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Shen HC, Bui KTA, Richard R, Toban N, Lévesque M, Meunier RS, Ross C, Makhzoum JP. Comparison of Interstitial Lung Disease Between Antineutrophil Cytoplasmic Antibodies Positive and Negative Patients: A Retrospective Cohort Study. ACR Open Rheumatol 2024. [PMID: 38733262 DOI: 10.1002/acr2.11679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/11/2024] [Accepted: 04/09/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVE Positive antineutrophil cytoplasmic antibodies (ANCAs) may occur in the setting of interstitial lung disease (ILD), with or without ANCA-associated vasculitis (AAV). We aim to compare the characteristics and clinical course of patients with ILD and positive ANCA (ANCA-ILD) to those with negative ANCA. METHODS We performed a single-center retrospective cohort study from 2018 to 2021. All patients with ILD and ANCA testing were included. Patient characteristics (symptoms, dyspnea scale, and systemic AAV), test results (pulmonary high-resolution computed tomography and pulmonary function tests), and adverse events were collected from electronic medical records. Descriptive statistics and the Fisher exact test were used to compare the outcomes of patients with ANCA-ILD to those with ILD and negative ANCA. RESULTS A total of 265 patients with ILD were included. The mean follow-up duration was 69.3 months, 26 patients (9.8%) were ANCA positive, and 69.2% of those with ANCA-ILD had another autoantibody. AAV occurred in 17 patients (65.4%) with ANCA-ILD. In 29.4% of patients, AAV developed following ILD diagnosis. Usual interstitial pneumonia was the most common radiologic pattern in patients with ANCA-ILD. There was no association between ANCA status and the evolution of dyspnea, diffusing capacity of the lungs for carbon monoxide, and lung imaging. Forced vital capacity improved over time in 42% of patients with ANCA-ILD and in 17% of patients with negative ANCA (P = 0.006). Hospitalization occurred in 46.2% of patients with ANCA-ILD and in 21.8% of patients with negative ANCA (P = 0.006). Both groups had similar mortality rates. CONCLUSION Routine ANCA testing should be considered in patients with ILD. Patients with ANCA-ILD are at risk for AAV. More research is required to better understand and manage patients with ANCA-ILD.
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Affiliation(s)
- Hao Cheng Shen
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
| | | | - Rachel Richard
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
| | - Nader Toban
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
| | - Marianne Lévesque
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
| | | | - Carolyn Ross
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
| | - Jean-Paul Makhzoum
- Hôpital du Sacré-Cœur de Montréal and Université de Montréal, Montreal, Canada
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Zhu W, Zhou C, Sun X, Xue P, Li Z, Zhang W, Zhao J, Zhang T, Peng M, Shi J, Wang C. Interstitial lung diseases associated with ANCA positivity: A different disease spectrum from interstitial pneumonia with autoimmune features. Respir Med Res 2024; 86:101111. [PMID: 38851036 DOI: 10.1016/j.resmer.2024.101111] [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: 01/16/2024] [Revised: 04/07/2024] [Accepted: 04/21/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Anti-neutrophil cytoplasmic antibody (ANCA) is a type of autoantibodies associated with vasculitis. ANCA positivity is commonly observed in interstitial lung disease (ILD) patients. 7%-10% of ANCA-positive ILD patients don't present any symptoms of systemic vasculitis and are termed ANCA-positive idiopathic interstitial pneumonia (ANCA-IIP). Some researchers propose that ANCA-IIP should be categorized as interstitial pneumonia with autoimmune features (IPAF), although the official ATS/ERS statements exclude ANCA-IIP from this classification. Whether ANCA-IIP should be categorized into the entity of IPAF is still debatable. METHODS Patients diagnosed with ANCA-IIP and those with IPAF were analyzed in a retrospective study of ILD. The clinical outcomes were determined through pulmonary function tests (PFTs) after a one-year follow-up, as well as assessing all-cause mortality. RESULTS 27 patients with ANCA-IIP and 143 patients with IPAF were analyzed from a cohort of 995 patients with ILD. Patients in the ANCA-IIP group had an older age and a high proportion of males compared to those in the IPAF group. PFT results at baseline were similar between the two groups, except for a better FEV1% in the ANCA-IIP group. Glucocorticoid and immunosuppressive therapy improved pulmonary function in patients with IPAF, but it continued to deteriorate after one year of treatment in the ANCA-IIP group. Furthermore, the all-cause mortality rate was significantly higher in the ANCA-IIP group than in the IPAF group (22.2% vs. 6.3%, P = 0.017). CONCLUSION The responses to glucocorticoid and immunosuppressive therapy differ between the ANCA-IIP and IPAF groups, leading to divergent prognoses. Therefore, it is inappropriate to classify ANCA-IIP as part of IPAF.
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Affiliation(s)
- Wenyan Zhu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Chunsheng Zhou
- 4+4 Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Sun
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Peijun Xue
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Zongru Li
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Weihong Zhang
- Department of Imaging, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ting Zhang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Min Peng
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China
| | - Juhong Shi
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing China.
| | - Chen Wang
- National Clinical Research Center for Respiratory Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing China
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Weidler S, Koss S, Wolf C, Lucas N, Brunner J, Lee-Kirsch MA. A rare manifestation of STING-associated vasculopathy with onset in infancy: a case report. Pediatr Rheumatol Online J 2024; 22:9. [PMID: 38178067 PMCID: PMC10768237 DOI: 10.1186/s12969-023-00934-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND STING-associated vasculopathy with onset in infancy (SAVI) is a rare type I interferonopathy caused by heterozygous variants in the STING gene. In SAVI, STING variants confer a gain-of-function which causes overactivation of type I interferon (IFN) signaling leading to autoinflammation and various degrees of immunodeficiency and autoimmunity. CASE PRESENTATION We report the case of a 5 year old child and his mother, both of whom presented with systemic inflammatory symptoms yet widely varying organ involvement, disease course and therapeutic response. Genetic testing revealed a heterozygous STING variant, R281Q, in the child and his mother that had previously been associated with SAVI. However, in contrast to previously reported SAVI cases due to the R281Q variant, our patients showed an atypical course of disease with alopecia totalis in the child and a complete lack of lung involvement in the mother. CONCLUSIONS Our findings demonstrate the phenotypic breadth of clinical SAVI manifestations. Given the therapeutic benefit of treatment with JAK inhibitors, early genetic testing for SAVI should be considered in patients with unclear systemic inflammation involving cutaneous, pulmonary, or musculoskeletal symptoms, and signs of immunodeficiency and autoimmunity.
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Affiliation(s)
- Sophia Weidler
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Sarah Koss
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christine Wolf
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Nadja Lucas
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Brunner
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
- Faculty of Medicine and Dentistry, Danube Private University, 3500, Krems, Austria
| | - Min Ae Lee-Kirsch
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Sweis JJG, Sweis NWG, Alnaimat F, Jansz J, Liao TWE, Alsakaty A, Azam A, Elmergawy H, Hanson HA, Ascoli C, Rubinstein I, Sweiss N. Immune-mediated lung diseases: A narrative review. Front Med (Lausanne) 2023; 10:1160755. [PMID: 37089604 PMCID: PMC10117988 DOI: 10.3389/fmed.2023.1160755] [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: 02/07/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
The role of immunity in the pathogenesis of various pulmonary diseases, particularly interstitial lung diseases (ILDs), is being increasingly appreciated as mechanistic discoveries advance our knowledge in the field. Immune-mediated lung diseases demonstrate clinical and immunological heterogeneity and can be etiologically categorized into connective tissue disease (CTD)-associated, exposure-related, idiopathic, and other miscellaneous lung diseases including sarcoidosis, and post-lung transplant ILD. The immunopathogenesis of many of these diseases remains poorly defined and possibly involves either immune dysregulation, abnormal healing, chronic inflammation, or a combination of these, often in a background of genetic susceptibility. The heterogeneity and complex immunopathogenesis of ILDs complicate management, and thus a collaborative treatment team should work toward an individualized approach to address the unique needs of each patient. Current management of immune-mediated lung diseases is challenging; the choice of therapy is etiology-driven and includes corticosteroids, immunomodulatory drugs such as methotrexate, cyclophosphamide and mycophenolate mofetil, rituximab, or other measures such as discontinuation or avoidance of the inciting agent in exposure-related ILDs. Antifibrotic therapy is approved for some of the ILDs (e.g., idiopathic pulmonary fibrosis) and is being investigated for many others and has shown promising preliminary results. A dire need for advances in the management of immune-mediated lung disease persists in the absence of standardized management guidelines.
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Affiliation(s)
| | | | - Fatima Alnaimat
- Division of Rheumatology, Department of Internal Medicine, The University of Jordan, Amman, Jordan
| | - Jacqueline Jansz
- Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Ting-Wei Ernie Liao
- School of Medicine, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Alaa Alsakaty
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Abeera Azam
- Department of Internal Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Hesham Elmergawy
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Hali A. Hanson
- UIC College of Pharmacy, University of Illinois Chicago, Chicago, IL, United States
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Israel Rubinstein
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
- Research Service, Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Nadera Sweiss
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL, United States
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Interstitial Lung Disease and Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis. Immunol Allergy Clin North Am 2023; 43:379-388. [PMID: 37055094 DOI: 10.1016/j.iac.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Interstitial lung disease is a common complication of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). It is seen most commonly in microscopic polyangiitis owing to the pathogenic effect of myeloperoxidase in the lung. Oxidative stress, neutrophil elastase release, and expression of inflammatory proteins by neutrophil extracellular traps result in fibroblast proliferation and differentiation and therefore fibrosis. Usually, interstitial pneumonia pattern fibrosis is common and associated with poor survival. Treatment for patients with AAV and interstitial lung disease lacks evidence, and those with vasculitis are treated with immunosuppression, whereas those with progressive fibrosis may well benefit from antifibrotic therapy.
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Doliner B, Rodriguez K, Montesi SB, Fu X, Sharma A, Wallace ZS. Interstitial lung disease in ANCA-associated vasculitis: associated factors, radiographic features and mortality. Rheumatology (Oxford) 2023; 62:716-725. [PMID: 35699465 PMCID: PMC9891428 DOI: 10.1093/rheumatology/keac339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence, clinical and radiographic features, and long-term outcomes of interstitial lung disease (ILD) in a United States-based ANCA-associated vasculitis (AAV) cohort. METHODS In this retrospective cohort study, we identified cases of ILD within the 2002-2019 Mass General Brigham AAV Cohort, a consecutive inception cohort of PR3- or MPO-ANCA+ AAV patients. ILD diagnosis and classification as fibrotic or non-fibrotic were confirmed by review of available chest imaging by two board-certified radiologists. Cox proportional hazard models, with age as the time scale, were used to estimate the association of AAV-ILD with all-cause mortality. RESULTS Of 684 patients in the MGB AAV Cohort, 91 (13%) had ILD which preceded the diagnosis of AAV by a mean of 2.2 years. AAV-ILD patients were older (67 vs 60 years, P < 0.001) than patients without ILD but the distribution of sex and race was similar. AAV-ILD patients were more often MPO-ANCA+ (93% vs 65%, P < 0.001); among MPO-ANCA+ patients (n = 470), 85 (18%) had ILD. The majority of ILD was fibrotic (76%) and UIP was the most common ILD pattern (42%). The baseline forced vital capacity (FVC) % predicted among ILD patients was 81 ± 20%. Fibrotic AAV-ILD was associated with a 58% higher risk of death (aHR 1.58, 95% CI 1.06, 2.37) compared with AAV patients without ILD. CONCLUSION ILD is a frequent complication of AAV, especially MPO-ANCA+ AAV, often preceding recognition of AAV. Fibrotic AAV-ILD is associated with a higher risk of death than AAV without ILD.
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Affiliation(s)
- Brett Doliner
- Department of Medicine, Massachusetts General Hospital.,Harvard Medical School
| | | | - Sydney B Montesi
- Harvard Medical School.,Division of Pulmonary and Critical Care Medicine
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Zachary S Wallace
- Harvard Medical School.,Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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7
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Sun K, Fisher JH, Pagnoux C. Interstitial Lung Disease in ANCA-Associated Vasculitis: Pathogenic Considerations and Impact for Patients' Outcomes. Curr Rheumatol Rep 2022; 24:259-267. [PMID: 35794350 DOI: 10.1007/s11926-022-01078-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on recent advances in the diagnosis, pathogenesis, clinical presentation, histopathological findings, and treatment approaches for antineutrophil cytoplasmic antibody (ANCA) vasculitis-associated interstitial lung disease (AAV-ILD) with a focus on literature published in the last 3 years. RECENT FINDINGS Although there is no validated definition of AAV-ILD, which contributes to some of the heterogeneity seen in study results, there has been an increasing number of publications in recent years on this topic. Most patients with AAV-ILD have MPO-ANCA vasculitis, and this association appears to reduce their 5-year-survival to 60-66% (Sun et al. BMC Pulm Med 21(1), 2021, Maillet et al. J Autoimmun 106, 2020). Median age of diagnosis ranges from mid-60 s to mid-70 s (Ando et al. Respir Med 107(4), 2013), Kagiyama et al. BMJ Open Respir Res 2(1):1-9, 2015, Hozumi et al. Lung 194(2):235-42, 2016, Liu et al. Chest 156(4):715-23, 2019, Maillet et al. J Autoimmun 106, 2020, Wurmann et al. Sarcoidosis Vasc Diffuse Lung Dis 37(1):37-42, 2020, Watanabe et al. BMC Pulm Med 19(1), 2019). Computed tomography (CT) chest imaging for patients with AAV-ILD often shows a usual interstitial pneumonia (UIP) or nonspecific interstitial pneumonia (NSIP) pattern (12-58% and 13-61%, respectively) (Sun et al. BMC Pulm Med 21(1), 2021, Maillet et al. J Autoimmun 106, 2020, Wurmann et al. Sarcoidosis Vasc Diffuse Lung Dis 37(1):37-42, 2020, Watanabe et al. BMC Pulm Med 19(1), 2019, Baqir at al. Sarcoidosis Vasc Diffuse Lung Dis Off J WASOG 36(3):195-201, 2019). Additionally, lung biopsies typically do not demonstrate active inflammation, or capillaritis, questioning whether these patients should be treated with either immunotherapy or anti-fibrotic therapy, or both (Hozumi et al. Lung 194(2):235-42, 2016, Liu et al. Chest 156(4):715-23, 2019, Kitching at al. Nat Rev Dis Prim 6(1):71, 2020, Tanaka et al. Respir Med 106(12):1765-70, 2012). Besides immunosuppressive treatments, recent advances in anti-fibrotic therapy may offer patients with progressive AAV-ILD an alternative and/or more effective and individualized treatment option.
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Affiliation(s)
- Kelly Sun
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Jolene H Fisher
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Ste 2-220, Box 8, Toronto, ON, M5T 3L9, Canada.
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8
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Kadura S, Raghu G. Antineutrophil cytoplasmic antibody-associated interstitial lung disease: a review. Eur Respir Rev 2021; 30:30/162/210123. [PMID: 34750115 DOI: 10.1183/16000617.0123-2021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/24/2021] [Indexed: 12/26/2022] Open
Abstract
Over the past three decades, an increasing number of publications have reported the association between interstitial lung disease (ILD) and anti-neutrophil cytoplasmic antibody (ANCA) or ANCA-associated vasculitis (AAV). With this increased awareness, we have reviewed the literature to date and provide an update in this narrative review. The vast majority of cases of ILD have been shown to be in the setting of positive anti-myeloperoxidase antibody and can be present in up to 45% of patients of microscopic polyangiitis, though cases of ILD associated with proteinase 3 ANCA have rarely been reported. Pulmonary fibrosis and ANCA positivity can occur with or without systemic involvement. The pathogenetic mechanisms establishing the relationship between ANCA and the development of pulmonary fibrosis remain unclear. Histologic and radiographic features of ANCA-ILD most commonly reveal usual interstitial pneumonia or non-specific interstitial pneumonia patterns, though other atypical features such as bronchiolitis have been described. ILD in the setting of AAV has been associated with worse outcomes, and thus early identification and treatment in these patients is appropriate. We advocate that ANCA antibody testing be performed as a baseline evaluation in patients presenting with idiopathic interstitial pneumonia. Suggested treatment of ANCA-ILD includes immunosuppression and/or antifibrotic agents, though supporting data and clinical trials to substantiate use of these therapies are needed.
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Affiliation(s)
- Suha Kadura
- Dept of Medicine, Center for Interstitial Lung Diseases, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Dept of Medicine, Center for Interstitial Lung Diseases, University of Washington, Seattle, WA, USA
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Kwon M, Lee AS, Mira-Avendano I, Rojas CA, Grage R, Abril A. Interstitial Lung Disease in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Patients: Comparison With Idiopathic Pulmonary Fibrosis. J Clin Rheumatol 2021; 27:324-330. [PMID: 32251058 DOI: 10.1097/rhu.0000000000001357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) may involve the kidney, respiratory tract, skin, or central and peripheral nervous system. Reports of interstitial lung disease (ILD) in AAV (AAV-ILD) have been increasing. METHODS We reviewed the medical records of all patients with AAV-ILD between January 1, 2007, and December 31, 2017, and compared their pulmonary involvement to patients with idiopathic pulmonary fibrosis (IPF). RESULTS We identified 24 patients with AAV-ILD: 14 with microscopic polyangiitis, 8 with granulomatosis with polyangiitis, and 2 with eosinophilic granulomatosis with polyangiitis. Perinuclear or myeloperoxidase ANCA was present in 16 cases (66.7%), whereas cytoplasmic or proteinase 3 ANCA was positive in 8 (33.3%). Usual interstitial pneumonia (UIP) was seen in 11 (45.8%), probable UIP in 1 (4.2%), indeterminate UIP in 2 (8.3%), and an alternate diagnosis in 10 (41.7%), and was further characterized as chronic hypersensitivity pneumonitis-like pattern seen in 6 (25%), nonspecific interstitial pneumonia-like pattern in 3 (12.5%), and cryptogenic organizing pneumonia-like pattern in 1 (4.2%). Forced vital capacity and diffusing capacity declined over time in patients with AAV-ILD. When compared with the IPF cohort, patients with AAV-ILD had intermediate survival and speed of lung function decline (3-year survival in AAV-ILD group was 94% vs 69% in IPF). CONCLUSIONS Antineutrophil cytoplasmic antibody-associated vasculitis ILD is a progressive and potentially fatal condition. Although most cases in the literature are associated with p-ANCA and positive myeloperoxidase, we found that a third of patients had c-ANCA or granulomatosis with polyangiitis. Our cohort adds experience in this rare manifestation of AAV.
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Affiliation(s)
- Minkyung Kwon
- From the Division of Pulmonary, Allergy, and Sleep Medicine
| | | | | | | | | | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
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Yamakawa H, Sato S, Nakamura T, Nishizawa T, Kawabe R, Oba T, Horikoshi M, Akasaka K, Amano M, Kuwano K, Sasaki H, Matsushima H. Prognostic value of radiological findings indeterminate for UIP pattern and anterior upper lobe honeycomb-like lesion in chronic fibrosing interstitial lung disease associated with MPO-ANCA. BMC Pulm Med 2021; 21:346. [PMID: 34732182 PMCID: PMC8565010 DOI: 10.1186/s12890-021-01718-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) is often positive in patients with interstitial lung disease (ILD), which is also often present in patients with microscopic polyangiitis (MPA). A possible association between MPO-ANCA, MPA, and idiopathic ILD remains unclear. The objective of this study was to determine whether high-resolution computed tomography (HRCT) classification based on recent idiopathic pulmonary fibrosis guideline and specific CT findings can obtain new knowledge of prognostic factors in all MPO-ANCA-positive patients with ILD including both idiopathic ILD and MPA-ILD. Methods We analyzed 101 consecutive MPO-ANCA-positive patients with respiratory disease. We assessed the diagnostic accuracy of CT findings, HRCT pattern, and specific radiological signs. Prognostic predictors were determined using Cox regression models. Results Subjects with chronic ILD included 22 patients with MPA-ILD and 39 patients with ILD but without MPA. A quarter of the patients were radiological indeterminate for usual interstitial pneumonia (UIP) pattern, which resulted in a better prognosis than that for UIP pattern. “Increased attenuation around honeycomb and traction bronchiectasis” and “anterior upper lobe honeycomb-like lesion” were found to be highly frequent radiological findings (39% and 30%, respectively). In addition, the latter finding was a significant negative prognostic factor. Conclusions Radiological indeterminate for UIP was a useful HRCT classification in MPO-ANCA-positive patients with ILD. In addition, anterior upper lobe honeycomb-like lesion was found to be specific radiological finding that was a significant prognostic factor. The present results might aid in the assessment of appropriate strategies of diagnosis in these patients.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan. .,Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiko Nakamura
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masanobu Horikoshi
- Department of Rheumatology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroki Sasaki
- Department of Radiology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
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Hu H, Keat K. Myeloperoxidase and associated lung disease: Review of the latest developments. Int J Rheum Dis 2021; 24:1460-1466. [PMID: 34498802 DOI: 10.1111/1756-185x.14213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/25/2021] [Indexed: 12/21/2022]
Abstract
Myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibodies (ANCA) are often detected in association with a variety of lung pathologies, the most common being interstitial lung disease (ILD). A growing cohort of patients are being diagnosed with MPO-ANCA in the context of ILD without ANCA-associated vasculitis. Clinically and radiologically, there is little to differentiate this cohort from MPO-ANCA-negative ILD patients; however, the pathophysiology is likely different and different treatments are likely required. We present here a brief summary of the proposed pathophysiology of MPO-ANCA-positive ILD, and a more detailed review of the latest evidence on management, including monitoring for development of ANCA-associated vasculitis, immunosuppression, anti-fibrotics, and novel agents that have yet to be trialled in human experiments.
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Affiliation(s)
- Hannah Hu
- Department of Immunology, Campbelltown Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Karuna Keat
- Department of Immunology, Campbelltown Hospital, Sydney, New South Wales, Australia.,Western Sydney University, Sydney, New South Wales, Australia
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12
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Kim MJ, Shin K. Interstitial Lung Disease and Diffuse Alveolar Hemorrhage, the Two Key Pulmonary Manifestations in Microscopic Polyangiitis. Tuberc Respir Dis (Seoul) 2021; 84:255-262. [PMID: 34418915 PMCID: PMC8497773 DOI: 10.4046/trd.2021.0065] [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: 04/16/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022] Open
Abstract
Microscopic polyangiitis (MPA) is an antineutrophil cytoplasmic antibody (ANCA)‒associated necrotizing vasculitis, which mainly affects small vessels in various organs, especially the lungs. The two key pulmonary manifestations, interstitial lung disease (ILD) and diffuse alveolar hemorrhage (DAH), increase the morbidity and death rate of patients with MPA. ILD is more common in MPA than in other ANCA-associated vasculitis subsets and is primarily associated with myeloperoxidase-ANCA. Unlike alveolar hemorrhage due to pulmonary capillaritis, ILD can initially manifest as isolated pulmonary fibrosis. Of note, its most frequent radiographic pattern is the usual interstitial pneumonia pattern, similar to the characteristic pattern seen in idiopathic pulmonary fibrosis. In this review we present the pathogenesis, clinical manifestations, and radiographic and histopathologic features of ILD and DAH in MPA. We also briefly summarize the outcome and therapeutic options for the two conditions.
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Affiliation(s)
- Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National Boramae Medical Center, Seoul, Republic of Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National Boramae Medical Center, Seoul, Republic of Korea
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13
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Trivioli G, Gopaluni S, Urban ML, Gianfreda D, Cassia MA, Vercelloni PG, Calatroni M, Bettiol A, Esposito P, Murtas C, Alberici F, Maritati F, Manenti L, Palmisano A, Emmi G, Romagnani P, Moroni G, Gregorini G, Sinico RA, Jayne DR, Vaglio A. Slowly progressive anti-neutrophil cytoplasmic antibody-associated renal vasculitis: clinico-pathological characterization and outcome. Clin Kidney J 2021; 14:332-340. [PMID: 33564436 PMCID: PMC7857823 DOI: 10.1093/ckj/sfaa139] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although rapidly progressive glomerulonephritis is the main renal phenotype of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), slow renal disease progression is sometimes observed. These forms have been rarely discussed; we analysed their prevalence, clinico-pathological characteristics and outcome. METHODS We screened patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis followed at seven referral centres and selected those with estimated glomerular filtration rate (eGFR) reduction <50% over a 6-month period preceding diagnosis. Data regarding patient features and response to treatment were retrieved. RESULTS Of 856 patients, 41 (5%) had slowly progressive renal AAV. All had MPA and all but one was P-ANCA/myeloperoxidase (MPO) ANCA-positive. At diagnosis, the median age was 70 years [interquartile range (IQR) 64-78] and extra-renal manifestations were absent or subclinical (interstitial lung lesions in 10, 24%). The median (IQR) eGFR was 23 mL/min/1.73 m2 (15-35); six patients (15%) had started renal replacement therapy (RRT). All had proteinuria (median 1180 mg/24 h, IQR 670-2600) and micro-haematuria. Main histologic findings were extracapillary proliferation at chronic stages and glomerulosclerosis; following Berden's classification, 6/28 biopsies (21%) were 'focal', 1/28 (4%) 'crescentic', 9/28 (32%) 'mixed' and 12/28 (43%) 'sclerotic'. At last follow-up (median 32 months, IQR 12-52), 20/34 patients (59%) treated with immunosuppression had eGFR improvement >25% as compared with diagnosis, while 4/34 (12%) had started RRT. CONCLUSIONS AAV may present with slow renal disease progression; this subset is hallmarked by advanced age at diagnosis, positive MPO-ANCA, subclinical interstitial lung lesions and chronic damage at kidney biopsy. Partial renal recovery may occur following immunosuppression.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Firenze, and Nephrology Unit, Meyer Children’s Hospital, Firenze, Italy
| | | | - Maria L. Urban
- Department of Experimental and Clinical Sciences, University of Firenze, Firenze, Italy
| | | | | | | | | | - Alessandra Bettiol
- Department of Neurosciences, Psychology, Pharmacology and Child Health, University of Firenze, Firenze, Italy
| | - Pasquale Esposito
- Department of Internal Medicine and Medical Specialties, University of Genova, Genova, Italy
| | - Corrado Murtas
- Nephrology Unit, Nephrology Unit, ASSL Oristano, ATS Sardegna, Oristano, Italy
| | - Federico Alberici
- Nephrology Unit, ASST Spedali Civili, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Federica Maritati
- Nephrology, Dialysis and Transplant Unit, Ospedali Riuniti, Ancona, Italy
| | - Lucio Manenti
- Nephrology Unit, Parma University Hospital, Parma, Italy
| | | | - Giacomo Emmi
- Department of Experimental and Clinical Sciences, University of Firenze, Firenze, Italy
| | - Paola Romagnani
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Firenze, and Nephrology Unit, Meyer Children’s Hospital, Firenze, Italy
| | | | | | | | | | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Firenze, and Nephrology Unit, Meyer Children’s Hospital, Firenze, Italy
- Correspondence to: Augusto Vaglio; E-mail:
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14
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Oristrell J, Loureiro-Amigo J, Solans R, Valenzuela MP, Monsálvez V, Segarra A, Amengual MJ, Marín A, Feijoo C, Tolosa C. Relapse rate and renal prognosis in ANCA-associated vasculitis according to long-term ANCA patterns. Clin Exp Immunol 2020; 203:209-218. [PMID: 33020895 DOI: 10.1111/cei.13530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/15/2020] [Accepted: 09/28/2020] [Indexed: 01/30/2023] Open
Abstract
Long-term observation of patients with ANCA-associated vasculitis (AAV) allows the identification of different longitudinal patterns of ANCA levels during follow-up. This study aimed to characterize these patterns and to determine their prognostic significance. All ANCA determinations performed in two university hospitals during a 2-year period were retrospectively reviewed. Patients were included in the analysis if they had high titers of anti-myeloperoxidase (anti-MPO) or anti-proteinase 3 (anti-PR3) antibodies at least once, ≥ 5 serial ANCA determinations and AAV diagnosed by biopsy or American College of Rheumatology (ACR) classification criteria. Patients' time-course ANCA patterns were classified as monophasic, remitting, recurrent or persistent. Associations between ANCA patterns and prognostic variables (relapse rate and renal outcome) were analysed by univariate and multivariate statistics. A total of 99 patients [55 with microscopic polyangiitis (MPA), 36 with granulomatosis with polyangiitis (GPA) and eight with eosinophilic granulomatosis with polyangiitis (EGPA)] were included. Median follow-up was 9 years. Among patients diagnosed with MPA or GPA, recurrent or persistent ANCA patterns were associated with a higher risk of clinical relapse [hazard ratio (HR) = 3·7, 95% confidence interval (CI) = 1·5-9·1 and HR = 2·9, 95% CI = 1·1-8·0, respectively], independently of clinical diagnosis or ANCA specificity. In patients with anti-MPO antibodies, the recurrent ANCA pattern was associated with worsening renal function [odds ratio (OR) = 5·7, 95% CI = 1·2-26·0]. Recurrent or persistent ANCA patterns are associated with a higher risk of clinical relapse. A recurrent ANCA pattern was associated with worsening renal function in anti-MPO-associated vasculitis.
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Affiliation(s)
- J Oristrell
- Internal Medicine Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
| | - J Loureiro-Amigo
- Internal Medicine Service, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - R Solans
- Internal Medicine Service, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - M P Valenzuela
- Nephrology Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
| | - V Monsálvez
- Internal Medicine Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
| | - A Segarra
- Nephrology Service, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - M J Amengual
- Immunology Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
| | - A Marín
- Immunology Service, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - C Feijoo
- Internal Medicine Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
| | - C Tolosa
- Internal Medicine Service, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Catalonia, Spain
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15
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Maria ATJ, Bourgier C, Martinaud C, Borie R, Rozier P, Rivière S, Crestani B, Guilpain P. [From fibrogenesis towards fibrosis: Pathophysiological mechanisms and clinical presentations]. Rev Med Interne 2020; 41:325-329. [PMID: 32046868 DOI: 10.1016/j.revmed.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/19/2020] [Indexed: 12/24/2022]
Abstract
Fibrogenesis is a universal and ubiquitous process associated with tissue healing. The impairment of tissue homeostasis resulting from the deregulation of numerous cellular actors, under the effect of specific cytokine and pro-oxidative environments can lead to extensive tissue fibrosis, organ dysfunction and significant morbidity and mortality. This situation is frequent in internal medicine, since fibrosis is associated with most organ insufficiencies (i.e. cardiac, renal, or hepatic chronic failures), but also with cancer, a condition with common pathophysiological mechanisms. Finally, fibrosis is a hallmark of numerous systemic autoimmune diseases such as connective tissue disorders (in particular systemic sclerosis), vasculitides, granulomatoses, histiocytoses, and IgG4-associated disease. Although the process leading to tissue fibrosis may be in part irreversible, new pharmacological approaches or cell therapies bring hope in the field of fibrotic conditions.
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Affiliation(s)
- A T J Maria
- Service de médecine interne, maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Faculté de médecine, Université de Montpellier, 2, rue de l'École-de-Médecine, 34060 Montpellier cedex 2, France; Inserm U1183, IRMB, Inserm, université Montpellier, CHU de Montpellier, Montpellier, France
| | - C Bourgier
- Département de radiothérapie, ICM-Val d'Aurelle, Montpellier, France; Inserm U1194, IRCM, Montpellier, France
| | - C Martinaud
- Unité de médicaments de thérapie innovante, centre de transfusion sanguine des armées, 1, rue du lieutenant-Batany, 92140 Clamart, France
| | - R Borie
- Service de pneumologie A, centre de référence des maladies pulmonaires rares, hôpital Bichat, DHU Fire, AP-HP, Paris, France; Inserm U1152, Paris, France; Université Paris Diderot, Paris, France
| | - P Rozier
- Service de médecine interne, maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Faculté de médecine, Université de Montpellier, 2, rue de l'École-de-Médecine, 34060 Montpellier cedex 2, France; Inserm U1183, IRMB, Inserm, université Montpellier, CHU de Montpellier, Montpellier, France
| | - S Rivière
- Service de médecine interne, maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier, France
| | - B Crestani
- Service de pneumologie A, centre de référence des maladies pulmonaires rares, hôpital Bichat, DHU Fire, AP-HP, Paris, France; Inserm U1152, Paris, France; Université Paris Diderot, Paris, France
| | - P Guilpain
- Service de médecine interne, maladies multi-organiques de l'adulte, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Faculté de médecine, Université de Montpellier, 2, rue de l'École-de-Médecine, 34060 Montpellier cedex 2, France; Inserm U1183, IRMB, Inserm, université Montpellier, CHU de Montpellier, Montpellier, France.
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16
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Maillet T, Goletto T, Beltramo G, Dupuy H, Jouneau S, Borie R, Crestani B, Cottin V, Blockmans D, Lazaro E, Naccache JM, Pugnet G, Nunes H, de Menthon M, Devilliers H, Bonniaud P, Puéchal X, Mouthon L, Bonnotte B, Guillevin L, Terrier B, Samson M. Usual interstitial pneumonia in ANCA-associated vasculitis: A poor prognostic factor. J Autoimmun 2019; 106:102338. [PMID: 31570253 DOI: 10.1016/j.jaut.2019.102338] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Progressive fibrosing interstitial lung disease (ILD) is rarely associated with antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). This study focused on the outcomes of ILD patients with associated AAV (AAV-ILD). METHODS AAV-ILD (cases: microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) with ILD) were compared to AAV patients without ILD (controls). ILD was defined as a usual interstitial pneumonia (UIP) or non-specific interstitial pneumonia (NSIP) pattern. Two controls were matched to each case for age (>or ≤65 years), ANCA status (PR3-or MPO-positive) and creatininemia (≥or <150 μmol/L). RESULTS Sixty-two cases (89% MPO-ANCA+) were included. Median age at AAV diagnosis was 66 years. ILD (63% UIP), was diagnosed before (52%) or simultaneously (39%) with AAV. Cases versus 124 controls less frequently had systemic vasculitis symptoms. One-, 3- and 5-year overall survival rates, respectively, were: 96.7%, 80% and 66% for cases versus 93.5%, 89.6% and 83.8% for controls (p = 0.008). Multivariate analyses retained age >65 years (hazard ratio (HR) 4.54; p < 0.001), alveolar haemorrhage (HR 2.25; p = 0.019) and UIP (HR 2.73; p = 0.002), but not immunosuppressant use, as factors independently associated with shorter survival. CONCLUSION For AAV-ILD patients, only UIP was associated with poorer prognosis. Immunosuppressants did not improve the AAV-ILD prognosis. But in analogy to idiopathic pulmonary fibrosis, anti-fibrosing agents might be useful and should be assessed in AAV-ILD patients with a UIP pattern.
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Affiliation(s)
- Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Tiphaine Goletto
- Department of Pulmonology, Hôpital Saint-Louis, APHP, Paris, France
| | - Guillaume Beltramo
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Henry Dupuy
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Stéphane Jouneau
- Department of Pulmonology, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR S, 1085, Rennes, France
| | - Raphael Borie
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Bruno Crestani
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Vincent Cottin
- Department of Pulmonology, Hôpital Louis-Pradel, Bron, France
| | - Daniel Blockmans
- Department of Internal Medicine, UZ Leuven Hospital, Leuven, Belgium
| | - Estibaliz Lazaro
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Jean-Marc Naccache
- Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Tenon, Service de Pneumologie, Site Constitutif Du Centre de Référence des Maladies Pulmonaires Rares OrphaLung, Paris, France
| | - Grégory Pugnet
- Department of Internal Medicine, CHU de Toulouse, Toulouse, France
| | - Hilario Nunes
- Department of Pulmonology, Hôpital Avicenne, APHP, Bobigny, France
| | - Mathilde de Menthon
- Department of Internal Medicine, Hôpital Bicêtre, APHP, Le Kremlin-Bicêtre, France
| | - Hervé Devilliers
- Department of Internal Medicine and Systemic Diseases, CHU Dijon-Bourgogne, Dijon, France
| | - Philippe Bonniaud
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Xavier Puéchal
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Loïc Guillevin
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
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17
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Flores-Suárez LF, Sacoto G. Interstitial Lung Disease and ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00127-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Zhao W, Dai H, Liu Y, Zhu M, Bao N, Ban C, Zhang S, Ren Y, Ye Q, Wang C. Clinical features and prognosis of microscopic polyangiitis with usual interstitial pneumonia compared with idiopathic pulmonary fibrosis. CLINICAL RESPIRATORY JOURNAL 2019; 13:460-466. [PMID: 31013398 DOI: 10.1111/crj.13032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/19/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Pulmonary involvement in microscopic polyangiitis (MPA) is common, little is known about the clinical features of MPA with interstitial pneumonia (MPA-IP). OBJECTIVES This study aimed to explore the prevalence of microscopic polyangiitis associated usual interstitial pneumonia (UIP)(MPA-UIP) and compare its clinical features and prognosis with those of MPA-non-UIP and idiopathic pulmonary fibrosis (IPF). METHODS A total of 73 patients with MPA-IP were identified and divided into MPA-UIP patients and MPA-non-UIP patients. The clinical characteristics and survival of MPA-UIP patients were analysed and compared with those of MPA-non-UIP patients and 68 patients with IPF. RESULTS The results showed that 34/73 (47%) MPA-IP patients were classified as MPA-UIP patients. Compared with MPA-non-UIP patients, MPA-UIP patients tend to have longer duration of symptoms prior to diagnosis and usually have pulmonary involvement as the initial presentation. However, they were less likely to have proteinuria and/or hematuria. Compared with IPF patients, MPA-UIP patients usually had multisystem damage, positive anti-neutrophil cytoplasmic autoantibodies and elevated levels of nonspecific inflammatory markers. MPA-UIP death was concentrated mainly in the first 3 months after diagnosis and resulted in a higher early mortality compared with IPF. CONCLUSION UIP is the most frequent type of MPA-IP. These patients tend to have longer duration of symptoms prior to diagnosis and usually have pulmonary involvement as the first presentation. However, they are less likely to have proteinuria and/or hematuria. MPA patients with UIP can be differentiated from IPF patients through comprehensive analysis of clinical and laboratory findings.
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Affiliation(s)
- Wen Zhao
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China.,Department of Respiratory Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, P.R. China
| | - Huaping Dai
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Centre for Respiratory Medicine, Beijing, P.R. China
| | - Yan Liu
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China
| | - Min Zhu
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China
| | - Na Bao
- Department of Radiology and Image, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, P.R. China
| | - Chengjun Ban
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China
| | - Shu Zhang
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China
| | - Yanhong Ren
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Centre for Respiratory Medicine, Beijing, P.R. China
| | - Qiao Ye
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China
| | - Chen Wang
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital-Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, P.R. China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Centre for Respiratory Medicine, Beijing, P.R. China
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19
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Hilhorst M, Maria ATJ, Kavian N, Batteux F, Borderie D, Le Quellec A, van Paassen P, Guilpain P. Impact of MPO-ANCA-mediated oxidative imbalance on renal vasculitis. Am J Physiol Renal Physiol 2018; 315:F1769-F1776. [DOI: 10.1152/ajprenal.00111.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Glomerulonephritis is a severe complication of microscopic polyangiitis (MPA), a small-vessel vasculitis associated with anti-myeloperoxidase antibodies (MPO-ANCA). We previously showed the pathogenic effects of MPO-ANCA that activate MPO to trigger an oxidative burst mainly through HOCl production, contributing to endothelial injury and lung fibrosis. The aim of this study was to investigate the relationship between MPO-induced oxidative stress, anti-oxidant defenses and renal histological lesions in MPA patients. We therefore analyzed histological data from a prospective cohort of ANCA-associated glomerulonephritis. Serum-mediated HOCl production, advanced oxidation protein products (AOPP), and thiol concentration in sera were determined. From 38 patients included, histological classification noted 50% focal glomerulonephritis, 15.8% crescentic-glomerulonephritis, and 34.2% mixed-glomerulonephritis. MPA patients’ sera displayed higher HOCl production by MPO ( P < 0.001), higher AOPP ( P < 0.001) and thiol ( P < 0.01) levels, compared with healthy subjects. The presence of cellular crescents was associated with higher serum-mediated HOCl production ( P = 0.049) and lower thiol levels ( P = 0.022) at disease onset. Higher thiol concentrations were associated with focal glomerulonephritis ( P = 0.042), less interstitial fibrosis ( P = 0.039) and hyalinosis ( P = 0.066). In remission, HOCl production was decreased ( P < 0.01), and thiol concentration remained high ( P = 0.39). Our findings suggest that HOCl production by activated MPO could contribute to the very early stage of glomerulonephritis, whereas thiol may exert a protective effect against the development of renal vasculitis and glomerulosclerosis. This study highlights the importance of oxidative defenses to counteract the process of MPO-ANCA associated glomerulonephritis.
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Affiliation(s)
- Marc Hilhorst
- Department of Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Alexandre TJ Maria
- Department of Internal Medicine and Multi-Organic Diseases, University Hospital, Montpellier, France
- Institute of Regenerative Medicine and Biotherapy, Institut national de la santé et de la recherche médicale U1183, Montpellier, France
| | - Niloufar Kavian
- Institut national de la santé et de la recherche médicale U1016, Institut Cochin, Faculty of Medicine Paris Descartes, Sorbonne Paris Cité, and Laboratory of Immunology, Cochin Hospital, Paris, France
| | - Frédéric Batteux
- Institut national de la santé et de la recherche médicale U1016, Institut Cochin, Faculty of Medicine Paris Descartes, Sorbonne Paris Cité, and Laboratory of Immunology, Cochin Hospital, Paris, France
| | | | - Alain Le Quellec
- Department of Internal Medicine and Multi-Organic Diseases, University Hospital, Montpellier, France
| | - Pieter van Paassen
- Department of Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - Philippe Guilpain
- Department of Internal Medicine and Multi-Organic Diseases, University Hospital, Montpellier, France
- Institute of Regenerative Medicine and Biotherapy, Institut national de la santé et de la recherche médicale U1183, Montpellier, France
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Alba MA, Jennette JC, Falk RJ. Pathogenesis of ANCA-Associated Pulmonary Vasculitis. Semin Respir Crit Care Med 2018; 39:413-424. [PMID: 30404109 DOI: 10.1055/s-0038-1673386] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antineutrophil cytoplasmic antibodies (ANCAs) are autoantibodies specific for antigens located in the cytoplasmic granules of neutrophils and lysosomes of monocytes. ANCAs are associated with a spectrum of necrotizing vasculitis that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Pulmonary vasculitis and related extravascular inflammation and fibrosis are frequent components of ANCA vasculitis. In this review, we detail the factors that have been associated with the origin of the ANCA autoimmune response and summarize the most relevant clinical observations, in vitro evidence, and animal studies strongly indicating the pathogenic potential of ANCA. In addition, we describe the putative sequence of pathogenic mechanisms driven by ANCA-induced activation of neutrophils that result in small vessel necrotizing vasculitis and extravascular granulomatous necrotizing inflammation.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- University of North Carolina Kidney Center, Chapel Hill, North Carolina.,UNC Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Martín-Nares E, Zuñiga-Tamayo D, Hinojosa-Azaola A. Prevalence of overlap of antineutrophil cytoplasmic antibody associated vasculitis with systemic autoimmune diseases: an unrecognized example of poliautoimmunity. Clin Rheumatol 2018; 38:97-106. [PMID: 30006919 DOI: 10.1007/s10067-018-4212-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 12/24/2022]
Abstract
We aimed to estimate the frequency of overlap of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with systemic autoimmune diseases. Retrospective single-center study to identify patients with AAV diagnosis and concomitant autoimmune systemic diseases, simultaneously, before or after the diagnosis of AAV. Sociodemographic characteristics, such as comorbidities; follow-up time; type of AAV; disease duration; relapses; treatment and response; clinical, serological, and histological characteristics; disease activity and damage; prognosis; dialysis requirements, and death were assessed. Twenty-eight of two hundred and forty-seven patients (11.3%) with AAV had a concomitant diagnosis of autoimmune disease. The predominant AAV type was renal-limited vasculitis (39%), followed by granulomatosis with polyangiitis (29%), mycroscopic polyangiitis (25%), and eosinophilic granulomatosis with polyangiitis (7%). Mean age at AAV diagnosis was 50 ± 17 years and 24/28 were ANCA positive. The main clinical manifestations were renal (79%), otorhinolaryngologic (43%), and pulmonary and peripheral neuropathy (32%). Sixteen patients (57%) experienced partial or total remission at a median follow-up of 34 months, and four patients (14%) died. The most frequent autoimmune disease overlapped was rheumatoid arthritis (39%), followed by Sjögren's syndrome and systemic sclerosis (14%), mixed connective tissue disease (11%), systemic lupus erythematosus and juvenile idiopathic arthritis (7%), and ankylosing spondylitis and IgG4-related disease (4%). In nine patients (32%), both diagnoses were simultaneous; in the rest, median time elapsed between the autoimmune disease and AAV diagnosis was 173 months. The prevalence of overlap AAV with other autoimmune diseases was low. The most common AAV phenotype was renal-limited vasculitis, and the most frequent overlap disease was rheumatoid arthritis.
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Affiliation(s)
- Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico
| | - Diego Zuñiga-Tamayo
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico.
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Idiopathic Interstitial Pneumonia as a Possible Cause of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Report. Arch Rheumatol 2018; 33:89-92. [PMID: 29901014 DOI: 10.5606/archrheumatol.2018.6532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/17/2017] [Indexed: 12/13/2022] Open
Abstract
There are conflicting data to date on the causal relationship between idiopathic interstitial pneumonia and antineutrophil cytoplasmic antibody (ANCA): (1) myeloperoxidase-ANCA may play a pathogenetic role in pulmonary fibrosis, or (2) pulmonary fibrosis may induce production of the antibody. In this article, we describe a case of an elderly female patient with microscopic polyangiitis that developed after positive conversion of myeloperoxidase-ANCA during the course of idiopathic interstitial pneumonia. Our experience as well as similar case reports may suggest that idiopathic interstitial pneumonia may induce production of ANCAs and even ANCA-associated vasculitis.
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Roszkiewicz J, Smolewska E. From fibrosis to diagnosis: a paediatric case of microscopic polyangiitis and review of the literature. Rheumatol Int 2018; 38:683-687. [PMID: 29294176 DOI: 10.1007/s00296-017-3923-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/26/2017] [Indexed: 11/30/2022]
Abstract
We herein describe a case of a 6-year-old girl diagnosed with microscopic polyangiitis (MPA) after a long diagnostic process demanding the cooperation of paediatric respiratory medicine specialists, rheumatologists, nephrologists and radiologist. First symptoms of MPA were observed after Mycoplasma pneumoniae infection and included persistent crepitations at the basis of both lungs and mild haematuria. CT imaging showed features of lung fibrosis, renal biopsy was indicative of mesangial proliferative glomerulonephritis, in the skin biopsy features of microscopic polyangiitis were described. In the laboratory tests pANCA antibodies specific for myeloperoxidase (MPO) were present in high titer. MPA with initial features of lung fibrosis is an unusual presentation of this rare disease, usually observed in adult population. This unique case illustrates the diagnostic and therapeutic challenges in paediatric vasculitis patients with an unusual initial presentation in the form of interstitial lung disease. In the manuscript we also discuss the possible aetiology of lung fibrosis in microscopic polyangiitis MPA and provide the review of the current literature on the topic of childhood-onset MPA.
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Affiliation(s)
- Justyna Roszkiewicz
- Department of Paediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland
| | - Elżbieta Smolewska
- Department of Paediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland.
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Alba MA, Flores-Suárez LF, Henderson AG, Xiao H, Hu P, Nachman PH, Falk RJ, Charles Jennette J. Interstital lung disease in ANCA vasculitis. Autoimmun Rev 2017; 16:722-729. [PMID: 28479484 DOI: 10.1016/j.autrev.2017.05.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 02/03/2023]
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) vasculitides are immune-mediated disorders that primarily affect small blood vessels of the airway and kidneys. Lung involvement, one of the hallmarks of microscopic polyangiitis and granulomatosis with polyangiitis, is associated with increased mortality and morbidity. In recent years, several retrospective series and case reports have described the association of interstitial lung disease (ILD) and ANCA vasculitis, particularly those positive for ANCA specific for myeloperoxidase. In the majority of these patients pulmonary fibrosis occurs concurrently or predates the diagnosis of ANCA vasculitis. More importantly, these studies have shown that ILD has an adverse impact on the long-term prognosis of ANCA vasculitis. This review focuses on the main clinical and radiologic features of pulmonary fibrosis associated with anti-neutrophil cytoplasmic antibodies. Major histopathology features, prognosis and therapeutic options are summarized.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitis Clinic, Instituto Nacional de Enfermedades Respiratorias (INER), Mexico City, Mexico
| | - Ashley G Henderson
- Division of Pulmonary & Critical Care Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hong Xiao
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peiqi Hu
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Patrick H Nachman
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- University of North Carolina Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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M'Saad S, Kammoun K, Yangui I, Fourati H, Feki W, Marouen F, Daoud E, Kammoun S. Micropolyangéite, syndrome d’emphysème des sommets et fibrose pulmonaire des bases. Rev Mal Respir 2016; 33:391-6. [DOI: 10.1016/j.rmr.2015.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 07/01/2015] [Indexed: 11/26/2022]
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Sato S, Yashiro M, Matsuoka N, Uematsu M, Asano T, Kobayashi H, Watanabe H, Ohira H. Successful Immunosuppressive Treatment of Mixed Connective Tissue Disease Complicated by Microscopic Polyangiitis. TOHOKU J EXP MED 2016; 239:111-6. [DOI: 10.1620/tjem.239.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Shuzo Sato
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Makiko Yashiro
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Naoki Matsuoka
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Manabu Uematsu
- Department of Pulmonary Medicine, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroko Kobayashi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroshi Watanabe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hiromasa Ohira
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
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Katsumata Y, Kawaguchi Y, Yamanaka H. Interstitial Lung Disease with ANCA-associated Vasculitis. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:51-6. [PMID: 26448696 PMCID: PMC4583098 DOI: 10.4137/ccrpm.s23314] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 02/01/2023]
Abstract
The association between interstitial lung disease (ILD) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), particularly microscopic polyangiitis (MPA), has been described in a number of case reports and case series reports in the last 2 decades. In addition, patients with pulmonary fibrosis and ANCA positivity but without other manifestations of systemic vasculitis have also been reported. Pulmonary fibrosis was clinically manifested at the time of diagnosis in the majority of AAV patients that developed this condition. Moreover, ANCA-positive conversion occurs in patients initially diagnosed with idiopathic pulmonary fibrosis, and as a result, other manifestations of systemic vasculitis develop in some of these patients. There is significant predominance of myeloperoxidase (MPO)-ANCA and MPA in patients with AAV and ILD. Radiological and pathological findings generally demonstrate usual interstitial pneumonia (pattern) in the lungs of these patients. In most studies, AAV patients with ILD have a worse prognosis than those without it.
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Affiliation(s)
- Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Hisashi Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
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Gocho K, Sugino K, Sato K, Hasegawa C, Uekusa T, Homma S. Microscopic polyangiitis preceded by combined pulmonary fibrosis and emphysema. Respir Med Case Rep 2015; 15:128-32. [PMID: 26236623 PMCID: PMC4501455 DOI: 10.1016/j.rmcr.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 02/23/2015] [Indexed: 11/14/2022] Open
Abstract
A 73-year-old male metalworker was admitted to our hospital with a 3-year history of progressive dry cough. Chest high-resolution computed tomography revealed emphysematous changes and reticular lesions, which is referred to as combined pulmonary fibrosis and emphysema (CPFE). Surgical lung biopsy specimens revealed unclassified interstitial pneumonia, including a nonspecific interstitial pneumonia pattern and usual interstitial pneumonia pattern. Two years after his first admission he developed rapid progressive renal dysfunction with an elevated level of myeloperoxidase-antineutrophil cytoplasmic antibody (428 EU). A renal biopsy specimen revealed interstitial nephritis and glomerulonephritis. Consequently, microscopic polyangiitis preceded by CPFE was diagnosed. Despite transient exacerbation of renal involvement, his general condition remained mostly stable during a 2-year period of corticosteroid treatment. He ultimately died from severe pneumococcal pneumonia associated with acute lung injury.
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Affiliation(s)
- Kyoko Gocho
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo 143-8541, Japan
| | - Keishi Sugino
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo 143-8541, Japan
| | - Keita Sato
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo 143-8541, Japan
| | - Chikako Hasegawa
- Department of Pathology, Toho University Omori Medical Center, Japan
| | - Toshimasa Uekusa
- Department of Pathology, Japan Labor Health and Welfare Organization Kanto Rosai Hospital, Japan
| | - Sakae Homma
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1, Omori-nishi, Ota-ku, Tokyo 143-8541, Japan
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29
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Kagiyama N, Takayanagi N, Kanauchi T, Ishiguro T, Yanagisawa T, Sugita Y. Antineutrophil cytoplasmic antibody-positive conversion and microscopic polyangiitis development in patients with idiopathic pulmonary fibrosis. BMJ Open Respir Res 2015; 2:e000058. [PMID: 25593704 PMCID: PMC4289718 DOI: 10.1136/bmjresp-2014-000058] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 11/22/2014] [Accepted: 12/01/2014] [Indexed: 12/22/2022] Open
Abstract
Background Increasing evidence indicates that antineutrophil cytoplasmic antibody (ANCA)-positive conversion occurs in patients initially diagnosed with idiopathic pulmonary fibrosis (IPF) and as a result, some of these patients develop microscopic polyangiitis (MPA). However, the incidence density of these patients is not well known. Objectives To explore the incidence of ANCA-positive conversion and development of MPA during the disease course in patients with IPF and to evaluate whether corticosteroid therapy reduces MPA development in patients with IPF with myeloperoxidase (MPO)-ANCA positivity at diagnosis or who later acquire MPO-ANCA positivity. Methods We retrospectively analysed the medical records of 504 Asian patients with IPF treated at our institution in Saitama, Japan. Results Of the 504 patients with IPF, 20 (4.0%) had MPO-ANCA and 16 (3.2%) had PR-3-ANCA when first evaluated. In 264 of 504 patients with IPF, ANCA was measured repeatedly and seroconversion to MPO-ANCA and PR3-ANCA occurred in 15 (5.7%) and 14 (5.3%) patients, respectively, and 9 of 35 patients who were either MPO-ANCA positive at IPF diagnosis or who subsequently seroconverted developed MPA. None of the nine patients who developed MPA had been previously treated with steroids. The incidence of MPA tended to be lower in patients treated than not treated with corticosteroids although this was not statistically significant. Conclusions Some patients with IPF with MPO-ANCA positivity at IPF diagnosis or with MPO-ANCA-positive conversion during follow-up developed MPA. Clinical trials to determine whether corticosteroid therapy can reduce MPA development and prolong survival in MPO-ANCA-positive patients with IPF should be considered.
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Affiliation(s)
- Naho Kagiyama
- Department of Respiratory Medicine , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
| | - Tetsu Kanauchi
- Department of Radiology , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
| | - Tsutomu Yanagisawa
- Department of Respiratory Medicine , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
| | - Yutaka Sugita
- Department of Respiratory Medicine , Saitama Cardiovascular and Respiratory Center , Saitama , Japan
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30
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Comarmond C, Crestani B, Tazi A, Hervier B, Adam-Marchand S, Nunes H, Cohen-Aubart F, Wislez M, Cadranel J, Housset B, Lloret-Linares C, Sève P, Pagnoux C, Abad S, Camuset J, Bienvenu B, Duruisseaux M, Hachulla E, Arlet JB, Hamidou M, Mahr A, Resche-Rigon M, Brun AL, Grenier P, Cacoub P, Saadoun D. Pulmonary fibrosis in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis: a series of 49 patients and review of the literature. Medicine (Baltimore) 2014; 93:340-349. [PMID: 25500703 PMCID: PMC4602438 DOI: 10.1097/md.0000000000000217] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Pulmonary fibrosis (PF) is an uncommon manifestation observed in patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV), particularly microscopic polyangiitis (MPA). While patients with PF associated with AAV seem to have a worse prognosis, these patients have been described only in case reports or small retrospective case series. In this retrospective multicenter study, we report the main features and long-term outcomes of patients with PF associated with AAV, fulfilling the American College of Rheumatology criteria and/or Chapel Hill definitions. Forty-nine patients (30 men [61%]; median age at diagnosis of AAV, 68 [interquartile range, 58-73] years) with PF associated with AAV were identified. Forty (81.6%) patients had MPA and 9 (18.4%) had granulomatosis with polyangiitis. The diagnosis of PF preceded the onset of vasculitis in 22 (45%) patients. Usual interstitial pneumonia was the main radiologic pattern (n = 18, 43%). ANCA were mostly of antimyeloperoxidase specificity (88%). All patients were treated with glucocorticoids as induction therapy, combined with cyclophosphamide (CYC) (n = 36, 73.5%) or rituximab (RTX) (n = 1, 2%). Factors associated with mortality included occurrence of chronic respiratory insufficiency (hazard ratio [HR], 7.44; 95% confidence interval [CI], 1.6-34.5; p = 0.003), induction therapy with glucocorticoids alone (HR, 2.94; CI, 1.05-8.33; p = 0.04), and initial weigh loss (HR, 2.83; CI, 1.05-7.65; p = 0.041). The 3-year survival rate in patients treated with glucocorticoids alone or combined with an immunosuppressant (CYC or RTX) as induction therapy was 64% (95% CI, 41-99) and 94% (95% CI, 86-100), respectively (p = 0.03). After a median follow-up of 48 months [interquartile range, 14-88 mo], 18 (37%) patients died, including 11 related to respiratory insufficiency. PF is a rare manifestation of AAV with a very poor prognosis. Induction therapy with CYC might improve the outcome.
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Affiliation(s)
- Cloé Comarmond
- From the Departement Hospitalo-Universitaire I2B (CC, B. Hervier, PC, DS), UPMC Univ Paris 06, UMR 7211, F-75005, Paris; INSERM, UMR_S 959 (CC, PC, DS), F-75013, Paris; CNRS, UMR 7211 (CC, PC, DS), F-75005, Paris; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology (CC, B. Hervier, FCA, PC, DS), F-75013, Paris; AP-HP, Hôpital Bichat, Service de Pneumologie A (BC), Université Paris Diderot-Paris VII, Paris; AP-HP, Hôpital Saint-Louis, Service de Pneumologie (AT), Université Paris Diderot-Paris VII, Sorbonne Paris Cité, INSERM UMR 717, Paris; Centre Hospitalier Régional et Universitaire de Tours, Service de Pneumologie (SAM), Tours; AP-HP, Centre Hospitalier et Universitaire d'Avicenne, Service de Pneumologie (HN), Bobigny; AP-HP, Hôpital Tenon, Service de Pneumologie (MW, J. Cadranel), UPMC-Paris VI, Paris; Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie (B. Housset), Créteil; AP-HP, Hôpital Lariboisière, Service de Médecine Interne A (CLL), Paris; Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service de Médecine Interne (PS), Lyon; AP-HP, Centre hospitalier et universitaire d'Avicenne, Service de Médecine Interne (SA), Bobigny; Centre Hospitalier Victor Dupouy, Service de Pneumologie (J. Camuset), Argenteuil; Centre Hospitalier et Universitaire de Caen, Service de Médecine Interne (BB), Caen; Centre Hospitalier Universitaire de Grenoble, Service de Pneumologie, Pôle Thorax et Vaisseaux (MD), Grenoble; Hôpital Claude Huriez, Service de Médecine Interne (EH), Université Lille Nord-de-France, Lille; AP-HP, Hôpital Européen Georges Pompidou, Service de Médecine Interne (JBA), Paris; Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, Service de Médecine Interne (MH), Nantes; AP-HP, Hôpital Saint-Louis, Service de Médecine Interne (AM), Université Paris Diderot-Paris VII, Paris; AP-HP, Hôpital Saint-Louis, Service de Biostatistiques (MRR), Université Paris Diderot-Paris VII, Paris; AP-HP, Groupe Hospitalier Pitié-Salpétrière, Service de Radiologie (ALB, PG), UPMC-Paris VI, Paris, France; and Mount Sinai Hospital, Division of Rheumatology (CP), University of Toronto, Toronto, Ontario, Canada
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Datta S, Kundu S, Ghosh P, De S, Ghosh A, Chatterjee M. Correlation of oxidant status with oxidative tissue damage in patients with rheumatoid arthritis. Clin Rheumatol 2014; 33:1557-64. [PMID: 24718487 DOI: 10.1007/s10067-014-2597-z] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 03/25/2014] [Accepted: 03/27/2014] [Indexed: 01/05/2023]
Abstract
Rheumatoid arthritis (RA) is a debilitating autoimmune disease whose etiology remains unknown, but studies have consistently implicated a plethora of inflammatory mechanisms culminating in chronic symmetric and erosive synovitis. Importantly, reactive oxygen species (ROS) have been attributed to directly contribute towards the destructive, proliferative synovitis evident in RA. Accordingly, this study aimed to establish whether the degree of oxidative stress and disease activity score (DAS28) correlated with the downstream effects of oxidative damage. The redox status of neutrophils sourced from synovial fluid (SF) was measured by flow cytometry in terms of total ROS and hydroxyl radicals. Among the molecular damage markers, protein carbonylation and lipid peroxidation were detected by spectrophotometry and S-nitrosothiols by fluorimetry. Neutrophils constituted the major cellular component of the SF of patients with RA and their levels of ROS and hydroxyl radicals correlated strongly with protein carbonylation and lipid peroxidation. However, all the oxidative damage markers correlated positively with DAS28. Taken together, in patients with RA, the strong correlation between levels of ROS and DAS28 with markers of oxidative damage suggests that measurement of oxidative stress could serve as a biomarker for monitoring disease severity in RA.
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Affiliation(s)
- Suhana Datta
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research, 244 B Acharya JC Bose Road, Kolkata, 700 020, India
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Yamashita H, Takahashi Y, Kaneko H, Kano T, Mimori A. A patient with diffuse cutaneous systemic sclerosis complicated by antineutrophil-cytoplasmic antibody-associated vasculitis exhibiting honeycomb lung without volume loss. Intern Med 2014; 53:801-4. [PMID: 24694501 DOI: 10.2169/internalmedicine.53.1599] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the case of a 72-year-old woman with diffuse cutaneous systemic sclerosis (SSc) complicated by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis who exhibited honeycomb lung without volume loss. On admission, chest computed tomography (CT) revealed honeycomb lung without volume loss in addition to increased density of the partition walls. A renal biopsy revealed global sclerosis and cellular crescent formation. Mononeuritis multiple subsequently occurred, and steroid pulse therapy with cyclophosphamide was administered. Repeat chest CT showed that the honeycomb lung was unchanged; however, overall reduced density of the partition walls was observed. It is necessary to recognise that vasculitis may develop in SSc patients who exhibit honeycomb lung without volume loss.
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Affiliation(s)
- Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
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Tzouvelekis A, Zacharis G, Oikonomou A, Mikroulis D, Margaritopoulos G, Koutsopoulos A, Antoniadis A, Koulelidis A, Steiropoulos P, Boglou P, Bakali M, Froudarakis M, Bouros D. Increased incidence of autoimmune markers in patients with combined pulmonary fibrosis and emphysema. BMC Pulm Med 2013; 13:31. [PMID: 23697753 PMCID: PMC3667148 DOI: 10.1186/1471-2466-13-31] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 04/24/2013] [Indexed: 12/18/2022] Open
Abstract
Background Combined pulmonary fibrosis and emphysema (CPFE) is an umbrella term encompassing upper lobe emphysema and lower lobe pulmonary fibrosis with pathogenesis elusive. The aim of our study was to investigate the incidence of autoimmune markers in patients with CPFE. Methods In this multicenter study we retrospectively evaluated records from patients with CPFE (n=40) and IPF (n=60) without emphysema. Baseline demographic characteristics, high-resolution computed tomography (HRCT), spirometry, histopathological, treatment, serum immunologic and survival data were investigated. B cell presence was estimated with CD20 immunostaining in representative lung biopsy samples from CPFE patients and control subjects. Results A statistically significant increased number of CPFE patients with elevated serum ANA with or without positive p-ANCA titers compared to patients with IPF without emphysema was observed. Patients with CPFE and positive autoimmune markers exhibited improved survival compared to patients with a negative autoimmune profile. A massive infiltration of clusters of CD20+ B cells forming lymphoid follicles within the fibrotic lung in CPFE patients with positive serum immunologic profile compared to patients with negative profile, was noted and positively correlated with improved survival. Conclusions A significant proportion of patients with CPFE may present with underlying auto-immune disorders that may reside insidiously and be associated with favorable prognosis. Early identification of these patients using a panel of auto-antibodies may lead to more targeted and effective therapeutic applications.
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Affiliation(s)
- Argyris Tzouvelekis
- Department of Pneumonology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis 68100, Greece
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Quéméneur T, Mouthon L, Cacoub P, Meyer O, Michon-Pasturel U, Vanhille P, Hatron PY, Guillevin L, Hachulla E. Systemic vasculitis during the course of systemic sclerosis: report of 12 cases and review of the literature. Medicine (Baltimore) 2013; 92:1-9. [PMID: 23263715 PMCID: PMC5370746 DOI: 10.1097/md.0b013e31827781fd] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Although the presence of antineutrophil cytoplasmic antibodies (ANCA) has been reported in patients with systemic sclerosis (SSc), the association of SSc and systemic vasculitis has rarely been described. We obtained information on cases of systemic vasculitis associated with SSc in France from the French Vasculitis Study Group and all members of the French Research Group on Systemic Sclerosis. We identified 12 patients with systemic vasculitis associated with SSc: 9 with ANCA-associated systemic vasculitis (AASV) and 3 with mixed cryoglobulinemia vasculitis (MCV). In all AASV patients, SSc was of the limited type. The main complication of SSc was pulmonary fibrosis. Only 2 patients underwent a D-penicillamine regimen before the occurrence of AASV. The characteristics of AASV were microscopic polyangiitis (n = 7) and renal limited vasculitis (n = 2). Anti-myeloperoxidase antibodies were found in 8 of the 9 patients. The Five Factor Score was above 1 in 3 of the 9 patients. Of the 3 patients with MCV, Sjögren syndrome was confirmed in 2. We compared our findings with the results of a literature review (42 previously reported cases of AASV with SSc). Although rare, vasculitis is a complication of SSc. AASV is the most frequent type, and its diagnosis can be challenging when the kidney is injured. Better awareness of this rare association could facilitate earlier diagnosis and appropriate management to reduce damage.
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Affiliation(s)
- Thomas Quéméneur
- From the Department of Nephrology and Internal Medicine (TQ, PV), Hospital of Valenciennes, Valenciennes; Université Paris Descartes, National Reference Centre for Scleroderma and Systemic Vasculitis (LM, LG), Cochin Hospital, Paris; Department of Internal Medicine (PC), AP-HP, Hôpital Pitié-Salpêtrière, Paris; Department of Rheumatology (OM), Bichat Hospital, Paris; Department of Vascular Medicine (UMP), Saint-Joseph Hospital, Paris; and Department of Internal Medicine, National Reference Centre for Scleroderma (PYH, EH), Claude Huriez Hospital, University of Lille, Lille, France
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