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Gilvaz VJ, Treaba D, Cunha JS. Fifty-Nine-Year-Old Male Patient Presenting With Ulcerating Palatal Lesions. Arthritis Care Res (Hoboken) 2024; 76:753-759. [PMID: 38508703 DOI: 10.1002/acr.25324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/17/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Vinit J Gilvaz
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Diana Treaba
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joanne S Cunha
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Mafla L, So RJ, Collins SL, Chan-Li Y, Lina I, Motz KM, Hillel AT. An Ovine Model Yields Histology and Gene Expression Changes Consistent with Laryngotracheal Stenosis. Laryngoscope 2024. [PMID: 38738796 DOI: 10.1002/lary.31499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/06/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Animal models for laryngotracheal stenosis (LTS) are critical to understand underlying mechanisms and study new therapies. Current animal models for LTS are limited by small airway sizes compared to human. The objective of this study was to develop and validate a novel, large animal ovine model for LTS. METHODS Sheep underwent either bleomycin-coated polypropylene brush injury to the subglottis (n = 6) or airway stent placement (n = 2) via suspension microlaryngoscopy. Laryngotracheal complexes were harvested 4 weeks following injury or stent placement. For the airway injury group, biopsies (n = 3 at each site) were collected of tracheal scar and distal normal regions, and analyzed for fibrotic gene expression. Lamina propria (LP) thickness was compared between injured and normal areas of trachea. RESULTS No mortality occurred in sheep undergoing airway injury or stent placement. There was no migration of tracheal stents. After protocol optimization, LP thickness was significantly increased in injured trachea (Sheep #3: 529.0 vs. 850.8 um; Sheep #4: 933.0 vs. 1693.2 um; Sheep #5: 743.7 vs. 1378.4 um; Sheep #6: 305.7 vs. 2257.6 um). A significant 62-fold, 20-fold, 16-fold, 16-fold, and 9-fold change of COL1, COL3, COL5, FN1, and TGFB1 was observed in injured scar specimen relative to unaffected airway, respectively. CONCLUSION An ovine LTS model produces histologic and transcriptional changes consistent with fibrosis seen in human LTS. Airway stent placement in this model is safe and feasible. This large airway model is a reliable and reproducible method to assess the efficacy of novel LTS therapies prior to clinical translation. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Laura Mafla
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Raymond J So
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Samuel L Collins
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Yee Chan-Li
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ioan Lina
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Kevin M Motz
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Alexander T Hillel
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Fouka E, Drakopanagiotakis F, Steiropoulos P. Pathogenesis of Pulmonary Manifestations in ANCA-Associated Vasculitis and Goodpasture Syndrome. Int J Mol Sci 2024; 25:5278. [PMID: 38791316 PMCID: PMC11121030 DOI: 10.3390/ijms25105278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Pulmonary manifestations of vasculitis are associated with significant morbidity and mortality in affected individuals. They result from a complex interplay between immune dysregulation, which leads to vascular inflammation and tissue damage. This review explored the underlying pathogenesis of pulmonary involvement in vasculitis, encompassing various forms such as granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and anti-GBM disease. Mechanisms involving ANCA and anti-GBM autoantibodies, neutrophil activation, and neutrophil extracellular trap (NETs) formation are discussed, along with the role of the complement system in inducing pulmonary injury. Furthermore, the impact of genetic predisposition and environmental factors on disease susceptibility and severity was considered, and the current treatment options were presented. Understanding the mechanisms involved in the pathogenesis of pulmonary vasculitis is crucial for developing targeted therapies and improving clinical outcomes in affected individuals.
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Affiliation(s)
- Evangelia Fouka
- Department of Respiratory Medicine, General Hospital G. Papanikolaou, Medical School, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece;
| | - Fotios Drakopanagiotakis
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
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Pechenenko AV, Van Der Veer SJ, Clutter CA. Polyuria, Sinopulmonary Symptoms, and Pituitary Mass. AACE Clin Case Rep 2024; 10:115-116. [PMID: 38799043 PMCID: PMC11127594 DOI: 10.1016/j.aace.2024.02.002] [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: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 05/29/2024] Open
Affiliation(s)
- Anita V. Pechenenko
- Division of Internal Medicine, Brooke Army Medical Center, JBSA- Fort Sam Houston, Texas
| | - Seth J. Van Der Veer
- Division of Rheumatology, Brooke Army Medical Center, JBSA- Fort Sam Houston, Texas
| | - Courtney A. Clutter
- Division of Endocrinology, Brooke Army Medical Center, JBSA- Fort Sam Houston, Texas
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Cler SJ, Ogden MA, Farrell NF, Roland LT, Diffie CE, Schneider JS. When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. Am J Otolaryngol 2024; 45:104207. [PMID: 38176206 DOI: 10.1016/j.amjoto.2023.104207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients. OBJECTIVE Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics. METHODS Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review. RESULTS 467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review. CONCLUSION GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.
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Affiliation(s)
- Samuel J Cler
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America.
| | - M Allison Ogden
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Nyssa Fox Farrell
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Lauren T Roland
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Colin E Diffie
- Washington University in St. Louis School of Medicine, Department of Medicine, Division of Rheumatology, United States of America
| | - John S Schneider
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
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Arora H, Sivasubramanian D, Sivakumar S, Sambandam A, Avula S. Seronegative Granulomatosis With Polyangiitis With Isolated Lung Lesions: A Case Report. Cureus 2024; 16:e59692. [PMID: 38841015 PMCID: PMC11150126 DOI: 10.7759/cureus.59692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 06/07/2024] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously referred to as Wegener's granulomatosis, is an uncommon form of necrotizing vasculitis that predominantly targets small and medium-sized blood vessels as a result of granulomatous inflammation. Granulomatosis with polyangiitis is defined by the existence of necrotizing granulomas in the upper respiratory tract, along with renal involvement, which includes necrotizing glomerulonephritis with extra capillary crescents. From a diagnostic perspective, there is a high correlation between GPA and proteinase-3 anti-neutrophil cytoplasmic antibody (PR3-ANCA) because of the release of inflammatory cytokines, reactive oxygen species (ROS), and lytic enzymes. While ANCA-positive serology is commonly used as the diagnostic criteria, we present a seronegative GPA case with isolated lung lesions. A 54-year-old woman was referred for an assessment of hemoptysis and alterations in her chest radiograph. The patient's laboratory results showed a positive QuantiFERON test but negative results for ANCA and antinuclear antibodies (ANA) tests. A chest CT scan showed the presence of several pulmonary nodules in both lungs, with some cavitation. A CT-guided biopsy was conducted on a nodule located in the lower lobe of the right lung. The results showed that the nodule had non-neoplastic chronic inflammation and an area of geographic necrosis. A second robotic-assisted left upper and lower lobe wedge resection was done, which showed white to tan granular lesions with necrotizing granulomatous inflammation and lymph nodes with anthracosis and a lot of histiocytes, which is typical of GPA. The patient received a six-month course of intravenous rituximab treatment.
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Affiliation(s)
- Harkesh Arora
- Hospital Medicine, Lovelace Medical Center, Albuquerque, USA
| | | | | | - Aditya Sambandam
- Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Sreekant Avula
- Internal Medicine, University of Minnesota, Minneapolis, USA
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Allam MN, Baba Ali N, Mahmoud AK, Scalia IG, Farina JM, Abbas MT, Pereyra M, Kamel MA, Awad KA, Wang Y, Barry T, Huang SS, Nguyen BD, Yang M, Jokerst CE, Martinez F, Ayoub C, Arsanjani R. Multi-Modality Imaging in Vasculitis. Diagnostics (Basel) 2024; 14:838. [PMID: 38667483 PMCID: PMC11049623 DOI: 10.3390/diagnostics14080838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Systemic vasculitides are a rare and complex group of diseases that can affect multiple organ systems. Clinically, presentation may be vague and non-specific and as such, diagnosis and subsequent management are challenging. These entities are typically classified by the size of vessel involved, including large-vessel vasculitis (giant cell arteritis, Takayasu's arteritis, and clinically isolated aortitis), medium-vessel vasculitis (including polyarteritis nodosa and Kawasaki disease), and small-vessel vasculitis (granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis). There are also other systemic vasculitides that do not fit in to these categories, such as Behcet's disease, Cogan syndrome, and IgG4-related disease. Advances in medical imaging modalities have revolutionized the approach to diagnosis of these diseases. Specifically, color Doppler ultrasound, computed tomography and angiography, magnetic resonance imaging, positron emission tomography, or invasive catheterization as indicated have become fundamental in the work up of any patient with suspected systemic or localized vasculitis. This review presents the key diagnostic imaging modalities and their clinical utility in the evaluation of systemic vasculitis.
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Affiliation(s)
- Mohamed N. Allam
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Nima Baba Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Kamal A. Awad
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Yuxiang Wang
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Steve S. Huang
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Ba D. Nguyen
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Ming Yang
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | | | - Felipe Martinez
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA (B.D.N.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (M.N.A.); (M.T.A.)
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Keteyian AJ, Shem D, Shupak RP, Peters SM. Diffusely erythematous and hemorrhagic gingiva. J Am Dent Assoc 2024; 155:349-352. [PMID: 37318398 DOI: 10.1016/j.adaj.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 06/16/2023]
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Teames C, Highland J, Cox D, Elstad M, Koening C, Smith M. The Diagnosis of Granulomatosis With Polyangiitis When Serology and Biopsies are Negative. OTO Open 2024; 8:e138. [PMID: 38751426 PMCID: PMC11094516 DOI: 10.1002/oto2.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/09/2023] [Indexed: 05/18/2024] Open
Abstract
Objective Granulomatosis with polyangiitis (GPA) is a potentially fatal condition which often manifests in the head and neck. Currently, diagnosis relies on antineutrophil cytoplasmic autoantibody (c-ANCA) serology and mucosal or renal biopsy. However, a significant proportion of patients with GPA limited to the head and neck are seronegative and biopsy negative. This study evaluates the role of clinical diagnosis of GPA in the absence of positive laboratory findings. Study Design Case series with chart review. Setting Academic Tertiary Medical Center. Methods This was a retrospective review of 143 patients treated in an outpatient otolaryngology clinic at a tertiary care hospital for known or suspected GPA from 1998 to 2021. Presenting symptoms, C-ANCA status at initial presentation, biopsy results, long-term serology results, and time to initiation of treatment were analyzed. Results Twenty-six of 143 (18.2%) patients were seronegative; only 3 of these patients (12%) had positive biopsies. Seventeen (73.9%) of these patients presented with nasal and sinus disease and 12 (52.2%) presented with airway involvement. Only 4 (17.4%) patients had renal involvement. Delay in treatment of patients with negative laboratory workup ranged from 0 months to 11 years. All patients who were seronegative and/or biopsy negative at presentation responded clinically to immunosuppressive therapy. Conclusion GPA cases are often limited to the upper respiratory tract, making diagnosis difficult, particularly in seronegative patients. These results suggest that, when GPA is suspected, despite negative serology, the diagnosis of GPA should be made on clinical grounds, and empiric therapy encouraged to prevent delay in treatment.
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Affiliation(s)
- Charles Teames
- Spencer Fox Eccles School of MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Julie Highland
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Daniel Cox
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Mark Elstad
- Department of Internal MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Curry Koening
- Department of Internal MedicineUniversity of Texas at AustinAustinTexasUSA
| | - Marshall Smith
- Department of OtolaryngologyUniversity of Utah HealthSalt Lake CityUtahUSA
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Iorio L, Pizzi M, Cecchin D, Davanzo F, Ghirardello A, Dei Tos AP, Doria A, Padoan R. Cutting-Edge Strategies for Renal Tumour-like Lesions in Granulomatosis with Polyangiitis: A Systematic Review. Diagnostics (Basel) 2024; 14:566. [PMID: 38473038 DOI: 10.3390/diagnostics14050566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is characterised by granulomatous inflammation and small-to-medium vessel necrotising vasculitis, mainly affecting respiratory tract and kidneys. Renal involvement presenting as tumour-like lesions poses diagnostic and treatment challenges. METHODS Following the observation of a GPA patient presenting with multiple renal tumour-like lesions, we conducted a systematic literature review on MEDLINE/PubMed, EMBASE, and Cochrane databases. Data gathered from the literature were analysed to summarise the diagnostic approach, management, and outcome of renal GPA-related tumour-like lesions. RESULTS a 49-year-old female presented with persistent constitutional symptoms and multiple bilateral renal lesions. Renal biopsy showed chronic interstitial inflammation with necrotising granulomas. Laboratory tests disclosed positive anti-proteinase 3 (PR3) anti-neutrophil cytoplasmic antibody (ANCA) leading to a final diagnosis of GPA. She was effectively treated with high-dose glucocorticoids and rituximab. Literature search yielded 41 articles, concerning 42 GPA patients with renal masses, presenting bilaterally in 23.8% of the cases. Positive PR3-ANCA was observed in 86.5% of the cases. Half of 42 patients showed kidney abnormalities. Treatment with glucocorticoids (83.3%) and immunosuppressive agents (80.9%) resulted in an overall good remission rate and favourable prognosis. CONCLUSIONS GPA should be considered in the differential diagnoses of kidney tumour-like lesions. The diagnosis is challenging, and histological examination greatly contributes to the diagnostic work-up.
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Affiliation(s)
- Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Marco Pizzi
- Surgical Pathology and Cytopathology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Federica Davanzo
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Anna Ghirardello
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Angelo Paolo Dei Tos
- Surgical Pathology and Cytopathology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, 35121 Padua, Italy
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Odom JQ, Mangan AR, Gibson AC, Larson M, Dornhoffer JL, Saadi RA. Diagnosis and management of facial nerve palsy secondary to granulomatosis with polyangiitis - A systematic review. Am J Otolaryngol 2024; 45:104132. [PMID: 38039912 DOI: 10.1016/j.amjoto.2023.104132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Granulomatosis with polyangiitis is associated with otolaryngologic complaints in 70-95 % of cases, with the most common being serous otitis media. In rare cases, patients may experience facial nerve palsy in conjunction with otologic or nasal symptoms; and, often, initially present to an otolaryngologist. It is important for healthcare professionals to be able to recognize the nuisances of facial nerve palsy as a potential presentation of granulomatosis with polyangiitis. STUDY DESIGN Systematic review. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol, PubMed and MED-LINE Databases were queried for articles published from January 2007 to December 2022 describing facial nerve palsy in the context of Granulomatosis with polyangiitis, formerly known as Wegener's Granulomatosis. The keywords included "facial nerve palsy", "facial palsy", "granulomatosis with polyangiitis", "Wegener's granulomatosis", "ANCA positive" in the title/abstract. All full-text articles available in English were screened, including single case presentations. Abstracts, commentaries, and publications deemed outside the scope of our study aims were excluded from review. After removal of duplicate articles, a total of 85 articles were screened. After applying inclusion and exclusion criteria, 14 articles were included in the review. RESULTS There were a total of 28 reports of facial nerve palsy in the literature in patients who were eventually diagnosed with granulomatosis with polyangiitis. The patients' ages ranged from 14 to 68 years old. None of the patients had been previously diagnosed with GPA, and a majority of them presented initially with other otologic symptoms. Hearing loss was reported in 24 patients (86 %), otalgia was present in 11 patients (39 %), and otorrhea was present in 6 patients (21 %). Bilateral facial paralysis was reported in 10 patients in the literature (36 %). In total, 16 patients underwent surgery for facial paralysis: 6 tympanomastoidectomies, 4 mastoidectomies, 2 explorative tympanotomies. Surgery was generally considered ineffective in resolving facial weakness. All patients ended up receiving some combination of steroids and immunosuppressant, most commonly prednisolone and cyclophosphamide or rituximab, which was eventually transitioned to azathioprine for maintenance. Unlike auditory thresholds, which remained decreased in two patients, all patients recovered facial function following appropriate medical treatment of their vasculitis. CONCLUSIONS Facial nerve paralysis in patients with granulomatosis with polyangiitis is a rare but treatable phenomenon. In patients with intractable otitis media, unresolving facial palsy, or a combination of otologic issues, it is important to consider GPA as a possible source. The prognosis for facial function appears to be excellent in patients who undergo appropriate treatment for vasculitis, but further studies are needed for confirmation.
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Affiliation(s)
- John Q Odom
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Andrew R Mangan
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Michael Larson
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John L Dornhoffer
- University of Arkansas for Medical Sciences, Little Rock, AR, USA; Arkansas Children's Hospital, Little Rock, AR, USA
| | - Robert A Saadi
- University of Arkansas for Medical Sciences, Little Rock, AR, USA; Arkansas Children's Hospital, Little Rock, AR, USA.
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12
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Korkmaz I, Barut Selver O, Egrilmez S, Yagci A, Keser G, Aksu K, Palamar M. Ocular manifestations of granulomatosis with polyangiitis: report from a tertiary eye care center. Int Ophthalmol 2024; 44:16. [PMID: 38321188 DOI: 10.1007/s10792-024-02989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/19/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE To report demographic characteristics and ophthalmological manifestations of patients with granulomatosis with polyangiitis (GPA) in a tertiary eye care center in Turkey. METHODS Medical records of patients with GPA-related ocular manifestations evaluated between 2013 and 2023 were included. Demographic and clinical characteristics of the patients including nature of systemic involvement, ophthalmologic symptoms and signs, laboratory investigations and treatment modality were reviewed. RESULTS Twelve eyes of 10 patients (5 female/5 male) were included. The mean age was 57.2 ± 12.2 (35-71) years. Five (50%) patients were already diagnosed with GPA. Ocular involvement was the first manifestation of GPA in 3 patients. The remaining 2 patients had simultaneous systemic and ocular symptoms at presentation. Conjunctival hyperemia (9 eyes) and pain (7 eyes) were the most frequent presenting symptoms followed by blurred vision (3 eyes). The frequencies of ocular manifestations were as follows:episcleritis (3 eyes), isolated peripheral ulcerative keratitis (PUK) (3 eyes), scleritis (3 eyes), simultaneous PUK and scleritis (2 eyes) and periorbital mass (1 eye). CONCLUSION Ophthalmological manifestations can be the initial findings in GPA. Since GPA can affect different structures of the eye, it sometimes might be challenging for ophthalmologists. Therefore, it is crucial for ophthalmologists to be well-informed about GPA-related ocular findings and to have a high index of suspicion for GPA. Although PUK associated with scleritis is highly suggestive for GPA, isolated cases of PUK or scleritis can be seen in GPA. Therefore, it is important to adopt a multidisciplinary approach, consider GPA in differential diagnosis, and benefit from accurate diagnostic tests.
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Affiliation(s)
- Ilayda Korkmaz
- Department of Ophthalmology, Ege University Medical Faculty Hospital, 35100, Bornova, Izmir, Turkey
| | - Ozlem Barut Selver
- Department of Ophthalmology, Ege University Medical Faculty Hospital, 35100, Bornova, Izmir, Turkey
| | - Sait Egrilmez
- Department of Ophthalmology, Ege University Medical Faculty Hospital, 35100, Bornova, Izmir, Turkey
| | - Ayse Yagci
- Department of Ophthalmology, Ege University Medical Faculty Hospital, 35100, Bornova, Izmir, Turkey
| | - Gokhan Keser
- Department of Internal Medicine, Division of Rheumatology, Ege University, Izmir, Turkey
| | - Kenan Aksu
- Department of Internal Medicine, Division of Rheumatology, Ege University, Izmir, Turkey
| | - Melis Palamar
- Department of Ophthalmology, Ege University Medical Faculty Hospital, 35100, Bornova, Izmir, Turkey.
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Hoying D, Dorney I, Otteson T, Thuener J, Kaelber DC. Assessing the Association Between Head and Neck Cancer and Granulomatosis with Polyangiitis. EAR, NOSE & THROAT JOURNAL 2024:1455613231223409. [PMID: 38321643 DOI: 10.1177/01455613231223409] [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: 02/08/2024] Open
Abstract
Objective: To determine the odds of head and neck cancer (HNC) in patients with a concurrent or prior diagnosis of granulomatosis with polyangiitis (GPA). Methods and Materials: The TriNetX Analytics Network, a federated research platform that aggregates de-identified electronic health record data of over 130 million patients worldwide, was queried for patients with at least one ICD-10 encounter diagnosis of GPA. Patients within this group with an encounter diagnosis of cancer of the sinonasal, oral cavity, oropharynx, nasopharynx, and larynx concurrent or after the initial encounter diagnosis of GPA were recorded and compared to a standardized control population to determine odds ratios with a 95% confidence interval (CI). Relevant confounding variables, including human papillomavirus, Epstein Barr virus, tobacco, and alcohol exposure, were balanced between cohorts by 1:1 propensity matching. Results: Of the patients in the GPA cohort, 126 (0.48%) had an ICD-10 diagnosis of HNC. When stratifying by head and neck subsites, 20 (0.08%), 18 (0.07%), 23 (0.09%), 70 (0.27%), and 22 (0.084%) GPA patients had an ICD-10 encounter diagnosis of cancer involving the sinonasal, nasopharynx, larynx, oral cavity, and oropharynx. When comparing the experimental GPA group with the standardized control population after matching, patients in the GPA group had 1.3 times (95% CI: 1.03-1.175) greater odds of HNC when including cases diagnosed after or concurrently with the diagnosis of the vasculitis. There was no statistical difference in the odds of cancer at each anatomical subsite between the GPA and control cohort after matching. Conclusion: Our study identifies a statistically significant increase in the odds of HNC encounter diagnoses in patients with GPA.
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Affiliation(s)
- David Hoying
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ian Dorney
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Todd Otteson
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jason Thuener
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David C Kaelber
- Department of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
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14
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Vainutienė V, Ivaška J, Dadonienė J, Beleškienė V, Ivaškienė T, Lesinskas E. Audiological Manifestations in Patients with Granulomatosis with Polyangiitis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:267. [PMID: 38399554 PMCID: PMC10890050 DOI: 10.3390/medicina60020267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Granulomatosis with Polyangiitis (GPA) is a rare, autoimmune, multisystemic disease characterized by vasculitis and necrotizing granuloma that commonly affects the upper and lower respiratory tract and kidneys. Audiovestibular dysfunction in GPA diseases may have different clinical presentations. The aim of the present study was to evaluate hearing function in patients with GPA and to compare the results with a healthy control group. Materials and Methods: A total of 34 individuals participated in the study. The GPA group consisted of 14 participants, and the control group was composed of 20 healthy participants with no signs or symptoms of ear disease. The ages ranged from 18 to 65 years old, with a mean age of 43.8 years. The participants underwent a complete audiological evaluation using otoscopy, impedance audiometry, pure tone audiometry, speech audiometry-evaluation of speech thresholds, and speech recognition in quiet. Both ears were tested. All of the participants of the study were native Lithuanian speakers. Data were statistically analyzed using the Statistical Analysis System software SAS® Studio 3.8. A p value < 0.05 was regarded as statistically significant. Results: 92.85% of patients from the GPA group reported hearing-related symptoms: hearing loss, tinnitus, and fullness in the ears. The arithmetic means of all hearing thresholds at frequencies from 125 Hz to 8000 Hz were significantly higher in the GPA group. The results revealed statistically significant differences between the two groups in the Speech Detection Threshold, Speech Recognition Threshold, Speech Discomfort level, and Word Recognition Scores. Conclusions: The frequency of hearing loss, the average hearing thresholds, and speech thresholds were higher in GPA patients than in healthy individuals. The most common type of hearing loss was sensorineural. Audiological assessments should be considered during the routine evaluation of patients with GPA disease to prevent hearing-related disabilities.
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Affiliation(s)
- Vija Vainutienė
- State Research Institute Centre for Innovative Medicine, Santariškių str. 5, LT-08406 Vilnius, Lithuania; (J.D.); (T.I.)
| | - Justinas Ivaška
- Clinic of Ear, Nose, Throat and Eye Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M.K. Čiurlionio str. 21, LT-03101 Vilnius, Lithuania; (J.I.); (V.B.); (E.L.)
| | - Jolanta Dadonienė
- State Research Institute Centre for Innovative Medicine, Santariškių str. 5, LT-08406 Vilnius, Lithuania; (J.D.); (T.I.)
- Department of Public Health, Faculty of Medicine, Vilnius University, M.K. Čiurlionio str. 21, LT-03101 Vilnius, Lithuania
| | - Vilma Beleškienė
- Clinic of Ear, Nose, Throat and Eye Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M.K. Čiurlionio str. 21, LT-03101 Vilnius, Lithuania; (J.I.); (V.B.); (E.L.)
| | - Tatjana Ivaškienė
- State Research Institute Centre for Innovative Medicine, Santariškių str. 5, LT-08406 Vilnius, Lithuania; (J.D.); (T.I.)
| | - Eugenijus Lesinskas
- Clinic of Ear, Nose, Throat and Eye Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M.K. Čiurlionio str. 21, LT-03101 Vilnius, Lithuania; (J.I.); (V.B.); (E.L.)
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15
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Anguamea-Maldonado J, Sanchez-Zazueta E, Vidal-Morales R. Pleural tuberculosis and endocarditis as complications of multifactorial origin in granulomatosis with polyangiitis: Clinical case report. REUMATOLOGIA CLINICA 2024; 20:104-107. [PMID: 38290955 DOI: 10.1016/j.reumae.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/08/2023] [Indexed: 02/01/2024]
Abstract
We present the case of a 36-year-old woman with a history of granulomatosis with polyangiitis; chronic kidney disease; systemic arterial hypertension. Debut with dyspnea, weakness, and hemoptysis, she was suspected in atypical pneumonia, discarded, persisting with tachypnea, tachycardia, chest pain. The protocol for pulmonary tuberculosis was started with negative sputum samples, positive blood culture for S. haemolyticus, chest tomography with left pneumothorax and ipsilateral pleural effusion, exudate-type pleural fluid was obtained, acid-fast staining, negative PCR for M. tuberculosis; A follow-up echocardiogram was performed due to a new murmur, reporting valvular vegetation, concluding a diagnosis of pleural tuberculosis and endocarditis as complications of multifactorial origin associated with immunosuppression in granulomatosis with polyangiitis.
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Affiliation(s)
- Jesús Anguamea-Maldonado
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 1 Ciudad Obregón, Sonora, Departamento de Medicina Interna, Sonora, Mexico.
| | - Eduardo Sanchez-Zazueta
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 1 Ciudad Obregón, Sonora, Departamento de Medicina Interna, Sonora, Mexico.
| | - Rene Vidal-Morales
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 1 Ciudad Obregón, Sonora, Departamento de Medicina Interna, Sonora, Mexico
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16
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Shao H, Liu D, Zheng X, Zhang J, Li W, Chen P, Qian Z, Yang J, Liu D. Ileal perforation involvement in Wegener granulomatosis comorbid with COVID-19 infection: A case report and review of the literature. Medicine (Baltimore) 2024; 103:e36973. [PMID: 38277571 PMCID: PMC10817022 DOI: 10.1097/md.0000000000036973] [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: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 01/28/2024] Open
Abstract
RATIONALE Granulomatosis with polyangiitis (GPA) is a systematic autoimmune disease. The typical clinical involvement of GPA entails the upper and lower respiratory tracts, and the kidneys. Gastrointestinal (GI) involvement is uncommon and unless detected and treated promptly, may lead to life-threatening complications such as perforation. We aim to review all available publications since the first description in 1982 dealing with GI perforation in patients with Wegener granulomatosis and draw attention to this serious situation. PATIENT CONCERNS We present a 54-year-old man diagnosed with GPA who presented initially with nasal symptoms and suffered ileal perforation following Corona Virus Disease 2019 infection. We also review previously reported patients with Wegener granulomatosis who had GI perforation to investigate the perforation site and period, pathology, diagnosis, and treatment methods. DIAGNOSES AND INTERVENTIONS The case of a GPA-diagnosed patient who presented initially with nasal symptoms and suffered ileal perforation following Corona Virus Disease 2019 infection. We recommended a renal puncture biopsy, steroids, and immunosuppressants to improve the patient condition. The patient and his family refused these treatment recommendations. OUTCOMES Our patient exhibited continued progressive vascular inflammatory changes and eventual irreversible systemic damage. These sequelae were attributed to the patient declining prednisolone and immunosuppressant therapy. LESSONS GI perforation is rare in GPA but severe complication. Consequently, we recommend that early diagnosis and treatment with steroid hormones and immunosuppressants for GPA patients with GI perforation.
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Affiliation(s)
- Huijuan Shao
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Dong Liu
- Department of Intensive Care Unit, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Xiaofeng Zheng
- Department of Gastroenterology, Second Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Jiucong Zhang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Wenbo Li
- Department of Intensive Care Unit, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Peng Chen
- Department of General Surgery, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Zhen Qian
- Department of Pathology, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Jie Yang
- Department of Pathology, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
| | - Dongmei Liu
- Department of Intensive Care Unit, The 940 Hospital of Joint Logistic Support Force of PLA, Lanzhou, China
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17
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Li Z, Zhang Q, Wang X, Shi F. Granulomatosis with polyangiitis presenting headache: A case report and review of literature. Medicine (Baltimore) 2024; 103:e36972. [PMID: 38215096 PMCID: PMC10783307 DOI: 10.1097/md.0000000000036972] [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: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024] Open
Abstract
RATIONALE Central nervous system involvement is a rare manifestation of active-phaselocalized Granulomatosis with polyangiitis (GPA). In hypertrophic dura meningitis, GPA with headache is typical. In this case, cerebral magnetic resonance (MR) enhancement revealed no meningeal thickening, to our knowledge, this manifestation had not been found previously. PATIENT CONCERNS The patient presented to the Rheumatology and Immunology Clinic with severe headache and hearing loss, and central nervous system granulomatosis with polyangiitis was confirmed after a series of examinations. The patient had no significant effect after treatment with cyclophosphamide (CTX), but after the use of rituximab, the headache and hearing loss were significantly improved, and laboratory indicators returned to normal levels. DIAGNOSIS We comprehensively screened for craniocerebral infection and malignant tumors, diagnosed central nervous system granulomatosis with polyangiitis. INTERVENTIONS We gave sequential treatment of rituximab. OUTCOMES All indicators are mostly back to normal when the patient was monitored at the outpatient clinic. LESSONS GPA and severe headache are more prevalent in hypertrophic dura meningitis, but the patient early headache could not be explained by hypertrophic dura meningitis or localized granulomatous lesions that invaded the central nervous system. Patients with severe headaches likely have vascular inflammation and local bone destruction at the base of the skull.
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Affiliation(s)
- Zhao Li
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Qiushuang Zhang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xuebin Wang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Fang Shi
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong, China
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18
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Maccio U, Gianolio A, Rets AV. Granulomas in bone marrow biopsies: clinicopathological significance and new perspectives. J Clin Pathol 2023; 77:8-15. [PMID: 37640519 DOI: 10.1136/jcp-2023-209104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Bone marrow granulomas in trephine biopsies are a rare and usually incidental finding. Possible causes include infectious (especially tuberculous and rarer non-tuberculous mycobacteria, but also many other bacterial, viral, fungal and parasitic agents) and non-infectious causes (especially medications, autoimmune disease, sarcoidosis, haematological and non-haematological malignancy). Necrotising granulomas are generally suggestive of an infectious aetiology (tuberculosis being the most common), whereas fibrin ring granulomas are associated with Q-fever and Epstein Barr Virus, although exceptions are possible. Every case suspicious for infectious aetiology should undergo further analysis like special staining (Ziehl-Neelsen for acid-fast rods) or molecular studies. The histomorphology should always be clinically correlated. In cases in which no infectious cause can be identified, untargeted metagenomics may represent a valid diagnostic tool that may become standard in the near future for bone marrow diagnostics. In this review, we have analysed the published data from 1956 up to today, and we report aspects of epidemiology, aetiology, diagnostic algorithms, differential diagnosis and the role of metagenomics in bone marrow biopsies with granulomas.
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Affiliation(s)
- Umberto Maccio
- Pathology and Molecular Pathology, University Hospital Zurich, Zürich, Switzerland
| | - Alessandra Gianolio
- Department of Medical Sciences, University of Turin, Torino, Piemonte, Italy
| | - Anton V Rets
- Department of Hematopathology, ARUP Laboratories Inc, Salt Lake City, Utah, USA
- Pathology, The University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Kempen JH, Newcomb CW, Washington TL, Foster CS, Sobrin L, Thorne JE, Jabs DA, Suhler EB, Rosenbaum JT, Sen HN, Levy-Clarke GA, Nussenblatt RB, Bhatt NP, Lowder CY, Goldstein DA, Leiderman YI, Acharya NR, Holland GN, Read RW, Dunn JP, Dreger KA, Artornsombudh P, Begum HA, Fitzgerald TD, Kothari S, Payal AR, Daniel E, Gangaputra SS, Kaçmaz RO, Liesegang TL, Pujari SS, Khachatryan N, Maghsoudlou A, Suga HK, Pak CM, Helzlsouer KJ, Buchanich JM. Use of Immunosuppression and the Risk of Subsequent Overall or Cancer Mortality. Ophthalmology 2023; 130:1258-1268. [PMID: 37499954 PMCID: PMC10811288 DOI: 10.1016/j.ophtha.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE To determine the incidence of all-cause and cancer mortality (CM) in association with immunosuppression. DESIGN Retrospective cohort study at ocular inflammatory disease (OID) subspecialty centers. We harvested exposure and covariate data retrospectively from clinic inception (earliest in 1979) through 2010 inclusive. Then we ascertained overall and cancer-specific mortalities by National Death Index linkage. We constructed separate Cox models to evaluate overall and CM for each class of immunosuppressant and for each individual immunosuppressant compared with person-time unexposed to any immunosuppression. PARTICIPANTS Patients with noninfectious OID, excluding those with human immunodeficiency infection or preexisting cancer. METHODS Tumor necrosis factor (TNF) inhibitors (mostly infliximab, adalimumab, and etanercept); antimetabolites (methotrexate, mycophenolate mofetil, azathioprine); calcineurin inhibitors (cyclosporine); and alkylating agents (cyclophosphamide) were given when clinically indicated in this noninterventional cohort study. MAIN OUTCOME MEASURES Overall mortality and CM. RESULTS Over 187 151 person-years (median follow-up 10.0 years), during which 15 938 patients were at risk for mortality, we observed 1970 deaths, 435 due to cancer. Both patients unexposed to immunosuppressants (standardized mortality ratio [SMR] = 0.95, 95% confidence interval [CI], 0.90-1.01) and those exposed to immunosuppressants but free of systemic inflammatory diseases (SIDs) (SMR = 1.04, 95% CI, 0.95-1.14) had similar mortality risk to the US population. Comparing patients exposed to TNF inhibitors, antimetabolites, calcineurin inhibitors, and alkylating agents with patients not exposed to any of these, we found that overall mortality (adjusted hazard ratio [aHR] = 0.88, 0.89, 0.90, 1.11) and CM (aHR = 1.25, 0.89, 0.86, 1.23) were not significantly increased. These results were stable in sensitivity analyses whether excluding or including patients with SID, across 0-, 3-, or 5-year lags and across quartiles of immunosuppressant dose and duration. CONCLUSIONS Our results, in a cohort where the indication for treatment was proven unassociated with mortality risk, found that commonly used immunosuppressants-especially the antimetabolites methotrexate, mycophenolate mofetil, and azathioprine; the TNF inhibitors adalimumab and infliximab, and cyclosporine-were not associated with increased overall and CM over a median cohort follow-up of 10.0 years. These results suggest the safety of these agents with respect to overall and CM for patients treated with immunosuppression for a wide range of inflammatory diseases. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Sight for Souls, Bellevue, Washington; MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; Department of Ophthalmology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.
| | - Craig W Newcomb
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri L Washington
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts
| | - Lucia Sobrin
- Department of Ophthalmology and Schepens Eye Research Institute, Massachusetts Eye and Ear Infirmary, and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer E Thorne
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Douglas A Jabs
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric B Suhler
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Portland Veteran's Affairs Medical Center, Portland, Oregon
| | - James T Rosenbaum
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon; Legacy Devers Eye Institute, Portland, Oregon
| | - H Nida Sen
- Department of Ophthalmology, George Washington University, Washington, District of Columbia; Janssen Retina Global Clinical Development, Princeton, New Jersey
| | - Grace A Levy-Clarke
- Department of Ophthalmology and Visual Sciences, West Virginia University, Morgantown, West Virginia
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirali P Bhatt
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Careen Y Lowder
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic, Cleveland, Ohio
| | - Debra A Goldstein
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Yannek I Leiderman
- Illinois Eye & Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Nisha R Acharya
- F.I. Proctor Foundation, Department of Ophthalmology, University of California San Francisco School of Medicine, San Francisco, California
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Russell W Read
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - James P Dunn
- Mid-Atlantic Retina, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Kurt A Dreger
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Pichaporn Artornsombudh
- Department of Ophthalmology, Somdech Phra Pinkloa Hospital, Royal Thai Navy, Bangkok, Thailand; Department of Ophthalmology, Chulalongkorn University, Bangkok, Thailand
| | - Hosne A Begum
- Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tonetta D Fitzgerald
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srishti Kothari
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts; Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ebenezer Daniel
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sapna S Gangaputra
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Teresa L Liesegang
- Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon
| | - Siddharth S Pujari
- Siddharth Netralaya Superspecialty Eye Hospital, Belgaum, Karnataka, India
| | - Naira Khachatryan
- Department of Ophthalmology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hilkiah K Suga
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia
| | - Clara M Pak
- MCM Eye Unit, MyungSung Christian Medical Center General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia; University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Kathy J Helzlsouer
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanine M Buchanich
- Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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20
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Bannour I, Ben Brahim M, Arfa S, Amor SB, Ben Mabrouk A, Berrich O, Hammemi S. Case Report: Case report: An unusual presentation of granulomatosis with polyangiitis. F1000Res 2023; 12:430. [PMID: 37900198 PMCID: PMC10600508 DOI: 10.12688/f1000research.133102.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 10/31/2023] Open
Abstract
Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.
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Affiliation(s)
- Ichrak Bannour
- Laboratory of Molecular Immuno-Oncology, Faculty of Medicine, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
- Immunology Laboratory, Fattouma Bourguiba Universitary Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Maroi Ben Brahim
- Biochemistry Laboratory, LR12ES05 LR-NAFS Nutrition-Functional Food and Vascular Health, Faculty of Medicine, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
- Internal Medicine and Endocrinology Department, Tahar Sfar University Hospital, Universite de Monastir, Monastir, Monastir, 5111, Tunisia
| | - Sondes Arfa
- Internal Medicine and Endocrinology Department, Tahar Sfar University Hospital, Universite de Monastir, Monastir, Monastir, 5111, Tunisia
| | - Soumaya ben Amor
- Department of Gastrology, Tahar Sfar University Hospital, Mahdia, Tunisia
| | - Asma Ben Mabrouk
- Internal Medicine and Endocrinology Department, Tahar Sfar University Hospital, Universite de Monastir, Monastir, Monastir, 5111, Tunisia
| | - Olfa Berrich
- Biochemistry Laboratory, LR12ES05 LR-NAFS Nutrition-Functional Food and Vascular Health, Faculty of Medicine, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
- Internal Medicine and Endocrinology Department, Tahar Sfar University Hospital, Universite de Monastir, Monastir, Monastir, 5111, Tunisia
| | - Sonia Hammemi
- Biochemistry Laboratory, LR12ES05 LR-NAFS Nutrition-Functional Food and Vascular Health, Faculty of Medicine, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
- Internal Medicine and Endocrinology Department, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
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21
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Patrick Eisenberg A, Collier V, Mangano A, Shergill K, Yos E. Subglottic Stenosis as a Presentation of Antineutrophil Cytoplasmic Antibody-Associated Glomerulonephritis. Cureus 2023; 15:e46899. [PMID: 37954789 PMCID: PMC10636656 DOI: 10.7759/cureus.46899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously Wegener's granulomatosis, is a necrotizing vasculitic disease process affecting the small- and medium-sized blood vessels. GPA is frequently associated with damage to the respiratory tract and kidneys but often affects other organ systems including the eyes, nasopharynx, and nervous system. Due to the vague nature of presenting symptoms and the progressive nature of GPA, it is essential to keep a broad differential to mitigate the high morbidity and mortality associated with the disease. Here we introduce a case of a GPA presenting as respiratory distress, stridor, and renal injury. We also review common clinical presentations, diagnostic evaluation, and treatment options.
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Affiliation(s)
| | - Victor Collier
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | - Andrew Mangano
- Internal Medicine, Mary Washington Healthcare, Fredericksburg, USA
| | | | - Ellen Yos
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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22
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Basnet A, Kansakar S, Sharma NR, Gautam S, Lamichhane S, Tiwari K, Pokhrel M, Singh S. Granulomatosis with polyangiitis mimicking COVID-19 pneumonia: A case report. Clin Case Rep 2023; 11:e8007. [PMID: 37808571 PMCID: PMC10558652 DOI: 10.1002/ccr3.8007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/27/2023] [Accepted: 09/21/2023] [Indexed: 10/10/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis characterized by small-to-medium-sized vessel involvement and the presence of antineutrophil cytoplasmic antibodies (ANCA). We present a case of a 26-year-old Asian woman who was transferred to our center from a nearby hospital, where she presented with shortness of breath, tested positive for COVID-19, and was being managed for COVID-19 pneumonia. She also had hemoptysis, skin lesions, and left foot numbness. Serological markers and VATS-guided lung biopsy confirmed the diagnosis. Treatment with methylprednisolone and rituximab led to stabilization, despite complications of subcutaneous emphysema and lower extremity neuropathic symptoms. Early recognition and appropriate management of GPA are crucial for optimal outcomes.
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Affiliation(s)
- Arjun Basnet
- Maimonides Medical Center Brooklyn New York United States
| | - Sajog Kansakar
- Maimonides Medical Center Brooklyn New York United States
| | | | | | | | - Kripa Tiwari
- Maimonides Medical Center Brooklyn New York United States
| | - Madalasa Pokhrel
- Montefiore New Rochelle Hospital New Rochelle New York United States
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Ghorishi A, Alayon A, Ghaddar T, Kandah M, Amundson PK. MR and CT angiography in the diagnosis of vasculitides. BJR Open 2023; 5:20220020. [PMID: 37953869 PMCID: PMC10636354 DOI: 10.1259/bjro.20220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 11/14/2023] Open
Abstract
Vasculitides represent the wide-ranging series of complex inflammatory diseases that involve inflammation of blood vessel walls. These conditions are characterized according to the caliber of the predominantly involved vessels. The work-up of vasculitides often includes imaging to narrow a differential diagnosis and guide management. Findings from CT and MR angiography in conjunction with a thorough history and physical exam are of utmost importance in making an accurate diagnosis. Further, imaging can be used for follow-up, in order to monitor disease progression and response to treatment. This wide-ranging literature review serves as the primary resource for clinicians looking to diagnose and monitor the progression of rare vascular inflammatory conditions. This article provides a comprehensive summary of the main findings on imaging related to each of these vasculitides. For each of the named vasculitis conditions, a thorough overview of the diagnostic modalities and their respective findings is described. Many specific hallmarks of pathology are included in this review article.
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Affiliation(s)
- Alex Ghorishi
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Amaris Alayon
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Tarek Ghaddar
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Maya Kandah
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States
| | - Per K Amundson
- School of Medicine, Indiana University, Indianapolis, United States
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24
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Risal UP, Pangeni RP, Pandey R, Regmi PR, Karki A, Shah A. Unilateral diaphragmatic palsy and pleuropericarditis in a patient with granulomatosis with polyangiitis: a case report. J Med Case Rep 2023; 17:381. [PMID: 37670370 PMCID: PMC10481465 DOI: 10.1186/s13256-023-04105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/27/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis predominantly affecting upper and lower respiratory tract and kidneys. Unilateral diaphragmatic palsy could be a rare manifestation of GPA. Here we report a case of GPA in a 45-year-old male with unilateral diaphragmatic palsy with pleuropericarditis. CASE PRESENTATION We report a case of a 45-year-old Khas male who presented with acute onset chest pain and shortness of breath who had elevated right hemidiaphragm, bilateral pleural effusion and pericardial effusion who was later diagnosed as GPA. CONCLUSIONS GPA should be suspected in all patients with diaphragmatic palsy and pleuropericarditis with appropriate clinical and laboratory picture.
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Affiliation(s)
- Ujjwol Prasad Risal
- Department of Internal Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal.
| | - Raju Prasad Pangeni
- Department of Pulmonology and Sleep Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Rakshya Pandey
- Department of Pulmonology and Sleep Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Pradeep Raj Regmi
- Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Aditi Karki
- Perfect Diagnostic Centre, Samakhusi, Kathmandu, Nepal
| | - Avish Shah
- Everest Hospital, New Baneshwor, Kathmandu, Nepal
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Odler B, Windpessl M, Eller K, Säemann MD, Lhotta K, Neumann I, Öberseder G, Duftner C, Dejaco C, Rudnicki M, Gauckler P, Hintenberger R, Zwerina J, Thiel J, Kronbichler A. [Diagnosis and therapy of granulomatosis with polyangiitis and microscopic polyangiitis-2023: consensus of the Austrian society of nephrology (ÖGN) and Austrian society of rheumatology (ÖGR)]. Wien Klin Wochenschr 2023; 135:656-674. [PMID: 37728651 PMCID: PMC10511611 DOI: 10.1007/s00508-023-02262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
ANCA-associated vasculitides (AAV) are rare, complex systemic diseases that are often difficult to diagnose, because of unspecific clinical symptoms at presentation. However, the clinical course may be very dramatic and even life-threatening, necessitating prompt diagnosis and treatment.Therefore, it is important to increase disease awareness among physicians and support colleagues who are not confronted with these rare diseases on a regular basis. Here, the Austrian Society of Nephrology (ÖGN) and the Austrian Society of Rheumatology (ÖGR) provide a joint consensus on how to best diagnose and manage patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).
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Affiliation(s)
- Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | | | - Christina Duftner
- Department Innere Medizin II, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | | | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Rainer Hintenberger
- Abteilung Innere Medizin 2 (Gastroenterologie und Hepatologie, Endokrinologie und Stoffwechsel, Nephrologie, Rheumatologie), JKU, Linz, Österreich
| | - Jochen Zwerina
- 1. Medizinische Abteilung, Hanusch Krankenhaus, Wien, Österreich
| | - Jens Thiel
- Klinische Abteilung für Rheumatologie und Immunologie, Bereich Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
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Yun SY, Choi YJ, Chung SR, Suh CH, Kim SC, Lee JH, Baek JH. Image findings of anti-neutrophil cytoplasmic antibody-associated vasculitis involving the skull base. Clin Radiol 2023; 78:e568-e573. [PMID: 37164808 DOI: 10.1016/j.crad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/02/2023] [Accepted: 04/05/2023] [Indexed: 05/12/2023]
Abstract
AIM To investigate computed tomography (CT) and magnetic resonance imaging (MRI) features of skull bases involving anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). MATERIALS AND METHODS A retrospective review was undertaken to identify an institutional historical cohort of 17 patients with confirmed AAV who underwent CT or MRI and had skull base involvement between 2002 and 2021. Two radiologists reviewed the extent and features of the lesions, bone changes, and other MRI findings. RESULTS A total of 17 patients (12 men; mean age ± standard deviation, 46.5 ± 17.1 years) were selected. AAV presented as infiltrative lesions with involvement at various sites. Most cases involved the paranasal sinuses (PNS; 88%, 15/17), nasopharynx (88%, 15/17), pterygopalatine fossa (82%, 14/17), and parapharyngeal space (82%, 14/17), frequently accompanied by mucosal irregularity of the PNS and nasopharynx (71%, 12/17). Central skull base and temporal bone involvement were seen in 53% (9/17) and 38% (6/16) of cases, respectively. On T1-weighted imaging (WI) and T2WI MRI, all lesions (15/15) showed predominant signal iso-intensity to grey matter. CONCLUSIONS Although radiological findings of AAV are non-specific and skull base involvement is less common, AAV may be considered if infiltrative lesions predominantly involving the PNS, nasopharynx, pterygopalatine fossa, and parapharyngeal space with combined bone changes of skull base are seen.
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Affiliation(s)
- S Y Yun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Radiology, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Y J Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - S R Chung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C H Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S C Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J H Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J H Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Knopp BW, Baran J, Casey R. Childhood-Onset Granulomatosis With Polyangiitis as a Palatal Defect: A Case Report. Cureus 2023; 15:e42855. [PMID: 37664394 PMCID: PMC10473442 DOI: 10.7759/cureus.42855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a necrotizing systemic vasculitis of small and medium-sized vessels with renal and sinopulmonary involvement. Its symptoms include chronic sinusitis, recurrent pneumonia, glomerulonephritis, constitutional symptoms, and skin manifestations with a typical onset in the fourth to sixth decade of life. We present a rare case of GPA in a 16-year-old female who presented with facial numbness and nasal regurgitation via a palatal defect. The patient reported a several-month history of recurrent epistaxis and chronic nasal congestion accompanied by several weeks of night sweats, lower right-sided facial numbness and pain, nasal regurgitation of food and liquids, and a 30-pound weight loss. A physical exam found a 3-cm defect on the right side of her palate. CT of the sinuses showed significant sinonasal destruction and petrous apicitis. GPA was confirmed via pathognomonic chest X-ray findings and biopsy results. The patient was treated with maxillary antrostomy and anterior ethmoidectomy and a follow-up was scheduled to address sequelae of the destructive sinopulmonary lesions. This case report highlights a unique presentation of GPA with an insidious development of autoimmune sinonasal destruction in an adolescent female. This presentation is rare and highlights the importance of considering autoimmune disease in cases of tissue destruction where the etiology is not apparent, even in patients at low risk for autoimmune conditions.
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Affiliation(s)
- Brandon W Knopp
- Endocrinology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Jessica Baran
- Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Robert Casey
- Pediatrics, Joe DiMaggio Children's Hospital, Hollywood, USA
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28
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Coviello E, Puma F, Pourmolkara D, Mandarano M, Napolitano AG. Massive, life-threatening hemoptysis due to localized granulomatosis with polyangiitis. J Cardiothorac Surg 2023; 18:239. [PMID: 37496070 PMCID: PMC10373328 DOI: 10.1186/s13019-023-02302-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/10/2023] [Indexed: 07/28/2023] Open
Abstract
Massive hemoptysis may be related to a wide spectrum of diseases whose differential diagnosis can be challenging, also due to the medical emergency condition.We present a case of a 33-year-old woman presented to our department with sudden, life-threatening hemoptysis from unknown etiology, which required a rescue pulmonary lobectomy after resuscitation maneuvers. Histology proved to be a localized Wegener granulomatosis. Our case shows that granulomatosis should always be considered among the possible, although rarer, causes of massive hemoptysis.
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Affiliation(s)
- Eleonora Coviello
- Department of Thoracic Surgery, University of Perugia Medical School, Piazzale Giorgio Menghini 3, Perugia, 06129, Italy.
- Thoracic Surgery Unit, Department of Surgical Sciences, Santa Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, 06134, Italy.
| | - Francesco Puma
- Department of Thoracic Surgery, University of Perugia Medical School, Piazzale Giorgio Menghini 3, Perugia, 06129, Italy
| | - Domenico Pourmolkara
- Department of Thoracic Surgery, University of Perugia Medical School, Piazzale Giorgio Menghini 3, Perugia, 06129, Italy
| | - Martina Mandarano
- Department of Anatomic Pathology and Histology, University of Perugia Medical School, Piazzale Giorgio Menghini 3, Perugia, 06129, Italy
| | - Antonio Giulio Napolitano
- Department of Thoracic Surgery, University of Perugia Medical School, Piazzale Giorgio Menghini 3, Perugia, 06129, Italy
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29
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Byszewska A, Skrzypiec I, Rymarz A, Niemczyk S, Rękas M. Ocular Involvement of Granulomatosis with Polyangiitis. J Clin Med 2023; 12:4448. [PMID: 37445483 DOI: 10.3390/jcm12134448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly referred to as Wegener's disease, is a form of ANCA-associated vasculitis. It manifests mainly in the kidneys and the upper respiratory tract, but ocular involvement is not uncommon. In this article, four cases with ocular manifestations are presented with comprehensive photographic documentation. We describe the way to proper diagnosis, which may be long, the possible treatment, and the final outcomes. Our patients had the following ocular manifestations of GPA: retinal vasculitis, anterior necrotizing scleritis, medial orbital wall and orbital floor erosion with middle face deformation, compressive optic neuropathy due to retrobulbar inflammatory mass, and the abscess of the eyelids, inflammatory intraorbital mass causing exophthalmos and diplopia. This manuscript includes the description of severe forms of GPA, the initial signs and symptoms, relapses, and difficulties in achieving remission. The extraocular involvement is described with diagnostic modalities and laboratory findings. One of the reported cases was diagnosed by an ophthalmologist on the basis of ocular symptoms in the early stages of the disease. Our outcomes are compared with those discussed in the literature.
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Affiliation(s)
- Anna Byszewska
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Izabela Skrzypiec
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Aleksandra Rymarz
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Stanisław Niemczyk
- Nephrology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
| | - Marek Rękas
- Ophthalmology Department, Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
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30
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Probasco B, Melnychuk V, Hong A, Gabra A, Lieberman S. A Case of Granulomatosis with Polyangiitis Masquerading as Community Acquired Pneumonia. J Community Hosp Intern Med Perspect 2023; 13:103-107. [PMID: 37877061 PMCID: PMC10593167 DOI: 10.55729/2000-9666.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 10/26/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) has a multitude of presentations, including appearing as a refractory community-acquired pneumonia (CAP) or an isolated localized pulmonary disease. This case describes a patient suspected to have a CAP before further workup and lung biopsy revealed his diagnosis of GPA. This case report demonstrates GPA's diverse presentations, critical complications such as diffuse alveolar hemorrhage (DAH) and cardiac tamponade, and nuanced management options.
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Affiliation(s)
- Brianna Probasco
- Department of Internal Medicine, HCA Florida Northwest Hospital,
USA
| | | | - Angelina Hong
- Department of Internal Medicine, HCA Florida Northwest Hospital,
USA
| | - Abanoub Gabra
- Department of Pathology, HCA Florida Northwest Hospital,
USA
| | - Scott Lieberman
- Department of Pulmonology and Critical Care, HCA Florida Northwest Hospital,
USA
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31
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Huang J, Xu Y. Autoimmunity: A New Focus on Nasal Polyps. Int J Mol Sci 2023; 24:ijms24098444. [PMID: 37176151 PMCID: PMC10179643 DOI: 10.3390/ijms24098444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) has long been considered a benign, chronic inflammatory, and hyperplastic disease. Recent studies have shown that autoimmune-related mechanisms are involved in the pathology of nasal polyps. Activated plasma cells, eosinophils, basophils, innate type 2 lymphocytes, mast cells, and proinflammatory cytokine in polyp tissue indicate the mobilization of innate and adaptive immune pathways during polyp formation. The discovery of a series of autoantibodies further supports the autoimmune nature of nasal polyps. Local homeostasis dysregulation, infection, and chronic inflammation may trigger autoimmunity through several mechanisms, including autoantigens overproduction, microbial translocation, molecular mimicry, superantigens, activation or inhibition of receptors, bystander activation, dysregulation of Toll-Like Receptors (TLRs), epitope spreading, autoantigens complementarity. In this paper, we elaborated on the microbiome-mediated mechanism, abnormal host immunity, and genetic changes to update the role of autoimmunity in the pathogenesis of chronic rhinosinusitis with nasal polyps.
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Affiliation(s)
- Jingyu Huang
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yu Xu
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Research Institute of Otolaryngology-Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
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32
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Smith MH, Mintline M. Acute Immune-Mediated Lesions of the Oral Cavity. Oral Maxillofac Surg Clin North Am 2023; 35:247-259. [PMID: 37019507 DOI: 10.1016/j.coms.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Although acute immune-mediated lesions of the oral cavity (AIML) can have an onset over several months, they often demonstrate rapid onset and can be self-limited. Despite the self-limiting nature of some disorders, patients with AIML can have significant pain and multisystem involvement. It is vital for the oral health care provider to arrive at the proper diagnosis with distinction from overlapping conditions, as the oral manifestations may be harbingers of more serious systemic complications.
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Affiliation(s)
- Molly Housley Smith
- Pathology and Cytology Laboratory, 290 Big Run Road, Lexington, KY 40503, USA.
| | - Mark Mintline
- WesternU Health Oral Pathology, 701 East 2nd Street, Room 3204, Pomona, CA 91766, USA
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33
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Singh H, Kumar U, Senapati S. Translational implications of humoral and cellular immune dysfunction in granulomatosis with polyangiitis. Cytokine 2023; 164:156154. [PMID: 36812668 DOI: 10.1016/j.cyto.2023.156154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/11/2023] [Indexed: 02/22/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is a rare systemic ANCA (Anti-neutrophil cytoplasmic antibodies) associated vasculitis (AAV). In the last couple of decades, GPA has emerged as a disease of concern due to rapid increase in the prevalence and incidence especially in developing countries. Unknown aetiology and rapid progression have made GPA a critical disease. Thus, establishing specific tools to facilitate early and faster disease diagnosis and efficient disease management has immense importance. GPA may develop in genetically predisposed individuals on receiving the external stimulus (i.e. microbial pathogen, pollutant etc.) that triggers the immune response. B-cell activating factor (BAFF) produced by the neutrophils, promotes the B-cell maturation and survival which leads to increased ANCA production. Abnormal B-cell and T-cell proliferation and their cytokine response plays a major role in disease pathogenesis and granuloma formation. ANCA interacts with neutrophils and induces the neutrophil extracellular traps (NETs) formation and reactive oxygen species (ROS) production which leads to the endothelial cell injury. This review article summarizes the critical pathological events and how cytokines and immune cells shape the GPA pathogenesis. Decoding this complex network would facilitate in developing tools for diagnosis, prognosis and disease management. Recently developed specific monoclonal antibodies (MAbs) targeting cytokines and immune cells are being used for safer treatment and achieving longer remission.
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Affiliation(s)
- Harinder Singh
- Immunogenomics Laboratory, Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda, India.
| | - Uma Kumar
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Sabyasachi Senapati
- Immunogenomics Laboratory, Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda, India.
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34
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Rai DK, Gupta VB, Bharti S, Sharma P, Ameet H. Granulomatosis with polyangiitis presenting as exudative pleural effusion: A rare case report. Lung India 2023; 40:177-179. [PMID: 37006106 PMCID: PMC10174663 DOI: 10.4103/lungindia.lungindia_263_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/26/2022] [Accepted: 11/13/2022] [Indexed: 03/05/2023] Open
Affiliation(s)
| | | | - Shreekant Bharti
- Department of Pathology/Laboratory Medicine, AIIMS Patna, Bihar, India
| | - Priya Sharma
- Department of Pulmonary Medicine, AIIMS Patna, Bihar, India E-mail:
| | - H Ameet
- Department of Pulmonary Medicine, AIIMS Patna, Bihar, India E-mail:
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Burns JT, Oberman JP. Limited Otologic Chronic Granulomatosis Polyangiitis: A Delayed Diagnosis. EAR, NOSE & THROAT JOURNAL 2023:1455613231157938. [PMID: 36789519 DOI: 10.1177/01455613231157938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
- Joseph T Burns
- Frederick Breathe Free Sinus & ENT Center, Affiliate of National Breathe Free Sinus & Allergy Centers, Frederick, MD, USA
| | - James P Oberman
- Frederick Breathe Free Sinus & ENT Center, Affiliate of National Breathe Free Sinus & Allergy Centers, Frederick, MD, USA
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Labrador AJP, Valdez LHM, Marin NRG, Ibazetta KAR, Chacón JAL, Fernandez AJV, Valencia MSV, Marchant SW, Sanchez KBT, Villacrez C. Oral granulomatosis with polyangiitis a systematic review. Clin Exp Dent Res 2023; 9:100-111. [PMID: 36600477 PMCID: PMC9932239 DOI: 10.1002/cre2.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Granulomatosis with polyangiitis is an unusual multisystemic inflammatory disease, with vasculitis of small- and medium-sized vessels, with a predilection for upper lower airways and kidneys. The etiology remains unknown although it may originate from different stimuli, in genetically susceptible patients. MATERIALS AND METHODS A detailed database search was performed. The variables were demographics, localization, histopathological findings, antineutrophil cytoplasmic autoantibody, cytoplasmic (c-ANCA) tests, treatment, and follow-up. RESULTS Fifty-two cases were identified; the mean age was 49.6 years, with a range from 6 to 87 years. It was most frequently seen in females (57.7%). The most common race was white (59.6%). The most frequent location was in the maxillary gingiva (28.8%), followed by both the upper and lower gingiva (19.2%). The most common clinical presentation was "strawberry gingivitis" (61.5%). The main symptom was pain, in 50%. Regarding the c-ANCA test, it was positive in 71.2% of cases. The most common therapy was prednisone and cyclophosphamide, utilized in 51.9%. The average follow-up was 23.6 months, and 88.5% of patients were still alive at follow-up. CONCLUSION The diagnosis initially was difficult to establish, an early diagnosis and treatment are mandatory. If untreated the disease can be associated with morbidity and mortality. For the oral clinician, this disease needs to be addressed in the differential diagnosis of oral lesions.
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Affiliation(s)
- Alberto J. Peraza Labrador
- Centro de Odontologia IntegralAcariguaVenezuela
- Department of Diagnostic SciencesTexas A&M University School of DentistryTexasEstados Unidos
| | | | | | | | | | | | | | | | | | - Cesar A. Villacrez
- Dental Implant DepartmentUniversidad Señor de SIPAN Dental SchoolLimaPeru
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Gastrointestinal Hemorrhage With Gastritis and Pancolitis as the Sole Presentation for Granulomatosis With Polyangiitis Flare. ACG Case Rep J 2022; 9:e00897. [PMID: 36561493 PMCID: PMC9762923 DOI: 10.14309/crj.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/01/2022] [Accepted: 09/16/2022] [Indexed: 12/23/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, is a rare small vessel vasculitis affecting mainly Whites. The prevalence of GPA in the United States is estimated to be 3 of 100,000 individuals. Classically, GPA affects upper airways, lungs, and kidneys, with the upper airways being the most common site. Occasionally, other organs affected by GPA include eyes, skin, joints, and the nervous system. The gastrointestinal system is rarely affected; however, some cases have been reported. In this case report, we present a patient with hemorrhagic gastritis and pancolitis consistent with GPA and discuss features from the literature of gastrointestinal manifestations in patients with GPA.
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Verstappen G, Michel O, Halewyck S, Topsakal V, Pössneck A. Infected nasal gout tophus: A case report. Clin Case Rep 2022; 10:e6695. [PMCID: PMC9743314 DOI: 10.1002/ccr3.6695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Gout is a common form of inflammatory arthritis, characterized by the deposition of monosodium urate crystals. If chronically present and not adequately treated by serum urate reducers, gout tophi can develop at various locations. Here, we report the first infected gout tophus at the septal cartilage and nasal tip.
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Affiliation(s)
- Gill Verstappen
- Department of Otorhinolaryngology ‐ Head and Neck SurgeryUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
| | - Olaf Michel
- Department of Otorhinolaryngology ‐ Head and Neck SurgeryUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
| | - Stijn Halewyck
- Department of Otorhinolaryngology ‐ Head and Neck SurgeryUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
| | - Vedat Topsakal
- Department of Otorhinolaryngology ‐ Head and Neck SurgeryUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
| | - Antje Pössneck
- Department of Otorhinolaryngology ‐ Head and Neck SurgeryUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
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39
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Muacevic A, Adler JR, Mendes M, Macedo E, Apolinário I. Granulomatosis With Polyangiitis: A Clinical Case. Cureus 2022; 14:e32410. [PMID: 36636531 PMCID: PMC9831614 DOI: 10.7759/cureus.32410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is characterized by inflammation and the destruction of small- and medium-caliber blood vessels in the presence of circulating ANCAs. Anti-neutrophil cytoplasmic antibody-associated vasculitis predominantly affects the lung and kidney with a multifactorial pathogenesis. This case refers to a 55-year-old woman with constitutional symptoms, hypoacusis, cough, and bloody sputum. Physical examination revealed polypnea and decreased lung auscultation at the bases; blood work showed elevated inflammatory parameters, acute kidney injury, and hematuria; pulmonary computed tomography revealed areas of peribronchial thickening in both lungs; immunological study resulted in positive ANCA-PR3. Corticotherapy and double immunosuppression with cyclophosphamide and rituximab were initiated, which resulted in clinical and analytical improvement. This case of granulomatosis with polyangiitis (GPA), with pulmonary, renal, cutaneous, and ear involvement, allows us to demonstrate the importance of timely clinical suspicion and initiation of immunosuppression for a favorable disease prognosis.
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40
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Nowak K, Kozłowski M, Piekara E, Gołembiewska E, Huzarski T, Cymbaluk-Płoska A. An Unusual Case of Vulvar Involvement in the Course of Granulomatosis with Polyangiitis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13862. [PMID: 36360741 PMCID: PMC9657397 DOI: 10.3390/ijerph192113862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 10/22/2022] [Indexed: 06/16/2023]
Abstract
Granulomatosis with polyangiitis is a rare autoimmune disease with the presence of c-ANCA in most cases. It involves necrotizing inflammation in small and medium-sized vessels with multiple granulomas. The disease can affect many systems, but the typical triad of attacked systems are the upper and lower respiratory tracts and kidneys, with varying degrees of severity. Involvement of the respiratory tract may manifest, among other symptoms, as nasal crusting, nosebleeds, and dyspnea. Among patients with granulomatosis with polyangiitis, only less than 1% develop genitourinary system involvement. We present a case study of a 36-year-old woman with an 8-year-long GPA history and a lesion, which, due to its appearance and accompanying symptoms, aroused the suspicion of a neoplasm but was proven to be a granuloma with a nontypical location. The systemic disease was treated with glucocorticosteroids and cyclophosphamide. The lesion on the labium minus was surgically removed. We concluded that the macroscopic picture of GPA of the vulva and vulvar cancer is similar. The patient's medical history may help differentiate GPA and vulvar cancer. Although vulvar GPA is extremely rare, it should be considered in the differential diagnosis of vulvar lesions, especially those suspected to be oncological.
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Affiliation(s)
- Katarzyna Nowak
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Mateusz Kozłowski
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Emilia Piekara
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Edyta Gołembiewska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Tomasz Huzarski
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Aneta Cymbaluk-Płoska
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
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A Case of Granulomatosis with Polyangiitis (GPA) Where a Multicystic Nasal Septal Abscess Aided in the Diagnosis. Case Rep Otolaryngol 2022; 2022:7415498. [PMID: 36275996 PMCID: PMC9581696 DOI: 10.1155/2022/7415498] [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: 06/27/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022] Open
Abstract
A 69-year-old male patient presented to the hospital with a chief complaint of nasal obstruction. Physical examination revealed swelling of the anterior nasal septum and nasal dorsum and tender indurated oedema of the dorsum of both hands. Blood tests showed an elevated inflammatory response, and contrast-enhanced computed tomography (CT) showed a polycystic abscess in the nasal septum. Emergency surgery and histopathology were performed on the day of the initial visit for incisional drainage. Intraoperative findings showed white necrosis between the nasal septal cartilage and nasal septal mucosa, as well as white necrosis and pus accumulation in the periosteum and soft tissue of the piriform aperture and the nasal bone. The patient underwent endoscopic dissection and drained as much as possible, and the abscess and surrounding normal nasal septal mucosa were sampled for diagnostic purposes. The patient was diagnosed with vasculitis based on the clinical findings, pathological examination results, and blood test results. After the diagnosis was confirmed, steroid and cyclophosphamide pulse administration was initiated, and the swelling of the anterior nasal septum and nasal dorsum and the bilateral dorsal indentation oedema improved markedly. The patient is now doing well and will continue to be carefully monitored in the outpatient clinic.
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42
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Pangastuti M, Rizqandaru T, Suwarsa O, Dharmadji HP, Sutedja E. Multiple Bullous and Ulcers as Cutaneous Manifestations of Wegener's Granulomatosis: A Rare Case Report. Clin Cosmet Investig Dermatol 2022; 15:2159-2164. [PMID: 36238442 PMCID: PMC9552674 DOI: 10.2147/ccid.s385464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
Bullous dermatoses is a heterogeneous group of blistering skin disorders that can either be inherited or acquired. Subepidermal blisters may result in ulceration and scarring following their rupture. Wegener’s granulomatosis (WG) is a granulomatous necrotizing vasculitis affecting small- to medium-sized blood vessels. It is associated with anti-neutrophil cytoplasmic antibodies (ANCA) and can be manifested cutaneously as multiple bullous and ulcers. A case of WG was reported in an 18-year-old man presented with multiple skin bullous and ulcers. The patient was diagnosed with WG based on the findings from nasopharyngoscopy examination that revealed crusts in his nasal cavity; necrotizing granulomatous appearance on chest radiograph; hematuria on urinalysis; and positive ANCA blood test. This patient received a combination of methylprednisolone and methotrexate, resulting in improvement within four weeks of therapy. His multiple skin ulcers were treated with a combination of dialkyl carbamoyl chloride, hydrocolloid, and hydrogel dressings. This patient was in complete remission state after six months of treatment, which later followed by a relapse episode that occurred within one year. WG with multiple skin bullous and ulcers can mimic other diseases. Various examinations such as histopathology, direct immunofluorescence, and ANCA blood test may aid in determining the etiology of skin bullous and ulcers.
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Affiliation(s)
- Miranti Pangastuti
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia,Correspondence: Miranti Pangastuti, Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, Indonesia, Tel +6281223114874, Email
| | - Trustia Rizqandaru
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Oki Suwarsa
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Hartati Purbo Dharmadji
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Endang Sutedja
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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43
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Muacevic A, Adler JR. Limited Granulomatosis With Polyangiitis Presenting as Recurrent Lung Abscess Without Pneumonia. Cureus 2022; 14:e29858. [PMCID: PMC9627860 DOI: 10.7759/cureus.29858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/07/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a systemic necrotizing vasculitis affecting small and medium-sized vessels and is associated with antineutrophil cytoplasmic antibodies (ANCA). GPA is a systemic disease but can present in a limited form, where the respiratory system is the most commonly involved. Here, we report a case of a 54-year-old African American female who presented with chronic cough and got diagnosed with recurrent right-sided empyema without pneumonia. She underwent a right thoracotomy, and the biopsy showed necrotizing granulomatous inflammation with vasculitis and rare non-necrotizing granuloma, suggesting GPA. Diagnosis of GPA was confirmed by strongly positive anti-proteinase 3 ANCA antibodies. Interestingly, her GPA is a limited form, and she had an excellent recovery after initiation of immunosuppression. Early diagnosis and treatment are critical for better outcomes and survival in GPA.
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44
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Manti F, Battaglia C, Pelaia C, Petullà M, Bertucci B, Laganà D. Migrant cavitation as primary involvement in a particular case of granulomatosis with polyangiitis. Radiol Case Rep 2022; 17:3535-3538. [PMID: 35923342 PMCID: PMC9340142 DOI: 10.1016/j.radcr.2022.06.074] [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: 04/16/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, is a necrotizing granulomatous vasculitis of the small and medium vessels involving the upper respiratory tract, lungs, and kidneys. In this case report, we will describe the case of a 60-year-old man who presented to our observation with recurrent episodes of hemoptoe, fever, and mucopurulent sputum. The diagnosis was made by radiological and laboratory tests.
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Affiliation(s)
- Francesco Manti
- Radiodiagnostic Institute, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
| | - Caterina Battaglia
- Radiodiagnostic Institute, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
- Corresponding author.
| | - Corrado Pelaia
- Respiratory Medicine Unite, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
| | - Maria Petullà
- Radiodiagnostic Institute, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
| | - Bernardo Bertucci
- Radiodiagnostic Institute, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
| | - Domenico Laganà
- Radiodiagnostic Institute, “Magna Græcia” University of Catanzaro, Catanzaro, Italy
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45
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Tee QX, Wong A, Nambiar M, Lau KK. Granulomatosis with polyangiitis: Common and uncommon presentations. J Med Imaging Radiat Oncol 2022; 66:1089-1096. [PMID: 36125112 PMCID: PMC10087946 DOI: 10.1111/1754-9485.13471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a multisystemic autoimmune small vessel vasculitis predominantly affecting the respiratory and renal systems. Other systems such as the central nervous system, orbital, cardiac and gastrointestinal systems may also be involved to a lesser degree. Although there are no imaging features that are pathognomonic for GPA, there are known radiological patterns suggestive of the disease and imaging plays an important role in diagnosis, assessment and monitoring of disease activity. This is more evident when combined with clinical features, biochemical values and histopathology results. This pictorial review aims to present both common and uncommon radiological features of GPA.
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Affiliation(s)
- Qiao Xin Tee
- Monash Imaging, Monash Health, Clayton, Victoria, Australia
| | - Aaron Wong
- Monash Imaging, Monash Health, Clayton, Victoria, Australia
| | - Mithun Nambiar
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kenneth K Lau
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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46
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Tokonami A, Ohta R, Katagiri N, Yoshioka N, Yamane F, Sano C. Autoimmune Vasculitis Causing Acute Bilateral Lower Limb Paralysis. Cureus 2022; 14:e27651. [PMID: 36072181 PMCID: PMC9437378 DOI: 10.7759/cureus.27651] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 01/07/2023] Open
Abstract
Autoimmune vasculitis is an autoimmune disease that causes various systemic symptoms, such as fever, fatigue, joint pain, and night sweats. Its clinical course depends on the severity of the inflammation, which can cause acute clinical progression of symptoms. Moreover, when the inflammation of the arteries occurs in the deeper parts of the body, a biopsy may be difficult to perform. Here, we report a case of autoimmune vasculitis in an elderly man who visited our hospital with a chief complaint of muscle pain and fever triggered by a rapid paralysis of both lower limbs. Autoimmune vasculitis can cause a variety of systemic symptoms depending on the size of involved arteries, and its clinical course depends on the severity of the inflammation. Prompt diagnosis and simultaneous treatment of symptoms, excluding other likely diseases, prevent the development of severe and long-term complications of autoimmune vasculitis.
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47
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Alawna R, Jalamneh T, Massad M, Alawna N, Rabaia A, Alrub FA. Granulomatosis with polyangiitis presenting with intestinal obstruction: A case report. Int J Surg Case Rep 2022; 97:107446. [PMID: 35914479 PMCID: PMC9403304 DOI: 10.1016/j.ijscr.2022.107446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Granulomatosis with polyangiitis is a rare vasculitis. The gastrointestinal symptoms and complications of the disease are rare in GPA patients. One the rarest is intestinal obstruction which when found was always caused by bowel perforation. CASE PRESENTATION Here we report the case of a 14 years-old female patient who is a known case of granulomatosis with polyangiitis presented with intestinal obstruction without perforation and treated conservatively. DISCUSSION Gastrointestinal involvement is seen in only 5-10 % of the cases and is a poor prognostic factor. This life-threatening complication could be caused by bowel perforation and as we describe here with bowel inflammation only without perforation. CONCLUSION Intestinal obstruction without perforations is a new complication of GPA. And conservative management should be considered in the plan of treatment.
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Affiliation(s)
- Reem Alawna
- Jenin Governmental Hospital, Jenin, West Bank, Palestine,Corresponding author at: main str. Jabaa, Jenin, West Bank, Palestine.
| | - Tala Jalamneh
- Jenin Governmental Hospital, Jenin, West Bank, Palestine
| | - Maram Massad
- Jenin Governmental Hospital, Jenin, West Bank, Palestine
| | | | | | - Fadi Abu Alrub
- Jenin Governmental Hospital, Jenin, West Bank, Palestine
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48
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Danieli MG, Antonelli E, Piga MA, Claudi I, Palmeri D, Tonacci A, Allegra A, Gangemi S. Alarmins in autoimmune diseases. Autoimmun Rev 2022; 21:103142. [PMID: 35853572 DOI: 10.1016/j.autrev.2022.103142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/10/2022] [Indexed: 12/18/2022]
Abstract
Alarmins are endogenous, constitutively expressed, chemotacting and immune activating proteins or peptides released because of non-programmed cell death (i.e. infections, trauma, etc). They are considered endogenous damage-associated molecular patterns (DAMPs), able to induce a sterile inflammation. In the last years, several studies highlighted a possible role of different alarmins in the pathogenesis of various autoimmune and immune-mediated diseases. We reviewed the relevant literature about this topic, for about 160 articles. Particularly, we focused on systemic autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, idiopathic inflammatory myopathies, ANCA-associated vasculitides, Behçet's disease) and cutaneous organ-specific autoimmune diseases (vitiligo, psoriasis, alopecia, pemphigo). Finally, we discussed about future perspectives and potential therapeutic implications of alarmins in autoimmune diseases. In fact, identification of receptors and downstream signal transducers of alarmins may lead to the identification of antagonistic inhibitors and agonists, with the capacity to modulate alarmins-related pathways and potential therapeutic applicability.
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Affiliation(s)
- Maria Giovanna Danieli
- Clinica Medica, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, via Tronto 10/A, 60126 Torrette di Ancona, Italy; Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Eleonora Antonelli
- PostGraduate School of Internal Medicine, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Mario Andrea Piga
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Ilaria Claudi
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Davide Palmeri
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Alessandro Tonacci
- Institute of Clinical Physiology, National Research Council of Italy (IFC-CNR), Via G. Moruzzi 1, 56124 Pisa, Italy.
| | - Alessandro Allegra
- Division of Haematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy.
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy.
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49
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Khatoon H, Sahana NS, Suresh T, Renuga S. Role of a dentist in early diagnosis of Granulomatosis with Polyangiitis: A rare case report. J Oral Maxillofac Pathol 2022; 26:425. [PMID: 36588840 PMCID: PMC9802520 DOI: 10.4103/jomfp.jomfp_92_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/28/2022] [Indexed: 01/03/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare multisystem disease characterized by a triad of necrotizing granulomas affecting the upper and lower respiratory tract, vasculitis and glomerulonephritis. Oral lesions are seen in 6-13% of cases, although not life threatening but might be the first symptoms reported by the patient. Here we present a case of gingival growth, later diagnosed as GPA owing to the timely recognition by the dentist. A 33-year-old female reported for evaluation of soft tissue growth in her lower left back tooth region present for past 3 months. She had no relevant medical or family history. Clinically it looked like a benign hypertrophic gingival enlargement. The histopathological picture was suggestive of vasculitis and nonspecific granuloma formation. On further examination altered Renal Function Test and cavitating granulomas were noted in her lungs along with a positive cytoplasmic ANCA (c-ANCA) test which led to the diagnosis of GPA.
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Affiliation(s)
- Hajira Khatoon
- Department of Oral Pathology and Microbiology, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
| | - N S Sahana
- Department of Oral Pathology and Microbiology, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
| | - T Suresh
- Department of Oral Pathology and Microbiology, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
| | - S Renuga
- Department of Oral Pathology and Microbiology, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
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Tzanninis I, Elserwey A, Mason A, Rawlins J. A rare case report of granulomatosis with polyangiitis presenting with thrombus of the ascending aorta. Clin Med (Lond) 2022; 22 Suppl 4:42-43. [PMID: 38614581 PMCID: PMC9600816 DOI: 10.7861/clinmed.22-4-s42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Alice Mason
- Southampton General Hospital, Southampton, UK
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