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Aya A, Prasad A, Aknouk M, Kochhar S, Okere A. A Rare Presentation of Granulomatosis With Polyangiitis with Multiple Cardiac Valvular Insufficiencies. Cureus 2022; 14:e28617. [PMID: 36185917 PMCID: PMC9523738 DOI: 10.7759/cureus.28617] [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] [Accepted: 08/30/2022] [Indexed: 11/08/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), earlier known as Wegener's granulomatosis, is an autoimmune inflammatory disorder that causes necrotizing vasculitis of small- and medium-sized blood vessels. It primarily affects the upper respiratory tract, lungs, and kidneys. Most of the cardiac involvement tends to be subclinical and is often not clinically apparent with involvement of the conduction pathway; myocarditis, pericarditis, or coronary artery involvement are associated with increased morbidity and mortality. These present with the symptoms of shortness of breath, cough, bilateral pedal edema, orthopnea, syncope, and features of heart failure such as elevated jugular venous pressure. We report a rare case of heart involvement with profound valvular deformity involving all four cardiac valves along with renal impairment in a 76-year-old female with recently diagnosed granulomatosis with polyangiitis.
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Khatri Chhetri RC, Gole S, Mallari AJP, Dutta A, Zahra F. An Unusual Case of Dilated Cardiomyopathy in Wegner’s Granulomatosis. Cureus 2022; 14:e25975. [PMID: 35832755 PMCID: PMC9273172 DOI: 10.7759/cureus.25975] [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] [Accepted: 06/15/2022] [Indexed: 11/06/2022] Open
Abstract
A 33-year-old male presented to the emergency with cough, hemoptysis, and shortness of breath. He was on steroids for suspected Still’s disease due to arthralgias and fever prior to presentation to the emergency. He developed sudden hypoxic respiratory failure and required mechanical ventilation. The initial imaging studies of the chest including computed tomography (CT) of the chest showed marked diffuse central and basilar predominant opacities with associated smooth septal thickening. Furthermore, the patient’s creatinine, troponin, B-type natriuretic peptide (BNP), rheumatoid factor, and D-dimer were elevated. Vasculitis workup, bronchoscopy, and echocardiogram were performed. The echocardiogram revealed severely decreased left ventricular systolic function with an ejection fraction of 24% with dilated left ventricle. The electrocardiogram did not show any findings of acute ischemia. He was started on pulse dose steroid and dobutamine drip along with intermittent diuresis. The patient was successfully extubated after two days of mechanical ventilation. He was started on cyclophosphamide in the hospital. Dobutamine was discontinued. He was moved to the general medical floor as his oxygenation improved, but later at night, he developed respiratory failure and required a bumetanide drip. The cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) (anti-PR-3 antibody) came back positive with titer >1:40, so Wegner’s granulomatosis was diagnosed. He received three sessions of plasmapheresis. The patient’s kidney function improved significantly, and the bumetanide drip was transitioned to intravenous pushes. His oxygenation improved significantly with saturations of 92% on room air. The patient was discharged on steroid, Bactrim, and systolic heart failure medications to follow up with rheumatology, nephrology, pulmonology, and cardiology in the office. Due to insurance issues, his outpatient care was delayed significantly. The patient followed up with rheumatology after two months and has been planned for rituximab induction and to continue steroid along with Bactrim. This case is worth reporting because it describes dilated cardiomyopathy (DCM) as a cardiac manifestation of Wegner’s granulomatosis. Early cardiac evaluation should be incorporated into the management of the patient suspected of Wegner’s granulomatosis.
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Granulomatosis with Polyangiitis with Myocarditis and Ventricular Tachycardia. Case Rep Med 2017; 2017:6501738. [PMID: 28912820 PMCID: PMC5585673 DOI: 10.1155/2017/6501738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/06/2017] [Indexed: 12/27/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, is a pulmonary-renal syndrome affecting small and medium sized blood vessels. The disease has a prevalence in studies ranging from 3 to 15.7 cases per 100,000, with a noted increasing incidence and prevalence in more recent studies. Pulmonary manifestations include hemorrhage, lung cavitary lesions, and pulmonary fibrosis. Within the kidney, GPA is known to cause rapidly progressive pauci-immune crescentic glomerulonephritis. Rare and severe cardiovascular manifestations include pericarditis, arrhythmias, myocarditis, and aortic valve disease. Our patient is a 43-year-old female with typical pulmonary and renal lesions from GPA and also acute myocarditis, multiple episodes of ventricular tachycardia, and a severe reactive thrombocytosis.
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Unusual cardiac involvement in granulomatosis with polyangiitis manifesting as acute congestive heart failure. Anatol J Cardiol 2017; 18:158-160. [PMID: 28766511 PMCID: PMC5731267 DOI: 10.14744/anatoljcardiol.2017.7732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Greulich S, Kitterer D, Kurmann R, Henes J, Latus J, Gloekler S, Wahl A, Buss SJ, Katus HA, Bobbo M, Lombardi M, Backes M, Steubing H, Schepat P, Braun N, Alscher MD, Sechtem U, Mahrholdt H. Cardiac involvement in patients with rheumatic disorders: Data of the RHEU-M(A)R study. Int J Cardiol 2016; 224:37-49. [DOI: 10.1016/j.ijcard.2016.08.298] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 08/19/2016] [Indexed: 01/08/2023]
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Standard and feature tracking magnetic resonance evidence of myocardial involvement in Churg-Strauss syndrome and granulomatosis with polyangiitis (Wegener's) in patients with normal electrocardiograms and transthoracic echocardiography. Int J Cardiovasc Imaging 2012; 29:843-53. [PMID: 23212274 PMCID: PMC3644401 DOI: 10.1007/s10554-012-0158-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 11/14/2012] [Indexed: 01/08/2023]
Abstract
The aim of the study was to evaluate the presence and spectrum of cardiac abnormalities identified by cardiac magnetic resonance (CMR) in subjects in clinical remission of Churg-Strauss syndrome (CSS) and granulomatosis with polyangiitis (Wegener's) (WG) with normal ECG and transthoracic echocardiography (TTE). Eleven (7 females, 4 males, mean age 42.4 ± 9.6 years) CSS and 10 (4 females, 6 males, mean age 45.3 ± 10.9 years) WG patients in clinical remission with normal ECG and TTE underwent CMR. Segmental peak-systolic myocardial strain (εps) was measured using feature tracking cine-sequence based technique. Left ventricular (LV) ejection fraction, end-diastolic volume and myocardial mass indexes were 66.2 ± 5.8 %, 66.1 ± 6.6 ml/m(2), and 61.0 ± 8.9 g/m(2), respectively. No patient showed regional wall motion abnormalities and signs of myocarditis. Nine CSS and 8 WG patients demonstrated decreased segmental longitudinal, circumferential or radial εps and myocardial late gadolinium enhancement (LGE) (6 subendocardial, 10 midwall, 8 subepicardial) areas. In CSS and WG subjects with LVLGE lesions the mean LVLGE extent was 2.0 ± 1.6 % and 2.3 ± 1.5 % (p = 0.65), respectively. Segmental εps was decreased longitudinally (-11.8 ± 5.6 %) for subendocardial LGE, radially (13.7 ± 8.7 %) for subepicardial LGE, and circumferentially (-16.6 ± 4.2 %), longitudinally (-13.2 ± 5.5 %) and radially (18.8 ± 8.1 %) for midwall LGE, if compared to longitudinal (-22.7 ± 5.1 %), circumferential (-23.6 ± 5.6 %) and radial (34.2 ± 15.7 %) εps in controls (11 females, 10 males, mean age 43.9 ± 10.5 years) (all p < 0.01). Despite clinical remission, normal ECG and TTE, most CSS and WG patients demonstrate decreased segmental εps and non-ischemic LGE lesions without signs of myocarditis.
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Miszalski-Jamka T, Szczeklik W, Nycz K, Sokołowska B, Górka J, Bury K, Musiał J. Two-dimensional speckle-tracking echocardiography reveals systolic abnormalities in granulomatosis with polyangiitis (Wegener's). Echocardiography 2012; 29:803-9. [PMID: 22497538 DOI: 10.1111/j.1540-8175.2012.01699.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Two-dimensional speckle-tracking echocardiography (STE) is a novel technique providing accurate assessment of myocardial function. However, its value in granulomatosis with polyangiitis (Wegener's) (WG) has not been studied. OBJECTIVE To assess the presence and frequency of systolic left ventricular (LV) dysfunction using STE and to determine incremental value of STE over standard echocardiography to detect myocardial abnormalities in WG. METHODS Twenty-two WG patients (11 males, 11 females, mean age 46.8 ± 12.3 years) and 22 sex- and age-matched healthy subjects underwent standard and STE. Global longitudinal, circumferential, and rotational deformation parameters were calculated. RESULTS All patients had LV ejection fraction (EF) >50%. LVEF was 65.0 ± 7.5% and LV end-diastolic volume index 44.8 ± 11.8 mL/m(2) . Regional LV wall motion abnormalities were found in 7 (32%), while abnormal global STE determined systolic dysfunction in 16 (73%) subjects (P = 0.008). Global longitudinal, circumferential and radial peak-systolic deformational parameters (strain or strain rate) were decreased in 11 (50%), 9 (41%), and 3 (14%) patients (P = 0.02), respectively. Comparing patients with abnormal and normal STE derived global systolic function, the former had higher cumulative disease extent index (10.6 ± 3.0 vs 7.5 ± 1.8; P = 0.03) and vasculitis damage index (7.9 ± 1.9 vs 6.0 ± 1.7; P = 0.04). CONCLUSIONS Despite normal LVEF the global systolic LV abnormalities detected by STE are common in WG. They correspond to the extent and severity of WG and are more frequent than regional wall motion abnormalities in standard echocardiography.
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Miszalski-Jamka T, Szczeklik W, Sokołowska B, Miszalski-Jamka K, Karwat K, Grządziel G, Mazur W, Kereiakes DJ, Musiał J. Cardiac involvement in Wegener's granulomatosis resistant to induction therapy. Eur Radiol 2011; 21:2297-304. [PMID: 21786089 PMCID: PMC3184393 DOI: 10.1007/s00330-011-2203-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 05/12/2011] [Accepted: 05/31/2011] [Indexed: 12/03/2022]
Abstract
Objectives The aim of the study was to assess cardiac involvement in patients with Wegener’s granulomatosis (WG), who failed to achieve remission following >6 months induction therapy for life or organ threatening disease. Methods Eleven WG patients (eight males, mean age 47 ± 13 years), who failed to achieve remission despite >6 months induction therapy, underwent transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). Results Cardiac involvement was present in 9 (82%) patients. Regional wall motion abnormalities were found in two individuals, but none had left ventricular (LV) ejection fraction <50%. Nine patients had late gadolinium enhancement (LGE) lesions involving LV myocardium and right ventricle free wall was involved in four patients. LGE lesions were found in subepicardial, midwall and subendocardial LV myocardial layers. CMR revealed myocarditis in six patients. Patients with myocarditis had a higher number of LV segments with LGE (5.2 ± 3.4 vs 1.0 ± 1.2, p = 0.03) and more frequent diastolic dysfunction by TTE (5 vs 0, p = 0.02) than those without. Pericardial effusion was observed in five patients, while localized pericardial thickening in six patients. Conclusions In WG resistant to >6 months induction therapy cardiac involvement is frequent and is characterized by foci of LGE lesions and signs of myocardial inflammatory process.
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Affiliation(s)
- Tomasz Miszalski-Jamka
- Center for Diagnosis, Prevention and Telemedicine, John Paul II Hospital, ul. Prądnicka 80, 31-202 Kraków, Poland.
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Cocco G, Gasparyan AY. Myocardial ischemia in Wegener's granulomatosis: coronary atherosclerosis versus vasculitis. Open Cardiovasc Med J 2010; 4:57-62. [PMID: 20360980 PMCID: PMC2847255 DOI: 10.2174/1874192401004020057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 11/17/2009] [Accepted: 11/30/2009] [Indexed: 12/14/2022] Open
Abstract
Wegener's granulomatosis (WG) is one of the most common small- and medium-sized necrotizing vasculitides that mainly affects the upper and lower respiratory tract and the kidneys. Cardiac manifestations in WG are relatively rare, and their role and place among different causes of mortality remain largely unknown. Substantially increased number of reports describing involvement of all structures of the heart, which underlie conduction disturbances, valvular disease, ischemic heart disease and other potentially serious conditions, underscores importance of comprehensive cardiovascular investigations and monitoring of patients with WG. The majority of previous reports and our current observation distinguish coronary vasculitis and thrombosis as a cause of myocardial ischemia and cardiovascular co-morbidities in WG. It seems plausible that inflammatory processes in this disease, like in some other systemic vasculitidies, do not predispose to accelerated atherogenesis. However, characteristic small- and medium-sized vasculitis still can manifest as myocardial ischemia and infarction. We overview diverse cardiac manifestations and present our own rare case of angina in the oligosymptomatic debut of WG. Importantly, in this case, coronarography failed to reveal atherosclerotic disease or thrombotic occlusion. However, magnetic resonance imaging (MRI) with adenosine test revealed subendocardial ischemia. As a result of immunosuppressive therapy with a steroid and cyclophosphamide, myocardial ischemia disappeared.
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Cocco G, Gasparyan AY. Myocardial Ischemia in Wegener’s Granulomatosis: Coronary Atherosclerosis Versus Vasculitis. Open Cardiovasc Med J 2010. [DOI: 10.2174/1874192401004010057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Wegener’s granulomatosis (WG) is one of the most common small- and medium-sized necrotizing vasculitides that mainly affects the upper and lower respiratory tract and the kidneys. Cardiac manifestations in WG are relatively rare, and their role and place among different causes of mortality remain largely unknown. Substantially increased number of reports describing involvement of all structures of the heart, which underlie conduction disturbances, valvular disease, ischemic heart disease and other potentially serious conditions, underscores importance of comprehensive cardiovascular investigations and monitoring of patients with WG. The majority of previous reports and our current observation distinguish coronary vasculitis and thrombosis as a cause of myocardial ischemia and cardiovascular co-morbidities in WG. It seems plausible that inflammatory processes in this disease, like in some other systemic vasculitidies, do not predispose to accelerated atherogenesis. However, characteristic small- and medium-sized vasculitis still can manifest as myocardial ischemia and infarction. We overview diverse cardiac manifestations and present our own rare case of angina in the oligosymptomatic debut of WG. Importantly, in this case, coronarography failed to reveal atherosclerotic disease or thrombotic occlusion. However, magnetic resonance imaging (MRI) with adenosine test revealed subendocardial ischemia. As a result of immunosuppressive therapy with a steroid and cyclophosphamide, myocardial ischemia disappeared.
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