New insight into the rheumatoid vasculitis

Choroidal thickness in eyes of rheumatoid arthritis patients measured using optical coherence tomography: A systematic review and meta-analysis

Rheumatoid arthritis (RA), an autoimmune disease, affects eyes in 25% of cases. Retinal alterations in RA can function as biomarkers as early risk indicators for developing sight-threatening conditions. Optical coherence tomography (OCT) provides high-resolution images of the retina and its component's thickness measures. The purpose of this review is to compare the choroidal thickness (CT) of RA patients and healthy controls. We examined the databases of PubMed, Scopus, and Embase. Depending on the heterogeneity, an appropriate model was used for the meta-analysis. Additionally, meta-regression, publication bias, subgroup analyses, and quality evaluation were carried out. We evaluated 8 studies involving 363 RA patients and 343 healthy controls. Our findings demonstrated that RA participants had significantly lower CT at 500 and 1500 µm nasal and temporal to the fovea compared to controls. The subfoveal, 1000 µm temporal and nasal to the fovea, and average CT, however, did not demonstrate statistical significance. The results of this study demonstrate that choroidal thickness is different in RA patients from healthy controls in several areas. OCT measurements may be related to both the visual acuity and the possibility of developing several rheumatic-ophthalmic problems. Future research is thus needed to get more firm findings.

A Rare Case of Superior Vena Cava Syndrome in a Patient With Rheumatoid Arthritis and IgA Nephropathy

Superior vena cava syndrome (SVCS) is a vascular condition resulting from an impaired venous return to the right atrium. The majority of SVCS cases are caused by mass effect in which extrinsic compression of the vessel leads to obstruction of blood flow. In less common cases of SVCS, thrombus formation and luminal narrowing can result in poor return through the SVC. Inflammatory causes of SVCS are even rarer and poorly documented. IgA nephropathy and rheumatoid arthritis (RA) are two autoimmune diseases with the potential to cause vasculitis, thus increasing the likelihood of intraluminal vessel occlusion. We report a rare case of SVCS in a 65-year-old female with a past medical history significant for atrial fibrillation, IgA nephropathy, chronic kidney disease stage IIIA, and RA who presented with headache, dizziness, and neck pain and swelling extending down the left upper extremity for three days. Inflammatory SVCS is uncommon and cases of SVCS secondary to RA and IgA nephropathy are underreported in the literature thus far. Our hope in presenting this case is to encourage a greater degree of suspicion for vascular complications, such as SVCS, in patients with autoimmune and inflammatory conditions.

Differentialdiagnose Vaskulitis und Vaskulopathie aus dermatologischer Sicht

Vaskulopathien und Vaskulitiden stellen diagnostisch und therapeutisch eine interdisziplinäre Herausforderung dar. Zugrunde liegen unterschiedliche pathophysiologische Mechanismen, die zu vielfältigen klinischen Krankheitsbildern führen können und therapeutisch unterschiedliche Ansätze erlauben. Sowohl Vaskulitiden als auch Vaskulopathien müssen nicht zwangsläufig mit einer Systembeteiligung einhergehen, sondern können auch als rein kutane Varianten auftreten. Aufgrund mangelnder pathognomonischer Laborparameter ist die Diagnose häufig klinisch zu stellen. Dieser Artikel soll den differentialdiagnostischen Blick, insbesondere auf die kutanen Manifestationsformen bei Vaskulopathien und Vaskulitiden, schärfen.

Intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis: A case report

OBJECTIVE

We describe a case of intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis (RA).

CASE PRESENTATION

A 29-year-old man with a medical history of RA since 18 years of age was admitted to our hospital for vomiting, dysarthria, and conscious disturbance. At 23, he underwent ligation of the left internal carotid artery (ICA) with superficial temporal artery to middle cerebral artery anastomosis because of acute infarct of the left hemisphere caused by arterial dissection of the left ICA. During the current admission, computed tomography (CT) revealed subarachnoid hemorrhage, and digital subtraction angiography (DSA) demonstrated dissecting aneurysms of the left intracranial vertebral artery (VA) and right extracranial VA. We diagnosed him with a ruptured dissecting aneurysm of the left intracranial VA and performed endovascular parent artery occlusion on the left VA. For the right unruptured VA aneurysm, we performed coil embolization simultaneously. At 2 weeks after the endovascular treatment, follow-up DSA revealed that multiple de novo dissecting aneurysms developed on the origin of the left VA and left and right internal thoracic arteries. Those aneurysms were treated with coil embolization. Other remaining aneurysms on the left thyrocervical trunk, right transverse cervical artery, and both common iliac arteries were treated by conservative therapy. While continuing medical treatment for RA, the patient recovered and was discharged to a rehabilitation hospital.

CONCLUSION

Considering that RA-induced vasculitis can be a potential risk of vascular complications including multiple arterial dissections, physicians should carefully perform endovascular interventional procedures for patients with long-term RA.

Biological therapy in rheumatoid vasculitis: a systematic review

Rheumatoid vasculitis (RV) is one of the most severe extra-articular manifestations of rheumatoid arthritis, with significant morbidity and mortality, requiring aggressive treatment with corticosteroids and/or immunosuppressants. Recently, biological drugs were included in its therapeutic armamentarium. The objective of this study was to perform a systematic review on the use of biological drugs in the treatment of RV. A systematic literature review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations and searching articles in MEDLINE/PubMed, Cochrane, SciELO, Scopus, and Virtual Health Library electronic databases. Secondary references were also evaluated. The methodological quality of the selected studies was evaluated by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Altogether, five articles, assessing the use of biological drugs, were included. Globally, 35 patients participated in the studies, of which 21 were treated with rituximab (RTX) in cycles of 1000 mg every 2 weeks; 9 used infliximab 5 mg/kg; 3 used infliximab 3 mg/kg; and 2 used etanercept 25 mg twice/week. In general, an improvement in clinical picture, reduction of the mean daily dose of corticosteroids, and improvement in the Birmingham Vasculitis Activity Score was achieved by the end of the treatment. Complete remission occurred in almost 70% of the cases. The adverse effect rate was 34%, mainly due to infections. There were two deaths, one due to sepsis and the other due to uncontrolled vasculitis, after the biological drug withdrawal, following the development of sepsis. Based on the results of the present review, we believe that the use of biological therapy such as RTX and anti-tumor necrosis factor α can be beneficial in treating this complication.

Connective Tissue Disorder-Associated Vasculitis

Vasculitides secondary to connective tissue diseases are classified under the category of 'vasculitis associated with systemic disease' in the revised International Chapel Hill Consensus Conference (CHCC) nomenclature. These secondary vasculitides may affect any of the small, medium or large vessels and usually portend a poor prognosis. Any organ system can be involved and the presentation would vary depending upon that involvement. Treatment depends upon the type and severity of presentation. In this review, we describe secondary vasculitis associated with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, relapsing polychondritis, systemic sclerosis, Sjogren's syndrome and idiopathic inflammatory myositis, focusing mainly on recent advances in the past 3 years.