Wegener's granulomatosis and the heart

Cardiac valvular involvement in granulomatosis with polyangiitis in long-term observation

INTRODUCTION AND OBJECTIVES

Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic autoantibody (ANCA)-associated systemic vasculitis and is characterized by inflammation of blood vessels. The aim of the present study was to assess cardiac valvular changes in patients with GPA in a cohort of 105 patients followed for a mean of six years.

METHODS

We followed 105 patients (mean age 50.4 years, 67 female) for a mean of 6.2±1.3 years. Echocardiography and laboratory tests were performed in all patients.

RESULTS

At baseline, 43% of patients were diagnosed with aortic regurgitation (AR), which was the most common valvular lesion. Moreover, it was the only valvular involvement that significantly increased during observation (p=0.01). In a multivariate model, only D-dimer level was a predictor of AR in this group of patients (OR 8.0 (95% CI: 1.7-38.2, p=0.01).

CONCLUSIONS

Involvement of the heart valves is a common finding in patients with GPA, but significant valvular disease is a rare complication. The most common valvular disease in this group of patients is AR. Aortic valves are also the most prone to degeneration in the course of the vasculitis.

A Rare Case of High-Grade Atrioventricular Block in Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is an autoimmune disease that affects small and medium-sized vessels. It is classically known to present with renal and respiratory tract symptoms. However, the disease can manifest in other organ systems, especially cardiovascular involvement. Though there are multiple reports of cardiac involvement in GPA, it is not commonly evaluated and is often overlooked in patients with GPA. Heart disease in GPA has a wide range of presentations ranging from subacute and silent to severe abnormalities, which can prove fatal if not identified and treated appropriately. Identifying cardiac involvement early in patients with no apparent signs can help with prevention strategies and follow-up to avoid significant complications. Pericarditis is the most common pathology noted in GPA, followed by cardiomyopathy, coronary artery disease, valvular disease, and conduction abnormality. In our report, we present a case of GPA in a young male with asymptomatic conduction abnormality of the heart. Although it was silent at the presentation, identifying the initial electrocardiogram (ECG) changes prompted us to admit him to the telemetry floor. Continuous telemetry monitoring helped us identify the progression of the conduction abnormality, which otherwise could have been missed. This led us to correlate to his symptoms which he later developed during his admission course. His symptoms subsided after prompt treatment. If not identified early, these cardiac abnormalities can delay management, leading to increased disease burden and morbidity. Hence, essential cardiac work with at least ECG and continuous telemetry monitoring is recommended.

An Unusual Case of Dilated Cardiomyopathy in Wegner’s Granulomatosis

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.

Cardiac imaging of a patient with unusual presentation of granulomatosis with polyangiitis: A case report and review of the literature

BACKGROUND

Recent evidence suggests that cardiac involvement in patients with granulomatosis with polyangiitis (GPA) occurs more frequently than previously reported. Multimodality cardiac imaging is gaining attention in the diagnosis, prognostication, and follow-up of such patients; however, the data remain scarce.

RESULTS

2D-TTE was useful for initial screening; while both cardiac magnetic resonance imaging and 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) metabolic imaging with rubidium-82 PET perfusion imaging were useful for characterization of myocardial disease. 18FDG-PET/CT was very useful for the follow-up of cardiac disease activity following treatment.

CONCLUSION

18FDG-PET/CT is sensitive for the detection of cardiac involvement by GPA and is useful for the tissue characterization and follow-up of disease activity following treatment.

Granulomatosis With Polyangiitis (Wegener's Granulomatosis) Complicated by Pericarditis: Our Experience of Two Cases and Comparative Review of Literature

•

GPA is a systemic necrotizing vasculitis of medium and small vessels.

•

GPA classically involves the upper and lower respiratory tracts and the kidneys.

•

Pericarditis is a common cardiac manifestation, but RP is rarely described.

•

A systematic literature search yielded 13 cases of acute pericarditis secondary to GPA, which are analyzed in this review.

•

The potential role of Anakinra for debilitating RP secondary to GPA is described.

Recurrent gastrointestinal bleeding due to jejunal artery vasculitis as debut presentation of granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is characterised by systemic necrotising vasculitis of small arteries and veins with multitude of organ involvement, with the most common being the upper and lower respiratory tract and renal system. Gastrointestinal involvement is a rare late manifestation with a high mortality rate and usually results in intestinal perforation. Our patient presented with gastrointestinal bleeding secondary to jejunal artery vasculitis. Gastrointestinal bleeding as initial presentation of GPA is very rarely documented. CT mesenteric angiogram is helpful for the localisation of bleed in these cases. In case of refractory bleeding, surgical excision is required.

Aortic valve replacement due to granulomatosis with polyangiitis: a case series

Background

Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is a systemic inflammatory process predominantly affecting upper and lower respiratory tract and kidneys. Valvular heart disease is a rare manifestation of GPA.

Case summary

We report two cases of acute valvular heart disease mimicking acute endocarditis caused by GPA. Both patients were middle-aged females with acute aortic valve regurgitation suggestive of possible infective endocarditis. In their recent medical history, atypical otitis and sinusitis were noted. The first patient was admitted with heart failure and the second patient because of persisting fever. Echocardiogram revealed severe aortic regurgitation with an additional structure on two cusps, suggestive of infective endocarditis in both patients. Urgent surgical replacement was performed; however, intraoperative findings did not show infective endocarditis, but severe inflammatory changes of the valve and surrounding tissue. In both patients, the valve was replaced by a prosthetic valve. Microscopic examination of the valve/myocardial biopsy showed diffuse acute and chronic inflammation with necrosis and necrotizing granulomas, compatible with GPA after infectious causes were excluded. Disease remission was obtained in both patients, in one patient with Rituximab and in the other with Glucocorticoids and Cyclophosphamide. Both had an uneventful follow-up.

Discussion

Granulomatosis with polyangiitis can be a rare cause of acute aortic valve regurgitation mimicking infective endocarditis with the need for surgical valve replacement. Atypical ear, nose, and throat symptoms can be a first sign of GPA. Symptom recognition is important for early diagnosis and appropriate treatment to prevent further progression of the disease.

Novel Pharmacotherapies for Recurrent Pericarditis: Current Options in 2020

Abstract

Recent advances have shown impressive results by anti-interleukin 1 (IL-1) agents in refractory idiopathic recurrent pericarditis.

Purpose of Review

We critically discuss the current state of the art of therapy of relapsing pericarditis, with a focus on new pharmacological approaches and on specific clinical settings such as pregnancy, pediatric patients, and secondary forms of relapsing pericarditis.

Recent Findings

Antagonism of the IL-1 is highly effective in idiopathic recurrent pericarditis with autoinflammatory features. Currently, available anti-IL-1 agents are anakinra and canakinumab. Rilonacept is another IL-1 antagonist, currently studied in the phase-3 clinical trial RHAPSODY. Available data suggest similar efficacy and safety profiles of these three agents, although only anakinra has been tested in randomized clinical trials. These agents have slightly different pharmacological properties, being canakinumab a specific IL-1ß antagonist while anakinra and rilonacept are unselective IL-1α and IL-1ß blockers. To date, there is no evidence that specificity against IL-1ß affects safety and efficacy in patients with relapsing pericarditis, although it has been proposed that unspecific blockage might be useful in severe disease.

Summary

Anakinra is the first anti-IL-1 agent with well-documented efficacy and safety in adult and pediatric patients with idiopathic relapsing pericarditis. Other anti-IL-1 agents are currently under study. Future research should clarify the optimal duration of therapy and tapering schedule of treatment with these agents. Moreover, biomarkers would be required to understand which patients will benefit from early administration of IL-1 blockers due to refractoriness to conventional therapy and which others will suffer from recurrences during the tapering of these agents. Lastly, future studies should focus on the subjects with the autoimmune or the pauci-inflammatory phenotype of idiopathic refractory pericarditis.

Common presentation of rare cardiac diseases: Arrhythmias

Ventricular or supraventricular ectopic beats or atrial fibrillation may be the first presentation of uncommon cardiac disease, both acquired and genetically determined. In some patients, these manifestations can be the first sign of the underlying cardiac disorder. In others, however, they are also important as prognostic indicators, reflecting electrical instability and risk. Most cardiology clinics are busy environments where the implementation of complex diagnostic algorithms is not feasible. However, it is equally impossible to reach a final diagnosis, among the thousands of rare diseases that involve the heart, moving from a first line clinical and instrumental examination. Cardiac and extra-cardiac red flags, an accurate family and clinical history and ECG interpretation may be of help in identifying a rare disease. Advanced imaging and laboratory testing at experienced referral centers is then necessary to reach a final diagnosis, but the first step in the right direction, based on these simple elements, is the most important. We here review arrhythmic presentations of rare or relatively rare diseases, and suggest a simple "rule out-rule in" approach to help direct clinical suspicion and minimize risk of neglect.

Granulomatosis with Polyangiitis with Myocarditis and Ventricular Tachycardia

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.

Complete Resolution of Wegener's Granulomatosis Lung Granuloma After Aortic Root Replacement

Wegner's granulomatosis (WG) is an autoimmune systemic vasculitis that results in necrotizing granulomas. We report a WG patient with a lung granuloma and aortic root dilatation, who underwent aortic root replacement on cardiopulmonary bypass (CPB). Intraoperatively, the patient suffered an aortic dissection, which was repaired immediately under deep hypothermic circulatory arrest (DHCA). Follow-up imaging showed complete granuloma resolution, despite absence of immunosuppressive therapy. Immune stimulation following CPB is well described; here, the opposite was observed and DHCA effects are discussed.

Acute Myocarditis in a Patient with Newly Diagnosed Granulomatosis with Polyangiitis

A 22-year-old woman recently diagnosed with granulomatosis with polyangiitis (GPA) was admitted to the department of cardiology due to chest pain and shortness of breath. The ECG showed widespread mild PR-segment depression, upwardly convex ST-segment elevation, and T-wave inversion. The troponin T level was elevated at 550 ng/L. Transthoracic echocardiography showed basal inferoseptal thinning and hypokinesis, mild pericardial effusion, and an overall preserved left ventricular ejection fraction of 55%. Global longitudinal strain, however, was clearly reduced. Cardiac magnetic resonance imaging (MRI) showed findings consistent with myocarditis but the etiology of the apical hypokinesis could not be determined with certainty and may well have been due to a myocardial infarction, a notion supported by a coronary angiogram displaying slow flow in the territory of the left anterior descending artery. Finally, an endomyocardial biopsy confirmed the diagnosis of myocarditis. The cardiac symptoms subsided upon treatment with high-dose prednisolone and rituximab.

Granulomatosis with polyangiitis (Wegener): clinical aspects and treatment

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis, which affects small- and medium-sized blood vessels and is often associated with cytoplasmic ANCA. GPA occurs in patients between 45 and 60 years old of both genders, and is rarely observed in blacks. The prevalence of GPA increases along a south-north gradient in Europe (20 to 150/million). The main clinical characteristics involve the upper and/or lower respiratory tract and kidneys. Ear, nose and throat manifestations with recurrent sinusitis and crusting rhinorrhea are usually severe. Lung nodules are frequently seen, sometimes excavated. Renal involvement is characterized by rapidly progressive necrotizing glomerulonephritis with extracapillary crescents. Limited forms of GPA predominantly affect the upper respiratory tract, whereas generalized forms of GPA include renal manifestations and/or alveolar hemorrhage and/or vital organ involvement with an altered general condition. The combination of immunosuppressant drugs and corticosteroids has converted this typically fatal illness into one in which 80% of patients achieve remission. However, despite considerable therapeutic progress over the last decades, relapses remain frequent (50% at 5 years), and maintenance treatment is now the main therapeutic challenge.

Development of multi-organ involvement including a left atrial myxoma-like lesion in a patient with granulomatosis with polyangiitis

A 76-year-old woman suffering from granulomatosis with polyangitis (GPA) developed organizing pneumonia with positive antineutrophil cytoplasmic antibodies and microscopic hematuria. Prednisolone improved the hematuria and radiological findings; however, after tapering the dose of prednisolone, a posterior left atrial wall mass was detected in association with a fever. Both regressed spontaneously, although secretory otitis media and sinusitis were noted; the resected sinusitis specimen exhibited vasculitis highly suggestive of GPA. The clinical picture of GPA with multi-organ involvement can vary. Recognizing the various manifestations of GPA is therefore necessary in order to provide an appropriate diagnosis and disease management.

Wegener's granulomatosis mimicking inflammatory bowel disease and presenting with chronic enteritis

Wegener’s granulomatosis, also known as anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, is a small vessel vasculitis with primarily pulmonary, renal, and sinus disease manifestations. The prevalence of Wegener’s granulomatosis is three cases per 100,000 patients. Cardiovascular, neurologic, cutaneous, and joint manifestations have been reported in many case reports and case series. Gastrointestinal manifestations are less noted in Wegener’s granulomatosis, although they have been previously reported in the form of intestinal perforation and intestinal ischemia. Additionally, there are characteristic findings of vasculitis that are noted with active Wegener’s granulomatosis of the small bowel. We report a case of an elderly patient who presented with weight loss, diarrhea, and hematochezia. His symptoms were chronic and had lasted for more than 1 year before diagnosis. Inflammatory bowel disease or chronic enteritis due to Salmonella arizonae because of reptile exposure originally were suspected as etiologies of his presentation. The findings of proteinuria, renal failure, and pauci-immune glomerulonephritis on renal biopsy, in conjunction with an elevated c-ANCA titer, confirmed the diagnosis of Wegener’s granulomatosis with associated intestinal vasculitis. This case demonstrates an atypical presentation of chronic duodenitis and jejunitis secondary to Wegener’s granulomatosis, which mimicked inflammatory bowel disease.

Glomerular disease in patients with infectious processes developing antineutrophil cytoplasmic antibodies

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.

Silent Ischemic Heart Disease in a Patient with Necrotizing Glomerulonephritis due to Wegener's Granulomatosis

OBJECTIVE: Wegener's granulomatosis (WG) is a necrotizing vasculitis that mainly affects the respiratory tract and kidneys, but can also affect other systems such as the eye, joints, skin, muscles, nerves, and gastrointestinal tract. Cardiac involvement is traditionally believed to be rare. We report a patient with silent myocardial infarction (MI) and review previously reported cases showing this association. METHODS: A Medline database search of cases published between January 1978 and July 2008 both in English and Spanish, reporting silent MI complicating WG, was conducted. RESULTS: We describe a typical patient with WG who had both respiratory and renal involvement and died unexpectedly following a silent MI after a period of clinical improvement induced by treatment with prednisone and cyclophosphamide. We report necropsy findings and the association with 5 additional cases of WG with silent MI reported in the literature. CONCLUSIONS: Clinicians should be aware of potential cardiac involvement due to WG. Careful evaluation of each patient, with or without cardiac symptoms, using ECG, echocardiogram, and myocardial enzymes is prudent.

Asymptomatic intracardiac mass in a 14-year-old girl with granulomatosis with polyangiitis: Case report

Granulomatosis with polyangiitis (GPA; Wegener's granulomatosis) is a systemic necrotizing vasculitis of unknown etiology that commonly involves the upper airways, lungs, and kidneys. Cardiac involvement with an intracardiac mass is an exceedingly rare manifestation of this disease, especially in the pediatric population where, to our knowledge, only one article exists to date that has described such a finding. In this report, we present the case of an adolescent female who initially presented with renal failure and an intracardiac mass. Subsequent work-up led to a diagnosis of granulomatosis with polyangiitis (GPA). Cardiac manifestations in pediatric GPA are not common; however, they may be more prevalent than reported given recent adult literature and concern for clinically silent abnormalities.

Two-dimensional speckle-tracking echocardiography reveals systolic abnormalities in granulomatosis with polyangiitis (Wegener's)

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.

Valvular involvement in ANCA-associated systemic vasculitis: a case report and literature review

BACKGROUND

Antineutrophil cytoplasmic antibodies (ANCA)-associated systemic vasculitides have a variety of presentations, but cardiac valvular involvement is rarely diagnosed and its management is not established.

CASE PRESENTATION

We report the case of a 44 year old man who presented with an ANCA-associated systemic vasculitis and aortic regurgitation of unusual mechanism. Transthoracic and transesophageal echocardiography disclosed septal hypertrophy preventing a complete closure of the aortic valve and thus responsible for a massive aortic regurgitation. After 4 months of immunosuppressive therapy, the valve lesion did not subside and the patient had to undergo aortic valve replacement. This report also reviews the 20 cases of systemic ANCA-associated vasculitis with endocardial valvular involvement previously reported in the English language medical literature.

CONCLUSIONS

Valvular involvement in ANCA-associated systemic vasculitides is rarely reported. Most of these lesions are due to Wegener's granulomatosis and half are present when the diagnosis of vasculitis is made. The valvular lesion is usually isolated, aortic regurgitation being the most frequent type, and often requires valve replacement in the months that follow it's discovery.

Acute aortic valvular regurgitation with pulmonary haemorrhage in Wegener's granulomatosis presenting as dyspnoea: a rare presentation

A 40-year-old man with Wegener's granulomatosis with renal and ocular involvement was admitted with symptoms of fever, malaise and cough not responding to oral antibiotics. On initial assessment, he had patchy consolidation but was also found to have a new cardiac murmur. He was mildly anaemic. Within 2 days of hospital stay his haemoglobin dropped and he became tachypnoeic. High-resolution CT found extensive pulmonary infiltrates, which suggested pulmonary haemorrhage, and blood cultures were negative. He was on antibiotics because of suspected infective endocarditis and this made any immunosuppressive treatment for active Wegener's granulomatosis very difficult. After extensive discussion with tertiary centres he had pulse methylprednisolone for 3 days. His echo detected aortic regurgitation but no vegetations. His antibiotics were stopped and he had cyclophosphomide to control his active Wegener's granulomatosis. He improved remarkably with immunosuppression and non-invasive ventilation and was discharged. He had a further echo, which confirmed moderate aortic regurgitation. He is awaiting cardiac catheter studies but the fact is acute aortic regurgitation has happened due to active Wegener's granulomatosis along with pulmonary haemorrhage. This is a very rare presentation.

Arrhythmias and conduction defects in rheumatological diseases--a comprehensive review

OBJECTIVES

To review the clinical aspects of cardiac arrhythmias and conduction disturbances in several common and less encountered adult rheumatic diseases and to underline the importance of prompt diagnosis and management in these patients.

METHODS

The PubMed database was searched for articles published between the years 1960 and 2008 for keywords referring to autoimmune diseases. All relevant English-written articles were reviewed. Most were uncontrolled series and case reports, due to the lack of prospective studies and randomized trials.

RESULTS

Rheumatologic conditions may affect the cardiovascular system and increase morbidity and mortality. Rhythm and conduction defects are usually mild but may be life-threatening; in certain diseases, such as in systemic lupus erythematosus they may resolve following therapy with corticosteroids. Conduction defects occur frequently in patients with spondyloarthropathies and in those with various forms of vasculitis. Enhanced variation of the QT interval may be a sensitive marker of a higher arrythmogenic tendency in patients with autoimmune conditions.

CONCLUSIONS

It is important to identify patients at high risk for cardiac arrhythmias. Treating such patients with arrhythmias should not differ fundamentally from other patients. Nevertheless, appropriate clinical attention and judgment should be applied to exclude the possibility that arrhythmias reflect uncontrolled myocardial inflammation.

Detection of coronary artery lesions and myocardial necrosis by magnetic resonance in systemic necrotizing vasculitides

OBJECTIVE

Myocardium and coronary arteries can occasionally be affected in patients with systemic necrotizing vasculitides; however, such involvement has not been systematically assessed using cardiovascular magnetic resonance imaging (MRI).

METHODS

Magnetic resonance angiography and contrast-enhanced MRI were applied for the assessment of coronary arteries (the left anterior descending [LAD], left circumflex [LCx], and right coronary artery [RCA]) and myocardium, respectively, in 39 patients with vasculitis who were asymptomatic for cardiac disease (16 with microscopic polyangiitis [MPA], 11 with Wegener's granulomatosis [WG], 9 with Churg-Strauss syndrome [CSS], and 3 with polyarteritis nodosa [PAN]). Data were compared with age-matched disease-control patients with rheumatoid arthritis (n = 20) or systemic lupus erythematosus (n = 13), and with healthy control individuals with normal coronaries (n = 40).

RESULTS

Patients with MPA, WG, and PAN (but not with CSS) were found to display significantly increased maximal diameters of coronary arteries compared with healthy controls (for MPA and WG; P < 0.001 for LAD and RCA, and P < 0.01 for LCx) and with both disease-control groups (for only MPA; P < 0.01 for LAD and RCA, and P < 0.05 for LCx). Fusiform coronary aneurysms were detected in patients with MPA (4/16) and PAN (2/3), whereas coronary ectasias were evident in patients with MPA (14/16) and WG (2/11). The presence of myocardial necrosis (by assessment of late gadolinium-enhanced images) was identified only in patients with MPA (2/16) and CSS (3/8 studied).

CONCLUSION

Cardiovascular MRI assessment of patients with systemic vasculitis revealed coronary ectatic disease in the majority of patients with MPA and PAN, as well as in several patients with WG. Myocardial necrosis can be detected in MPA and CSS.

[Mitral regurgitation associated with Wegener's granulomatosis]

BACKGROUND

Wegener's granulomatosis (WG) is a granulomatous disease that can affect many organ systems. The most frequently involved organs include the upper and lower respiratory tract as well as the kidney. Cardiac involvement is rare.

METHODS

We report the case of a patient with grade 4 mitral insufficiency associated with severe WG.

RESULTS

Surgical analysis of the mitral valve revealed perforation of the anterior leaflet without evidence of endocarditis. Pathological examination of the anterior mitral leaflet revealed myxoid degeneration nodules and bacteriological examination was negative. As the perforated lesion was very close to the free margin of the anterior leaflet, valve replacement appeared a reasonable surgical option in a poor surgical candidate. Six months after the operation, the patient is doing well.

CONCLUSION

Wegener's granulomatosis is an autoimmune necrotizing vasculitis that can affect many organ systems. Cardiac involvement is rare. Heart in his globality can be affected by WG in many different ways. Cardiac valvular involvement in WG is rare. The aortic valve seems to be more frequently affected. Cardiologic investigations should have an important place at diagnosis and supervision.

Valvular injury in a patient with PR3-ANCA-associated glomerulonephritis

Background An 11-year-old boy who had hematuria at a routine health check-up was later diagnosed with proteinase 3 (PR3) antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis. Despite treatment with corticosteroids and immunosuppressants, he went on to develop end-stage renal disease. The patient received a renal transplant at the age of 16 years, but relapse of PR3-ANCA-related nephritis to the graft occurred three times. Each relapse was successfully treated with corticosteroids and immunosuppressants. An echocardiogram at the age of 19 years revealed moderate-to-severe aortic regurgitation. The patient died of pneumonia when he was 24 years old. Autopsy revealed a perforation in the noncoronary cusp of the aortic valve and recurrence of crescentic glomerulonephritis in the transplanted kidney.Investigations Physical examinations, urine and blood analyses, renal biopsies, echocardiograms and autopsy.Diagnosis PR3-ANCA-associated glomerulonephritis, recurrence of crescentic glomerulonephritis to the graft, aortic regurgitation and perforation in the noncoronary cusp of the aortic valve.Management Immunosuppressants and corticosteroids.

[Pericarditis: a giant cell arteritis manifestation]

INTRODUCTION

Temporal arteritis is a vasculitis in which inflammatory manifestations mainly involve the external carotid artery area but not exclusively. Through a clinical observation and a review of the literature, we suggest that inflammatory pericarditis could represent a manifestation of temporal arteritis.

EXEGESIS

A 75-year-old-woman was admitted for progressive physical deterioration which had been evolving for three months, associated with fever, frontotemporal cephalalgia and severe biological inflammatory syndrome. Chest X-ray reveals a cardiomegaly and suggests a pericarditis, which was rapidly confirmed by echocardiogram. Temporal artery biopsy concludes to the diagnosis of a giant cell arteritis. Steroids treatment is prescribed, leading to a rapid regression of the inflammatory state and the pericarditis without relapse after 6 months of follow-up.

CONCLUSION

Only prospective studies on systematic echocardiography when faced with the diagnosis of giant cell arteritis, whatever clinical symptoms, will enable to appreciate the prevalence and prognosis value of this manifestation. Moreover, temporal artery analysis seems to be justified when faced with a sub-acute or chronic "idiopathic" inflammatory pericarditis occurring in the elderly patient. Physiopathogeny is unknown but some hypothesis can be proposed: inflammatory cytokines storm, immune complexes deposition, giant cell vasculitis of pericardial arteries or inflammatory interstitial lesion of the pericardium with or without granuloma.

Endocarditis associated with antineutrophil cytoplasmic antibodies: a case report and review of the literature

We report a case of subacute bacterial endocarditis associated with small vessel vasculitis and a strongly positive cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) test. It is important to recognize this cause of positive c-ANCA because infectious endocarditis may closely mimic the clinical manifestations of ANCA-associated vasculitides such as Wegener granulomatosis or microscopic polyangiitis. Furthermore, ANCA-associated vasculitis may result in noninfectious endocarditis, which may be confused with bacterial endocarditis. In this paper, we review reported cases of ANCA-positive bacterial endocarditis and compare them to the reported cases of ANCA-associated idiopathic vasculitis with endocardial compromise.

Fatal endocarditis in Wegener's granulomatosis: mitral valve involvement and an intracardiac mass

Reported here is a 39-year-old man with Wegener's granulomatosis who had died due to endocarditis during his follow up. The concomitance of these two pathologies is discussed in the light of the pertinent literature.

Echocardiographic findings in patients with Wegener granulomatosis

OBJECTIVE

To describe the spectrum and clinical implications of echocardiographic findings associated with Wegener granulomatosis.

PATIENTS AND METHODS

We retrospectively reviewed the clinical records and echocardiographic data of consecutive patients with confirmed Wegener granulomatosis referred to the echocardiography laboratory during the 21-year period from 1976 through 1997.

RESULTS

Of the 85 patients Identified as having confirmed Wegener granulomatosis, 73 (86%) were found to have echocardiographic abnormalities. In 26 (36%) of these 73 patients, lesions appeared directly related to Wegener granulomatosis. We found regional wall motion abnormalities in 17 (65%) of these 26 patients. Left ventricular systolic dysfunction with decreased ejection fraction was found in 13 patients (50%) and pericardial effusion in 5 patients (19%). Other findings Included valvulitis, left ventricular aneurysm, and a large intracardlac mass. A significantly increased mortality rate was observed among patients who had cardiac involvement of Wegener granulomatosis found by echocardiography.

CONCLUSIONS

We found a high frequency of echocardiographic abnormalities that appear to be related to Wegener granulomatosis and associated with Increased mortality. Because cardiac involvement in Wegener granulomatosis often is silent and associated with Increased morbidity and worse prognosis, echocardlographic screening of patients with active Wegener granulomatosis may be of clinical value.

Vasculitis masquerading as aortic valve endocarditis

Small vessel vasculitis and endocarditis can both present with multisystem involvement and may present a diagnostic dilemma. Renal and cardiac involvement is common in small vessel vasculitis and rarely small vessel vasculitis may cause heart block. When a patient presents with diffuse symptoms, deteriorating renal function, and heart block, endocarditis and vasculitis should be included in the differential diagnosis. The case is discussed of a man with a history of aortic valve endocarditis who presented again with similar symptoms, deteriorating renal function, and heart block. There was no evidence of aortic valve endocarditis with abscess formation. A renal biopsy confirmed small vessel vasculitis and the patient responded promptly to immunosuppressive treatment. Correct diagnosis is essential in such cases, as immunosuppression in true endocarditis can be catastrophic. In this case, with the correct diagnosis, immunosuppression proved life saving and prevented erroneous aortic valve surgery.

Wegener's granulomatosis presenting as cardiac failure

Wegener's granulomatosis is a necrotizing vasculitis predominantly involving the respiratory tracts and kidneys. We report a case of young male with Wegener's granulomatosis presenting as cardiac failure.

Cardiac Wegener's granulomatosis masquerading as left atrial myxoma

A 56-year-old woman was referred with mitral regurgitation, left ventricular dysfunction, and a sessile mass on the anterior leaflet of her mitral valve. The initial impression from echocardiography was that she had a left atrial myxoma. At operation, we found an intense inflammatory process diagnosed as Wegener's granulomatosis. It also involved the aortic valve and contiguous myocardium.

Complete heart block in a patient with Wegener's granulomatosis in remission--a case report

Wegener's granulomatosis is a systemic inflammatory disorder of unknown cause that usually affects the upper and lower respiratory tracts as well as the kidney. Cardiac involvement is rare, although electrocardiographic abnormalities, coronary artery vasculitis, cardiac arrhythmias, and myocardial infarction have been reported in the literature. A 27-year-old female patient with Wegener's granulomatosis in remission is described in whom complete heart block developed in the 13th month of treatment with cyclophosphamide. A temporary pacing was applied and pulse methylprednisolone and cyclophosphamide were commenced. On the ninth day of treatment, normal sinus rhythm was achieved. In conclusion, cardiac rhythm abnormalities should always be kept in mind both in the diagnosis and follow-up of Wegener's granulomatosis.

Coronary arteritis in Wegener's granulomatosis causing fatal myocardial infarction

Wegener's granulomatosis is a systemic, granulomatous, inflammatory disorder affecting small vessels, which classically presents with respiratory tract involvement and focal segmental necrotizing glomerulonephritis but not usually with cardiac manifestations. Post-mortem histological examination revealed a diffuse coronary arteritis with an inflammatory infiltrate producing arterial occlusion and subsequent infarction of the myocardium. Post-mortem also showed lung granulomas, generalized small vessel vasculitis and focal segmental necrotizing glomerulonephritis.

New onset left bundle branch block with right axis deviation in a patient with Wegener's granulomatosis

Left bundle branch block (LBBB) is usually associated with a normal axis or left axis deviation (LAD). When it is seen in association with right axis deviation (RAD) it is felt to be a marker of diffuse advanced myocardial disease. We report a case of new onset LBBB with RAD in a patient with Wegener's granulomatosis who had an otherwise functionally and structurally normal heart. To our knowledge, this is the first case report of LBBB with RAD without severe cardiomyopathy, as well as the first case report of new onset LBBB as a result of Wegener's granulomatosis.