Lung involvement in Churg–Strauss syndrome as related to the activity of the disease

Systemic granulomatous diseases associated with multiple palpable masses that may involve the breast: case presentation and an approach to the differential diagnosis

Palpable mass is a common complaint presented to the breast surgeon. It is very uncommon for patients to report breast mass associated with palpable masses in other superficial structures. When these masses are related to systemic granulomatous diseases, the diagnosis and initiation of specific therapy can be challenging. The purpose of this paper is to report a case initially assessed by the breast surgeon and ultimately diagnosed as granulomatous variant of T-cell lymphoma, and discuss the main systemic granulomatous diseases associated with palpable masses involving the breast.

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): evolutions in classification, etiopathogenesis, assessment and management

PURPOSE OF REVIEW

Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome) is a peculiar hybrid condition of a systemic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and a hypereosinophilic disorder with frequent lung involvement that occurs in people with asthma. This review focuses on areas of evidence or persistent uncertainty in the classification, epidemiology, clinical presentation, diagnosis, prognosis and management of EGPA and attempts to identify clues to the mechanisms in the development or course of the disease.

RECENT FINDINGS

The 2013 revision of the EGPA definition formally placed the disease in the subset of ANCA-associated vasculitides. Recently published large case series underlined that the presence of ANCAs, found in 30-40% of EGPA, determines distinct but partly overlapping disease expression and the major detrimental effect of heart involvement on survival. There is some evidence that asthma in EGPA resembles a nonallergic eosinophilic asthma phenotype. Encouraging results have been reported for the treatment of EGPA with rituximab or with the eosinophil-targeted antiinterleukin-5 agent mepolizumab.

SUMMARY

The understanding of EGPA continues to advance, but many gaps in knowledge remain. The nomenclature remains a source of conceptual variance in terms of demonstrated presence or not of vessel inflammation or ANCAs in the diagnosis of EGPA. Distinguishing EGPA from hypereosinophilic syndromes can be problematic, and an understanding of the mechanistic relation between the vasculitis and the eosinophilic proliferation is profoundly lacking. Some evidence suggests distinct disease phenotypes, but this concept has not yet been translated to phenotype-adapted therapy.

Cutting edge issues in the Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a rare systemic small-vessel vasculitis that develops in the background of bronchial asthma, which is characterized by eosinophilia and eosinophilic infiltration of various tissues. It belongs to the group of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides. The triggering factors and pathogenesis of CSS are still unknown. The possible role of eotaxin-3 and CCR4-related chemokines in selective recruitment of eosinophils to the target tissues in CSS has been recently suggested, but the role of eosinophilic inflammation in the development of vasculitic lesions is not completely understood. From the clinical view, two distinct phenotypes of the disease are slowly emerging depending on the ANCA-positivity status. Glucocorticoids are still the mainstay of treatment; however, data are accumulating regarding the beneficial role of novel immunosuppressants and biologic compounds, especially in patients with poorer prognosis.

12-hydroxy-eicosatetraenoic acid (12-HETE): a biomarker of Churg-Strauss syndrome

BACKGROUND

Churg-Strauss syndrome (CSS) shares similarities with asthma and hypereosinophilic syndrome (HES). Eicosanoids--important inflammatory and signaling molecules--are present in exhaled breath condensate (EBC) and broncho-alveolar lavage fluid (BALF).

OBJECTIVES

To assess eicosanoid profile both in EBC and BALF of CSS subjects searching for a pattern characteristic of this syndrome.

METHODS

EBCs from 23 CSS patients, 30 asthmatics, 12 HES patients and 54 healthy controls (HC) were assessed quantitatively for 19 eicosanoids by a high-performance liquid chromatography - tandem mass spectrometry (HPLC-MS/MS). In addition, in 21 of 23 CSS subjects and in nine asthmatics, eicosanoids were determined in BALF.

RESULTS

EBC from CSS patients showed markedly elevated levels of 12-HETE as compared with other studied groups. BALF was characterized by a significant elevation of 12-HETE and its metabolite 12-tetranor HETE in CSS as compared with asthma. Clinical activity of CSS correlated with 12-HETE and its metabolites levels in BALF, but not in EBC.

CONCLUSION AND CLINICAL RELEVANCE

CSS is clearly distinguished from bronchial asthma, and HES by a marked increase in 12-HETE concentration in both EBC and BALF. This points to a possible new pathogenic mechanism in CSS and may help in future in establishing the diagnosis of CSS.

The course of asthma in Churg-Strauss syndrome

OBJECTIVES

Asthma is one of the key features of Churg-Strauss syndrome (CSS); however its course in the disease is unclear. The aim of this study was to analyze the asthma course in CSS patients.

PATIENTS AND METHODS

We conducted a retrospective study of 22 CSS patients. Medical documentation was studied and patients were questioned about asthma symptoms during follow-up visits, which took place at four points of the disease. These points, at which lung function tests were performed, were CSS diagnosis; introduction of treatment at hospital discharge; and assessment of the first and last clinical and laboratory CSS remissions. Asthma control and severity were assessed in compliance with current guidelines.

RESULTS

In the asthmatic group examined, 21 patients had an adult-onset asthma, with a mean age of onset 35.5 ± 11.8 years, preceded by sinusitis (100%) and nasal polyposis (36%). Asthma at its onset was severe in 68.5%, moderate in 27%, and very poorly controlled in 21 patients. Atopy was present in 64% of patients. Onset of vasculitic symptoms and CSS diagnosis was accompanied by high blood eosinophilia (maximal 7.2 x 10(3)/l [1.2 - 32], asthma exacerbation with airway obstruction in 16 patients (mean values of FEV1 68.8 ± 17.5% and FVC 84.8 ± 19.6%), and lung involvement. After introducing the treatment and achieving stable remission, asthma severity/control and lung function tests (forced expiratory volume in 1 s 92.7 ± 13.3%, and forced vital capacity 101 ± 15.5%; p < .001) improved.

CONCLUSIONS

Asthma in CSS, although severe as its onset improves after achieving CSS remission.

Pulmonary findings in Churg-Strauss syndrome in chest X-rays and high resolution computed tomography at the time of initial diagnosis

Churg-Strauss syndrome (CSS) is a rare, systemic, necrotizing, small- and middle-sized vessel vasculitis which is accompanied by blood eosinophilia, eosinophil infiltration of various tissues, and bronchial asthma. The lungs are the organs most often involved in CSS. The aim of this study was a retrospective evaluation of the pulmonary findings in chest X-rays and high resolution computed tomography (HRCT) in CSS patients at the time of initial diagnosis and to determine their frequency, character, and location. Seventeen CSS patients were studied (12 women; 5 men; aged 29-56 years). In all patients at the time of initial diagnosis, chest X-rays were performed, and in 15 patients, HRCT was performed additionally. The radiological images were evaluated independently by two radiologists who reached a decision by consensus. Out of 17 patients studied, chest X-rays revealed parenchymal abnormalities in 11, pleural effusion in three, and bronchial wall thickening in one. In five patients, no abnormalities in chest X-rays were found. In HRCT, abnormalities were found in all patients (15 patients, 100%). Predominant HRCT findings consisted of: ground-glass opacities and consolidations found in 13 patients (86.7%). Additionally, in four patients, pulmonary micronodules were described; in ten, interlobular septal thickening; in three, linear opacities; in ten, bronchial wall thickening and/or bronchial dilatation; and in three, pleural effusions. Ground-glass opacities and consolidation abnormalities distribution pattern were peripheral in seven and random in six patients. In patients with CSS, the most common pulmonary radiological findings are parenchymal opacities, which may be peripheral or random in distribution. Pathologic changes were found in 70.6% of patient in chest X-rays, and in 100%, when HRCT was performed. These changes are nonspecific; however, they should be not overlooked, as they may help in establishing the diagnosis and suggest the prognosis.