE OF REVIEW Nasal septum perforation (NSP) is a communication between the two nasal cavities. This review contributes to the better knowledge of NSP causes, diagnosis, and treatment. RECENT FINDINGS NSP prevalence is about 1%. Clinical presentation may range from absence of symptoms to the presence of bothersome sinonasal symptoms. NSP is more frequently caused by trauma or post-surgery, inflammatory diseases, and abuse substances. Conservative management (nasal irrigation, topical use of antibiotic or lubricant ointments, or placement of prosthesis) is considered the first-line treatment. Symptomatic NSP not improving with local therapies usually requires surgical approach. Selection of the technique for the endoscopic septal repair depends on perforation characteristics and surgeon experience. When NSP is diagnosed, its cause has to be promptly determined. Most of them can be controlled with conservative measures. Surgical/endoscopic approaches are usually needed in refractory cases, and new repair techniques have to be considered.
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13
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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: 65] [Impact Index Per Article: 8.1] [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.
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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:
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14
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Girard C, Charles P, Terrier B, Bussonne G, Cohen P, Pagnoux C, Cottin V, Cordier JF, Guillevin L. Tracheobronchial Stenoses in Granulomatosis With Polyangiitis (Wegener's): A Report on 26 Cases. Medicine (Baltimore) 2015; 94:e1088. [PMID: 26266344 PMCID: PMC4616693 DOI: 10.1097/md.0000000000001088] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tracheobronchial stenoses (TBSs) are potentially severe manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) that usually respond poorly to corticosteroids and immunosuppressive agents. We describe 26 GPA patients with ≥1 tracheal (mainly subglottic, SGS) and/or bronchial stenosis(ses) (BS(s)).Sixteen patients had solitary SGS and 10 had ≥1 BS(s). The male/female sex ratio was 9:17, and the median age at GPA diagnosis was 32 years (3:13 and 28 years, respectively, for SGS patients). Antineutrophil cytoplasm antibodies were proteinase 3-positive in 65.5% of the patients (50% of those with SGS).Despite conventional GPA therapy, 62% patients experienced ≥1 stenosis relapse(s) (81% of SGS patients, for a total of 1-8 relapses per patient). None of the several systemic or endoscopic treatments prevented future relapses. Cyclophosphamide induction therapy was effective in 4/6 patients with BS(s) and in 1 patient with SGS among the 7 treated. After many relapses, rituximab achieved remission in 3/4 SGS patients. Endoscopic treatments (dilation, laser, corticosteroid injection, etc.) had only transient efficacy. Other GPA manifestations relapsed independently of TBSs. One SGS patient died of acute respiratory distress syndrome.Our findings confirmed that TBSs are severe GPA manifestations that evolve independently of other organ involvements and do not respond to conventional systemic regimens. As previously described, our population was younger and comprised more females than usual GPA patients, especially those with SGS.The small number of patients and the wide variety of local and systemic treatments prevent us from drawing definitive conclusions about the contribution of each procedure. However, cyclophosphamide seemed to effectively treat BSs, but not SGS, and rituximab may be of interest for SGS management.
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Affiliation(s)
- Charlotte Girard
- From the Department of Internal Medicine (CG, PaC, BT, GB, LG), National Referral Center for Rare Autoimmune and Systemic Diseases, Cochin Hospital; INSERM U1060 (CG, PaC, BT, GB, LG), Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, University of Paris 5-René-Descartes, Paris; Department of Internal Medicine (CG), Department of Rheumatology, Mount Sinaï Hospital, Toronto, Ontario, Canada (CP), Edouard-Herriot University Hospital, Lyon; National Referral Center for Rare Pulmonary Diseases (VC, J-FC), Louis-Pradel Hospital, Lyon, France; and Department of Internal Medicine (PiC), Institut Mutualiste Montsouris, Paris
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Terrier B, Dechartres A, Girard C, Jouneau S, Kahn JE, Dhote R, Lazaro E, Cabane J, Papo T, Schleinitz N, Cohen P, Begon E, Belenotti P, Chauveau D, Diot E, Généreau T, Hamidou M, Hayem G, Le Guenno G, Le Guern V, Michel M, Moulis G, Puéchal X, Rivière S, Samson M, Gonin F, Le Jeunne C, Corlieu P, Mouthon L. Granulomatosis with polyangiitis: endoscopic management of tracheobronchial stenosis: results from a multicentre experience. Rheumatology (Oxford) 2015; 54:1852-7. [DOI: 10.1093/rheumatology/kev129] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Indexed: 12/13/2022] Open
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Janisiewicz AM, Klau MH, Keschner DB, Lehmer RR, Venkat KV, Medhekar SS, Chang PK, Badran K, Leary R, Garg R, Nguyen AA, Lee JT. Higher Antineutrophil Cytoplasmic Antibody (C-ANCA) Titers are Associated with Increased Overall Healthcare Use in Patients with Sinonasal Manifestations of Granulomatosis with Polyangiitis (GPA). Am J Rhinol Allergy 2015; 29:202-6. [DOI: 10.2500/ajra.2015.29.4147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by necrotizing granulomatous airway inflammation and vasculitis. Sinonasal involvement occurs in more than 80% cases, with antineutrophil cytoplasmic antibody (C-ANCA) titers used as a marker of disease severity. The purpose of this study was to determine whether C-ANCA levels impact radiographic findings and healthcare use in patients with sinonasal GPA. Methods A retrospective review was performed on GPA patients evaluated in a multidisciplinary rheumatologic/otolaryngologic clinic from 2008 to 2013. Data were collected with respect to age, gender, clinical presentation, C-ANCA titers, Lund-Mackay (LM) scores, surgical interventions, and healthcare use, the latter of which were determined by assessing the number of rheumatology/otolaryngology clinic visits, computed tomography (CT) scans, and email/telephone encounters. Results A total of 44 patients were identified, 11 male and 33 female. Sinonasal manifestations were evident in 70.4%, with chronic rhinosinusitis (CRS) (41.9%), septal perforation (38.7%), and crusting (32.2%) the most common findings. No significant differences in number of CT scans (p = 0.10) or mean LM scores (p = 0.47) were found between patients with more than or equal to 1:80 and less than 1:80 C-ANCA titers, respectively. However, overall healthcare use was increased in the more than or equal to 1:80 C-ANCA group (n = 28) compared with less than 1:80 (n = 16), with a significantly greater number of rheumatologic/otolaryngologic encounters (mean 121 versus 69.2, p = 0.03) noted. When otolaryngologic healthcare use was specifically examined, the average number of encounters was also higher in more than or equal to 1:80 C-ANCA patients (31.9 versus 22.9), but this difference was not statistically significant (p = 0.16). Conclusion Sinonasal GPA patients with presenting C-ANCA titers more than or equal to 1:80 demonstrated significantly greater overall healthcare use than their lower C-ANCA level counterparts (less than 1:80). However, no significant differences in otolaryngology resource use or LM scores were evident between the two titer groups.
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Affiliation(s)
| | - Marc H. Klau
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - David B. Keschner
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Randy R. Lehmer
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Kumar V. Venkat
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Swati S. Medhekar
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Parke K. Chang
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Karam Badran
- University of California, Irvine School of Medicine, Irvine, California
| | - Ryan Leary
- University of California, Irvine School of Medicine, Irvine, California
| | - Rohit Garg
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Andrew A. Nguyen
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Jivianne T. Lee
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Lenert A, Lenert P. Current and emerging treatment options for ANCA-associated vasculitis: potential role of belimumab and other BAFF/APRIL targeting agents. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:333-47. [PMID: 25609919 PMCID: PMC4294650 DOI: 10.2147/dddt.s67264] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprises several clinical entities with diverse clinical presentations, outcomes, and nonunifying pathogenesis. AAV has a clear potential for relapses, and shows unpredictable response to treatment. Cyclophosphamide-based therapies have remained the hallmark of induction therapy protocols for more than four decades. Recently, B-cell depleting therapy with the anti-CD20 antibody rituximab has proved beneficial in AAV, leading to Food and Drug Administration approval of rituximab in combination with corticosteroids for the treatment of AAV in adults. Rituximab for ANCA-associated vasculitis and other clinical trials provided clear evidence that rituximab was not inferior to cyclophosphamide for remission induction, and rituximab appeared even more beneficial in patients with relapsing disease. This raised hopes that other B-cell-targeted therapies directed either against CD19, CD20, CD22, or B-cell survival factors, B-cell activating factor of the tumor necrosis factor family (BAFF) and a proliferation-inducing ligand could also be beneficial for the management of AAV. BAFF neutralization with the fully humanized monoclonal antibody belimumab has already shown success in human systemic lupus erythematosus and, along with another anti-BAFF reagent blisibimod, is currently undergoing Phase II and III clinical trials in AAV. Local production of BAFF in granulomatous lesions and elevated levels of serum BAFF in AAV provide a rationale for BAFF-targeted therapies not only in AAV but also in other forms of vasculitis such as Behcet’s disease, large-vessel vasculitis, or cryoglobulinemic vasculitis secondary to chronic hepatitis C infection. BAFF-targeted therapies have a very solid safety profile, and may have an additional benefit of preferentially targeting newly arising autoreactive B cells over non-self-reactive B cells.
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Affiliation(s)
- Aleksander Lenert
- Division of Rheumatology, University of Kentucky, Kentucky Clinic, Lexington, KY, USA
| | - Petar Lenert
- Division of Immunology, Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA
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Isa H, Lightman S, Pusey CD, Taylor SRJ. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.
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Affiliation(s)
- Harold P Adams
- Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa Health Care Stroke Center, University of Iowa, Iowa City, IA, USA.
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Audemard A, Bienvenu B, Magnier R, Fournier L, Galateau-Salle F, Silva NM. Clinical images: Bronchial stenosis in granulomatosis with polyangiitis (Wegener's). ACTA ACUST UNITED AC 2013; 65:3303. [PMID: 23983058 DOI: 10.1002/art.38120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- A Audemard
- Caen University Hospital, and University of Caen, Caen, France
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Monach PA. L25. Medical treatment of subglottic stenosis in granulomatosis with polyangiitis (Wegener's). Presse Med 2013; 42:575-6. [DOI: 10.1016/j.lpm.2013.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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22
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Rasmussen N. L24. Local treatments of subglottic and tracheal stenoses in granulomatosis with polyangiitis (Wegener's). Presse Med 2013; 42:571-4. [DOI: 10.1016/j.lpm.2013.01.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
PURPOSE OF REVIEW Advances in genetics and clinical diagnostics, along with recently described clinical entities and refined classification schemes, have improved our understanding of diffuse and interstitial lung diseases in children. This review presents recent updates in these disorders in the context of systemic inflammatory conditions. RECENT FINDINGS Classification of childhood diffuse lung disease (DLD) using adult paradigms is not useful. Distinct clinical-pathologic entities exist in children. Infants are more likely to present with genetic and developmental disorders, and older children with inflammatory and immune-mediated conditions. A combination of clinical evaluation, high-resolution computed tomography scanning, pulmonary function testing and serology, with bronchoscopy and surgical lung biopsy in selected cases, is most useful in the evaluation of DLD in the context of rheumatologic conditions. Common causes of DLD, such as infection, especially in the setting of immunodeficiency, must be ruled out. Optimal therapy for specific disorders will require careful analysis of data from national registries. Emerging use of biomarkers and high-throughput molecular analysis will yield novel insight into these disorders. SUMMARY In the setting of known or suspected rheumatologic disorders, diagnosis and management of DLD are challenging, and require close collaboration among rheumatologists, pulmonologists, and other specialists.
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Endoscopic tracheoplasty: segmental tracheal ring resection in a porcine model. J Bronchology Interv Pulmonol 2012; 17:232-5. [PMID: 23168889 DOI: 10.1097/lbr.0b013e3181ea9a9b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endoscopic tracheoplasty is used for the relief of airway obstruction because of several benign conditions such as postintubation stenosis, inflammatory disorders such as Wegener granulomatosis, and benign neoplastic processes. Several endoscopic treatment modalities exist for these conditions, all with good initial results. However, recurrence is common and often requires frequent reintervention. Endoscopic segmental tracheal ring resection is a novel therapeutic approach that could potentially provide a durable solution. Endoscopic segmental tracheal ring resection was performed in 3 Yorkshire pigs under general anesthesia. A combination of bipolar cautery and sharp dissection was used to resect 25% to 33% of the circumference of a single tracheal ring. Technical success was achieved in all 3 animals with no intraoperative complications. Full-thickness excision, including the anterior perichondrium, was performed in 1 animal without violation of the pretracheal fascia, with no subcutaneous emphysema or clinically apparent pneumothorax. Average operative time was 31 minutes and estimated blood loss was minimal. Heart rate, oxygen saturation, and peak airway pressures were maintained within normal ranges during the procedure and for the 60-minute postoperative period. Histologic analysis of the resected specimen confirmed complete thickness excision of the segment of tracheal cartilage. Endoscopic tracheoplasty by segmental tracheal ring resection is a safe and feasible technique in a porcine model. Long-term durability could potentially outlast other endoscopic techniques for the treatment of bening tracheal stenosis. Survival studies in a porcine model of tracheal stenosis must be performed to assess the long-term outcomes of this approach.
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Update on the treatment of granulomatosis with polyangiitis (Wegener's). CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:164-76. [PMID: 22270373 DOI: 10.1007/s11936-012-0165-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OPINION STATEMENT Granulomatosis with polyangiitis (Wegener's) (GPA), formerly known as Wegener's granulomatosis, is a systemic vasculitis characterized by involvement of the upper airways, lungs, and kidneys. GPA shares many features with microscopic polyangiitis (MPA), so much so that recent trials have included both vasculitides. This article focuses on GPA only, as complete management includes modalities that are unique to this disease. The current treatment of GPA is stratified based on severity. For those patients who have active but non-severe GPA and do not have contraindications, methotrexate and glucocorticoids can induce and maintain remission. For patients with severe disease, options include glucocorticoids combined with either cyclophosphamide or rituximab. When cyclophosphamide is used, it is given for 3 to 6 months, after which time it is stopped and switched to methotrexate or azathioprine for remission maintenance. In randomized trials, rituximab was found to be as effective as cyclophosphamide to induce remission of severe active GPA. Given the recency of experience with rituximab, there remain a number of questions regarding relapse rate, use of repeat courses, long-term toxicity, and combination with maintenance agents. Until these questions are answered, the choice of whether to use cyclophosphamide or rituximab must be decided between the patient and physician. For patients with relapsing disease who have had prior cyclophosphamide exposure, rituximab is an excellent option. In newly diagnosed patients, the extensive experience with cyclophosphamide and its side effect profile must be weighed against these factors with rituximab. There has been limited experience with rituximab in patients with alveolar hemorrhage requiring mechanical ventilation or rapidly progressive glomerulonephritis requiring dialysis, as these patients were excluded from the largest randomized trial. Until such data become available, cyclophosphamide remains the agent with which there has been the greatest experience for efficacy in these settings.
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Arebro J, Henriksson G, Macchiarini P, Juto JE. New treatment of subglottic stenosis due to Wegener's granulomatosis. Acta Otolaryngol 2012; 132:995-1001. [PMID: 22668235 DOI: 10.3109/00016489.2012.674213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS The presented new endoscopic surgical technique offers a safe and successful approach for treatment of subglottic stenosis due to Wegener's granulomatosis. OBJECTIVE Subglottic stenosis is a potentially limiting and complex condition among patients with Wegener's granulomatosis. It causes various symptoms and often requires interventional therapy. The purpose of this study was to evaluate a new endoscopic submucosal technique. METHODS Altogether 13 consecutive patients with subglottic stenosis due to Wegener's granulomatosis were treated with a new endoscopic technique. The procedure was carried out endoscopically, removing the stenotic part submucosally, sealing back the raised mucosal flap, and the bare areas were soaked with mitomycin-C. Follow-up telephone interviews were carried out and hospital records were reviewed. RESULTS Patients included 3 males and 10 females, with an average age of 37.5 years. A total of 37 procedures were performed, with an average of 2.8 procedures per patient. There was a statistically significant reduction in the all symptoms related to the stenoses (p < 0.05). Mean follow-up period was 3.5 years (range 1.5-6.5 years). Overall success rate was 85%. Only one patient relapsed following adequate medical and surgical treatment. No perioperative mortality was recorded.
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Affiliation(s)
- Julia Arebro
- Department of Clinical Science, Intervention and Technology, Division of Otorhinolaryngology, Karolinska Institutet, Stockholm, Sweden
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Subglottic and tracheal stenosis due to Wegener's granulomatosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012. [PMID: 22826070 DOI: 10.1007/978-94-007-4546-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Wegener's granulomatosis (WG) is characterized histologically by necrotizing granulomatous angitis that most commonly involves the upper, lower respiratory tract and kidneys, but may affect any organ system. Otolaryngological manifestations are frequent and diverse but subglottic stenosis and tracheal stenosis are less common. The aim of the study was to assess the clinical features and the response to treatment in WG patients with subglottic or tracheal stenosis. The disease activity at the time of examination was scored in 55 patients with WG (29 females, 26 males) according to clinical, serological, radiological and bronchoscopic findings: subglottic and tracheal stenosis were observed in 9% and 5% of WG patients, respectively. CT scans of the larynx and trachea showed mucosal thickening extended 3-4 cm below the vocal cords in three and the thyroid cartilage in one patient. The degree of narrowing of the axial luminal diameter ranged 50-90%. Mechanical dilation of the stenosis and long-acting local corticosteroids may be of therapeutic benefit, along with conventional immunosuppressive treatment.
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Morales-Angulo C, García-Zornoza R, Obeso-Agüera S, Calvo-Alén J, González-Gay MA. Ear, Nose and Throat Manifestations of Wegener's Granulomatosis (Granulomatosis With Polyangiitis). ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012. [DOI: 10.1016/j.otoeng.2012.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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[Ear, nose and throat manifestations of Wegener's granulomatosis (granulomatosis with polyangiitis)]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012; 63:206-11. [PMID: 22439922 DOI: 10.1016/j.otorri.2011.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 11/19/2011] [Accepted: 12/02/2011] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a small vessel vasculitis often associated with clinical head and neck manifestations, which are sometimes the presenting symptoms of the disease. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with GPA and propose a work-up for the management and diagnosis for patients with suspicion or confirmed diagnosis of this ENT pathology. PATIENTS AND METHODS Retrospective review of the medical records of all patients diagnosed with GPA who were seen at the Department of Otolaryngology from a tertiary public hospital in Cantabria (Spain) over a 20-year period. Clinical and laboratory data, in particular those concerning ENT manifestations, were retrieved from the patients' medical records. RESULTS Twenty-five patients (age range: 30-81 years) were included in the study. Of these, 88% had ENT manifestations at some point in the course of the disease. In 28% of the cases, ENT features were the presenting manifestations. The most frequent ENT manifestations were sinonasal symptoms (52%), followed by otological manifestations (32%). CONCLUSIONS Patients with GPA often present with clinical ENT manifestations. Consequently, routine ENT physical examination must be performed in patients with suspected vasculitis to establish a diagnosis of GPA or to better determine the degree of organ system involvement in patients with GPA.
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Wester JL, Clayburgh DR, Stott WJ, Schindler JS, Andersen PE, Gross ND. Airway reconstruction in Wegener's granulomatosis-associated laryngotracheal stenosis. Laryngoscope 2012; 121:2566-71. [PMID: 22109754 DOI: 10.1002/lary.22367] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Open airway reconstruction is considered definitive treatment of laryngotracheal stenosis (LTS). Although most cases of LTS are not autoimmune, there are few data reported in patients with Wegener's granulomatosis. In this study, we aimed to assess outcomes of airway reconstruction in LTS patients with Wegener's compared to nonautoimmune patients. STUDY DESIGN Retrospective chart review of LTS cases managed with open airway reconstruction at an academic medical center. METHODS Patients who underwent open airway reconstruction for LTS due to Wegener's or nonautoimmune causes were identified from 1995 to 2010. Clinical, demographic, and procedural data were recorded. Fisher exact test, Mann-Whitney U test, and McNemar's test were used to test for significance. RESULTS A total of 53 patients were identified; eight Wegener's, 45 nonautoimmune, with median follow-up time of 8.3 and 1.8 years, respectively. Before reconstruction, there was no statistical difference between Wegener's and nonautoimmune patients with previous dilations (88% vs. 68%, P = .41) and tracheostomy dependence (50% vs. 42%, P = .72). Following reconstruction, 75% Wegener's and 36% nonautoimmune patients required further dilations (P = .05), with a decannulation rate of 75% and 58% (P = 1.0), respectively. CONCLUSIONS Wegener's patients have an increased need for dilations after open airway reconstruction for LTS. However, these patients can be decannulated after surgery at a rate similar to patients with nonautoimmune LTS.
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Affiliation(s)
- Jacob L Wester
- School of Medicine, Oregon Health and Science University, Portland, Oregon 97239, USA
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Barbosa-Cobos RE, Recillas-Gispert C, Arellanes-García L. [Ocular manifestations of primary systemic vasculitis]. REUMATOLOGIA CLINICA 2011; 7 Suppl 3:S12-7. [PMID: 22119276 DOI: 10.1016/j.reuma.2011.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
A variety of ophthalmic manifestations can occur in patients who have systemic vasculitides and may be the presenting feature. Ocular involvement is frequently found and can result in significant morbidity, even in blindness. Early diagnosis and treatment may improve visual outcome. The management is challenging and requires a multidisciplinary approach. Treatment of ocular manifestations and systemic disease usually follows the same path. The mainstay of treatment is the use of systemic corticosteroids, usually combined with steroid-sparing immunosuppressive drugs. New, promising, emerging therapies rely on the development of biologic agents, which seem useful in the ocular manifestations of systemic vasculitides.
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Affiliation(s)
- Rosa Elda Barbosa-Cobos
- Servicio de Reumatología, Hospital Juárez de México, Col. Magdalena de Salinas, Delegación GA Madero, México DF, México
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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]
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Solans Laque R, Lorente J, Canela M. Afección traqueobronquial en la granulomatosis de Wegener. Med Clin (Barc) 2011; 137:230-5. [DOI: 10.1016/j.medcli.2011.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 01/04/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
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Current world literature. Curr Opin Otolaryngol Head Neck Surg 2011; 19:58-65. [PMID: 21233627 DOI: 10.1097/moo.0b013e32834344aa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Life-Threatening Presentations of ANCA-Associated Vasculitis. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Current world literature. Curr Opin Ophthalmol 2010; 21:495-501. [PMID: 20948381 DOI: 10.1097/icu.0b013e3283402a34] [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]
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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