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Cler SJ, Ogden MA, Farrell NF, Roland LT, Diffie CE, Schneider JS. When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. Am J Otolaryngol 2024; 45:104207. [PMID: 38176206 DOI: 10.1016/j.amjoto.2023.104207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients. OBJECTIVE Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics. METHODS Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review. RESULTS 467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review. CONCLUSION GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.
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Affiliation(s)
- Samuel J Cler
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America.
| | - M Allison Ogden
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Nyssa Fox Farrell
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Lauren T Roland
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
| | - Colin E Diffie
- Washington University in St. Louis School of Medicine, Department of Medicine, Division of Rheumatology, United States of America
| | - John S Schneider
- Washington University in St. Louis School of Medicine, Department of Otolaryngology, United States of America
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2
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Ang T, Chaggar V, Tong JY, Selva D. Medication-associated orbital inflammation: A systematic review. Surv Ophthalmol 2024:S0039-6257(24)00020-1. [PMID: 38490453 DOI: 10.1016/j.survophthal.2024.03.003] [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: 10/29/2023] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2024]
Abstract
We performed a comprehensive systematic review to identify medication-associated orbital inflammation and to characterize its clinico-radiological features. We reviewed English-language articles describing medication-associated orbital inflammation (i.e., orbital myositis, dacryoadenitis and orbital fat) published to June, 2023. Isolated inflammation of the intraocular structures or globe alone (i.e. uveitis, scleritis, optic neuritis and perineuritis) were excluded. In medication-associated orbital inflammation, the extraocular muscles are preferentially affected, occurring in isolation or in combination with other orbital and/or intraocular structures. Clinico-radiological manifestations may be non-specific; however, certain medications may be distinguished according to the presence of systemic prodrome, laterality, associated intraocular inflammation, and predisposition to involve certain orbital structures. Rapid identification, discontinuation of the provoking medication, and systemic corticosteroid therapy (if appropriate) typically achieves a favorable visual prognosis. As new medications become adopted by clinicians, rare adverse effects will be further delineated.Medication-associated orbital inflammation is an important diagnostic consideration in orbital inflammatory disease. A careful medication history and clinical assessment may be revealing, permitting timely discontinuation of the offending agent and initiation of appropriate management.
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Affiliation(s)
- Terence Ang
- The University of Adelaide, Adelaide, South Australia, Australia.
| | - Viraj Chaggar
- The University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica Y Tong
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dinesh Selva
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Koster MJ, Guarda M, Ghaffar U, Warrington KJ. Rheumatic masqueraders: mimics of primary vasculitis - a case-based review. Expert Rev Clin Immunol 2024; 20:83-95. [PMID: 37837326 DOI: 10.1080/1744666x.2023.2270774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other. AREAS COVERED This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined. EXPERT OPINION The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Max Guarda
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Umar Ghaffar
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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Lacey MJ, Chapman MN. Infectious and Inflammatory Sinonasal Diseases. Oral Maxillofac Surg Clin North Am 2023:S1042-3699(23)00007-9. [PMID: 37032178 DOI: 10.1016/j.coms.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Rhinosinusitis is a commonly encountered disease. Imaging is not typically required in acute uncomplicated rhinosinusitis; however, it is integral in the evaluation of patients who present with prolonged or atypical symptoms or when acute intracranial complications or alternate diagnoses are suspected. Knowledge of the paranasal sinus anatomy is important to understand patterns of sinonasal opacification. Bacterial, viral, and fungal pathogens are responsible culprits and, with duration of symptoms, serve to categorize infectious sinonasal disease. Several systemic inflammatory and vasculitic processes have a predilection for the sinonasal region. Imaging, along with laboratory and histopathologic analysis, assist in arriving at these diagnoses.
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Affiliation(s)
- Marcus J Lacey
- Department of Radiology, Virginia Mason Medical Center, 1100 Ninth Avenue, C5-XR, Seattle, WA 98101, USA
| | - Margaret N Chapman
- Department of Radiology, Virginia Mason Medical Center, 1100 Ninth Avenue, C5-XR, Seattle, WA 98101, USA.
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Ortiz-Seller A, Hernández-Pons A, Pascual EV, Comín Pérez A, Dolz Gaitón R, Albert-Fort M. Severe Cocaine-Induced Midline Destructive Lesions (CIMDL) Leading to Orbital Apex Syndrome and Peripheral Ulcerative Keratitis. Ocul Immunol Inflamm 2022; 30:1956-1960. [PMID: 33872101 DOI: 10.1080/09273948.2021.1906913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To describe a case of cocaine-induced midline destructive lesions (CIMDL) associated with ocular autoimmune disease.Methods: Observational case report. RESULTS A 45-year-old man with history of chronic osteolytic sinusitis due to cocaine abuse presented with sudden vision loss in right eye. Ophthalmic examination revealed fixed right mydriasis with extraocular movements limitation and optic disc swelling. Computed tomography showed an orbital infiltrating mass. The diagnosis of orbital-apex syndrome secondary to CIMDL was established. Steroids and antibiotics therapy were started without vision improvement. At 6-months follow-up, a corneal ulcer with characteristics of peripheral ulcerative keratitis (PUK) was evidenced, coinciding with an upper respiratory bacterial infection. CONCLUSIONS CIMDL and PUK share common pathogenic pathways, with implication of autoimmune factors and exposure to infective antigens. We hypothesized that chronic cocaine use, along with persistent bacterial infection, could have triggered an inflammatory reaction, which contributed to CIMDL development and the appearance of PUK.
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Affiliation(s)
- Amparo Ortiz-Seller
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
| | | | - Elia Valls Pascual
- Department of Rheumatology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Alberto Comín Pérez
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Raquel Dolz Gaitón
- Department of Pathology, Hospital Universitari Doctor Peset, Valencia, Spain
| | - Mara Albert-Fort
- Department of Ophthalmology, Hospital Universitari Doctor Peset, Valencia, Spain
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6
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Nitro L, Pipolo C, Fadda GL, Allevi F, Borgione M, Cavallo G, Felisati G, Saibene AM. Distribution of cocaine-induced midline destructive lesions: systematic review and classification. Eur Arch Otorhinolaryngol 2022; 279:3257-3267. [PMID: 35138441 PMCID: PMC9130192 DOI: 10.1007/s00405-022-07290-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/24/2022] [Indexed: 11/04/2022]
Abstract
Purpose Intranasal cocaine is known to potentially lead to midline destructive lesions. The present systematic review was undertaken to systematically define the localization of cocaine-induced midline destructive lesions and their prevalence and to propose a practical classification of these lesions. Methods A PRISMA-compliant systematic review was performed in multiple databases with criteria designed to include all studies published until March 2021 providing a precise definition of cocaine-induced midline lesions in humans. We selected all original studies except case reports. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for lesion localization, patients’ demographics, exposure to cocaine, and relationship with external nose destruction. Results Among 2593 unique citations, 17 studies were deemed eligible (127 patients). All studies were retrospective case series. The destructive process determined a septal perforation in 99.2% of patients. The distribution prevalence decreased from the inferior third of the sinonasal complex (nasal floor and inferolateral nasal wall, respectively, 59% and 29.9% of patients) to the middle third (middle turbinate and ethmoid, 22.8% of patients), and ultimately to neurocranial structures (7.9% of patients). Nasal deformities were inconsistently reported across reviewed studies. Cocaine use duration, frequency, and status were reported only occasionally. Conclusion Based on the distribution prevalence observed, we propose a four-grade destruction location-based classification. Future prospective studies following the evolution of cocaine-induced lesions are needed to validate our classification, its relationship with lesion evolution, and whether it represents a reliable tool for homogeneous research results reporting.
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Affiliation(s)
- Letizia Nitro
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy
| | - Carlotta Pipolo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy.,ISGOS, the Italian Study Group on Odontogenic Sinusitis, Milan, Italy
| | - Gian Luca Fadda
- ISGOS, the Italian Study Group on Odontogenic Sinusitis, Milan, Italy.,Department of Otorhinolaryngology, San Luigi Gonzaga University Hospital, Università degli Studi di Torino, Turin, Italy
| | - Fabiana Allevi
- ISGOS, the Italian Study Group on Odontogenic Sinusitis, Milan, Italy.,Maxillofacial Surgery Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Mario Borgione
- Department of Otorhinolaryngology, San Luigi Gonzaga University Hospital, Università degli Studi di Torino, Turin, Italy
| | - Giovanni Cavallo
- Department of Otorhinolaryngology, San Luigi Gonzaga University Hospital, Università degli Studi di Torino, Turin, Italy
| | - Giovanni Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy.,ISGOS, the Italian Study Group on Odontogenic Sinusitis, Milan, Italy
| | - Alberto Maria Saibene
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy. .,ISGOS, the Italian Study Group on Odontogenic Sinusitis, Milan, Italy.
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A Unique Presentation of Levamisole-Induced Antineutrophil- Cytoplasmic-Antibody-Positive Vasculitis Presenting as Inflammatory Orbitopathy. Ophthalmic Plast Reconstr Surg 2021; 36:e96-e100. [PMID: 32221103 DOI: 10.1097/iop.0000000000001612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A 35-year-old woman with a history of cocaine abuse presented with progressively worsening OS pain. Neuroimaging revealed a 3-cm ill-defined left orbital lesion involving the intraconal and extraconal spaces. The orbital mass was biopsied via an anterior orbitotomy approach. Pathology demonstrated prominent angiocentric granulomatous and lymphoplasmacytic inflammation consistent with vasculitis. Laboratory tests were significant for neutropenia, positive perinuclear antineutrophil cytoplasmic antibodies with high titer, and positive myeloperoxidase antibodies, consistent with levamisole-induced vasculitis. To the authors' knowledge, this is the first reported case of cocaine-levamisole-induced vasculitis presenting as orbitopathy.
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8
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Pendolino AL, Unadkat S, Zhang H, Pendolino M, Bianchi G, Randhawa PS, Andrews PJ. The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review. SAGE Open Med 2020; 8:2050312120936731. [PMID: 32676189 PMCID: PMC7340348 DOI: 10.1177/2050312120936731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/29/2020] [Indexed: 01/28/2023] Open
Abstract
Background: The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission. Purpose: The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement. Materials and methods: A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020. Conclusion: Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.
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Affiliation(s)
- Alfonso Luca Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
| | - Samit Unadkat
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Henry Zhang
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Monica Pendolino
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Gerolamo Bianchi
- Division of Rheumatology, Department of Locomotor System, ASL 3, Genoa, Italy
| | - Premjit S Randhawa
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK
| | - Peter J Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, UK.,Ear Institute, University College London (UCL), London, UK
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Mirzaei A, Zabihiyeganeh M, Haqiqi A. Differentiation of Cocaine-Induced Midline Destructive Lesions from ANCA-Associated Vasculitis. IRANIAN JOURNAL OF OTORHINOLARYNGOLOGY 2018; 30:309-313. [PMID: 30245987 PMCID: PMC6147272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Cocaine-induced midline destructive lesions (CIMDL) are complications of regular nasal cocaine inhalation. CIMDL can mimic systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA), such as granulomatosis with polyangiitis (GPA). CASE REPORT In this article, we describe the case of a young woman who presented with nasal perforation induced by cocaine, along with positive perinuclear ANCA test (proteinase 3 antigen), misdiagnosed as limited GPA. The patient was treated with immunosuppressive therapy, which partially improved her symptoms. Admittance of cocaine use aided in the diagnosis of CIMDL. This patient was advised to stop cocaine use. Three-month follow-up revealed no further complications. CONCLUSION Considering the seropositivity of ANCA in both CIMDL and GPA, early diagnosis of CIMDL and its differentiation from GPA is crucial, and clinicians play an important role in this regard. Lack of distinct histologic characteristics of vasculitis or unresponsiveness to standard therapeutic regimens may favor the diagnosis of CIMDL syndrome. It is crucial to recognize that these conditions may have similar presentations, so that undesired and potentially toxic treatments can be prevented.
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Affiliation(s)
- Alireza Mirzaei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Mozhdeh Zabihiyeganeh
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.,Corresponding Author: Shafa Orthopedic Hospital, Baharestan Sq, Tehran, Iran. Tel: +98(21)33542000-8, E-mail:
| | - Ala Haqiqi
- Department of General Medicine, St. George’s University Hospitals NHS Foundation Trust, London, UK.
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10
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Destructive and painful ulcer in the posterior oral cavity and oropharynx. J Am Dent Assoc 2017; 148:678-683. [PMID: 28847374 DOI: 10.1016/j.adaj.2017.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/17/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
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Guntupalli L, Patel K, Faraji F, Brunworth JD. Autoimmune-related nasal septum perforation: A case report and systematic review. ALLERGY & RHINOLOGY 2017; 8:40-44. [PMID: 28381327 PMCID: PMC5380452 DOI: 10.2500/ar.2017.8.0191] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Inflammatory injury of nasal respiratory mucosa is a common feature of multisystem autoimmune disease. Certain autoimmune disorders are associated with nasal septum perforation (NSP). We performed a systematic review of the literature to better understand the association of NSP with specific autoimmune disorders. This is a case report of a 29-year-old woman with a history of arthralgia, autoreactive antibody titers, platelet dysfunction, and NSP. The constellation of symptoms and potential familial involvement indicated that the NSP in this patient was an early sign of an autoimmune disorder, an unknown autoimmune disorder, or a known disease with incomplete penetrance. Methods: A systematic review of the literature was performed by two independent reviewers. Relevant articles were reviewed, and data that pertained to autoimmune-related NSP were extracted and analyzed. Results: Overall, 140 cases of autoimmune-associated NSPs were reported. Granulomatosis with polyangiitis (48%), relapsing polychondritis (26%), and cocaine-induced midline lesions (15%) constituted 89.3% of the reported cases. Conclusion: NSP is a potential sign of systemic disease. The identification of an NSP, especially in the context of other unexplained symptoms or workup suggestive of an autoimmune disorder, should prompt clinical evaluation for multisystem autoimmune disease with consideration of granulomatosis with polyangiitis, relapsing polychondritis, or cocaine-induced midline lesions.
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Affiliation(s)
- Lohitha Guntupalli
- From the Department of Otolaryngology Head and Neck Surgery, School of Medicine, St. Louis University, St. Louis, Missouri
| | - Kunjan Patel
- From the Department of Otolaryngology Head and Neck Surgery, School of Medicine, St. Louis University, St. Louis, Missouri
| | - Farhoud Faraji
- From the Department of Otolaryngology Head and Neck Surgery, School of Medicine, St. Louis University, St. Louis, Missouri
| | - Joseph D. Brunworth
- From the Department of Otolaryngology Head and Neck Surgery, School of Medicine, St. Louis University, St. Louis, Missouri
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12
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D'Anza B, Langford CA, Sindwani R. Sinonasal imaging findings in granulomatosis with polyangiitis (Wegener granulomatosis): A systematic review. Am J Rhinol Allergy 2017; 31:16-21. [PMID: 28234146 DOI: 10.2500/ajra.2017.31.4408] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) (Wegener granulomatosis) frequently presents in the head and neck, and the sinonasal cavity is among the most common areas affected. Although the clinical findings, histologic appearance, and laboratory workup have been described, characteristic findings and the distribution of disease on sinonasal imaging are not well established. The appropriate imaging modality to evaluate for sinonasal involvement is also unclear. OBJECTIVE To describe the imaging characteristics, distribution, and location of sinonasal pathology in patients with GPA as noted on computed tomography and magnetic resonance imaging modalities. METHODS A systematic review was conducted of English language articles, by using appropriate search terms, which reported the computed tomography and magnetic resonance imaging findings specific to sinonasal disease in adult subjects with GPA. Studies were included only when they focused primarily on specific imaging results in patients with GPA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS A total of 50 articles were identified on an initial search of medical literature data bases. There were seven articles that comprised 224 patients who met inclusion criteria. All the articles were retrospective case series and descriptive in nature. A high incidence of patients with GPA who were imaged showed evidence of pathologic findings. The prevalence of key radiographic findings in patients with GPA were the following: mucosal thickening (87.7% of patients), bony destruction (59.9%), and septal erosion (59.4%). There were no randomized or prospective studies that compared imaging findings between patients with GPA and the controls, and no studies that correlated imaging findings with prognosis. CONCLUSION Sinus imaging in GPA revealed a spectrum of nonspecific findings. The constellation of septal erosion, mucosal thickening, and bony changes should raise suspicion for GPA. The current literature was insufficient to make any comments on the time course of sinonasal disease and imaging manifestations. Further comparative studies are needed to determine a role for sinonasal imaging in the diagnosis and prognosis of GPA.
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Affiliation(s)
- Brian D'Anza
- Division of Rhinology, Allergy, and Skull Base Surgery, ENT Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA
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13
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Cutaneous Leishmaniasis: An Overlooked Etiology of Midfacial Destructive Lesions. PLoS Negl Trop Dis 2016; 10:e0004426. [PMID: 26862748 PMCID: PMC4749285 DOI: 10.1371/journal.pntd.0004426] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/12/2016] [Indexed: 11/29/2022] Open
Abstract
Background Midline destructive lesions of the face (MDL) have a wide range of etiologies. Cutaneous Leishmaniasis (CL) is rarely reported as a possible cause. Methods Fifteen patients with solitary nasal lesions caused by CL were studied. The clinical data, biopsies/scrapings and PCR were collected/performed. Ridley’s Pattern (RP) and Parasitic Index (PI) were documented. Results Patients’ age ranged from 1 to 60 years including 7 males and 8 females. The duration of the observed lesions ranged from 1 to 18 months. Clinically, the lesions showed 6 patterns varying from dermal erythematous papulonodular with no epidermal changes to destructive erythematous plaque with massive central hemorrhagic crust. The clinical impression ranged from neoplastic to inflammatory processes. RP varied among the cases [RP 3 (n = 6), RP 4 (n = 3), RP 5 (n = 6)]. All cases show low PI [PI 0 (n = 7), PI 1 (n = 6), PI 2 (n = 1), and PI 3 (n = 1)]. Higher PI was noted in the pediatric group [average age 24 years for PI 0–1 vs. 6.5 years for PI 2–3]. Molecular speciation showed Leishmania tropica (n = 13) and Leishmania major (n = 2). All the patients received Meglumine Antimoniate (Glucantine) injections and had initial cure defined as complete scarring and disappearance of inflammatory signs within 3 months. Conclusion Leishmaniasis may cause MDL especially in endemic areas. PCR is instrumental in confirming the diagnosis. MDL caused by CL showed wide spectrum of clinical and microscopic presentation. Midline destructive lesions of the face (MDL) involve a process that leads to ulceration and loss of the normal structure. The possible causes vary from infectious to neoplastic. Cutaneous Leishmaniasis (CL) is a neglected tropical disease that is transmitted through the bite of one of the female phlebotomine sandflies and is continuing to spread in endemic and non-endemic regions secondary to environmental and human made changes. CL is rarely reported as a possible cause of MDL. With the influx of over 1,500,000 refugees from Leishmania-endemic areas in Syria seeking shelter from the current conflict in their country, Lebanon, a Leishmania under-endemic country, is facing an epidemic outbreak of CL. In this study, we obtained clinical and laboratory data on 15 patients with solitary nasal lesions caused by CL. We concluded that Leishmaniasis may cause MDL especially in endemic areas and that PCR is instrumental in confirming the diagnosis. Moreover, MDL caused by CL showed wide spectrum of clinical and microscopic presentation.
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14
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Janisiewicz AM, Klau MH, Keschner DB, Lehmer RR, Venkat KV, Medhekar SS, Chang PK, Badran K, Leary R, Garg R, Nguyen AA, Lee JT. Higher Antineutrophil Cytoplasmic Antibody (C-ANCA) Titers are Associated with Increased Overall Healthcare Use in Patients with Sinonasal Manifestations of Granulomatosis with Polyangiitis (GPA). Am J Rhinol Allergy 2015; 29:202-6. [DOI: 10.2500/ajra.2015.29.4147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Granulomatosis with polyangiitis (GPA) is an autoimmune disease characterized by necrotizing granulomatous airway inflammation and vasculitis. Sinonasal involvement occurs in more than 80% cases, with antineutrophil cytoplasmic antibody (C-ANCA) titers used as a marker of disease severity. The purpose of this study was to determine whether C-ANCA levels impact radiographic findings and healthcare use in patients with sinonasal GPA. Methods A retrospective review was performed on GPA patients evaluated in a multidisciplinary rheumatologic/otolaryngologic clinic from 2008 to 2013. Data were collected with respect to age, gender, clinical presentation, C-ANCA titers, Lund-Mackay (LM) scores, surgical interventions, and healthcare use, the latter of which were determined by assessing the number of rheumatology/otolaryngology clinic visits, computed tomography (CT) scans, and email/telephone encounters. Results A total of 44 patients were identified, 11 male and 33 female. Sinonasal manifestations were evident in 70.4%, with chronic rhinosinusitis (CRS) (41.9%), septal perforation (38.7%), and crusting (32.2%) the most common findings. No significant differences in number of CT scans (p = 0.10) or mean LM scores (p = 0.47) were found between patients with more than or equal to 1:80 and less than 1:80 C-ANCA titers, respectively. However, overall healthcare use was increased in the more than or equal to 1:80 C-ANCA group (n = 28) compared with less than 1:80 (n = 16), with a significantly greater number of rheumatologic/otolaryngologic encounters (mean 121 versus 69.2, p = 0.03) noted. When otolaryngologic healthcare use was specifically examined, the average number of encounters was also higher in more than or equal to 1:80 C-ANCA patients (31.9 versus 22.9), but this difference was not statistically significant (p = 0.16). Conclusion Sinonasal GPA patients with presenting C-ANCA titers more than or equal to 1:80 demonstrated significantly greater overall healthcare use than their lower C-ANCA level counterparts (less than 1:80). However, no significant differences in otolaryngology resource use or LM scores were evident between the two titer groups.
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Affiliation(s)
| | - Marc H. Klau
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - David B. Keschner
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Randy R. Lehmer
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Kumar V. Venkat
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Swati S. Medhekar
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Parke K. Chang
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Karam Badran
- University of California, Irvine School of Medicine, Irvine, California
| | - Ryan Leary
- University of California, Irvine School of Medicine, Irvine, California
| | - Rohit Garg
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
| | - Andrew A. Nguyen
- Department of Rheumatology, Irvine Medical Center, Southern California Permanente Medical Group, Irvine, California
| | - Jivianne T. Lee
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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15
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Trimarchi M, Bozzolo E, Pilolli F, Bertazzoni G, Campochiaro C, Sabbadini MG, Bussi M. Nasal mucosa narrow band imaging in granulomatosis with polyangiitis (Wegener granulomatosis): A preliminary study. Am J Rhinol Allergy 2015; 29:170-4. [PMID: 25781561 DOI: 10.2500/ajra.2015.29.4169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Narrow band imaging (NBI) endoscopy is a technique that allows for real-time visualization of mucosal and submucosal vascular patterns. OBJECTIVE Because granulomatosis with polyangiitis (GPA) (Wegener granulomatosis) is an autoimmune disease defined by vascular inflammation, we examined patients with GPA and with NBI to evaluate whether disease-specific mucosal vascular patterns were present. To the best of our knowledge, the use of NBI endoscopy for assessment of an immune system disease such as GPA has never been previously attempted. METHODS We conducted a prospective observational study by performing an endoscopic evaluation of upper airways with NBI on patients diagnosed with GPA; on patients with symptoms and signs suggestive for GPA, who were scheduled to undergo nasal biopsy to confirm diagnosis; on patients affected by chronic rhinosinusitis with nasal polyps; and on healthy controls. RESULTS We enrolled 69 patients. NBI vascular patterns in patients with GPA were consistently and recognizably different from healthy mucosal patterns in 53% of our cases. In patients with GPA, biopsy and NBI results were for the most part comparable, except for three cases. CONCLUSION Nasal mucosa NBI endoscopy can be considered a promising rapid and noninvasive live imaging technique for nasal mucosa GPA that, based on further study, could become a supplementary diagnostic tool in the complex workup of GPA and vasculitis.
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Affiliation(s)
- Matteo Trimarchi
- Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy
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16
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Crovetto-Martínez R, Aguirre-Urizar JM, Orte-Aldea C, Araluce-Iturbe I, Whyte-Orozco J, Crovetto-De la Torre MA. Mucocutaneous leishmaniasis must be included in the differential diagnosis of midline destructive disease: two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 119:e20-6. [PMID: 25442251 DOI: 10.1016/j.oooo.2014.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 08/18/2014] [Accepted: 09/09/2014] [Indexed: 01/05/2023]
Abstract
Midline destructive lesions have multiple possible etiologies, which can be grouped into neoplastic, infectious, or vasculitis-associated. The purpose of these case reports and literature review was to highlight the need to include mucocutaneous leishmaniasis in the diagnosis of midfacial lesions in any patient who has lived in Leishmania-endemic areas because this entity meets all of the clinical criteria to be considered a form of midline destructive lesion. We present two cases of mucocutaneous leishmaniasis that occurred in a Bolivian male immigrant and a European male traveler to Panama, in whom lesions were misdiagnosed as different midline destructive lesions with different causes (Wegener, vasculitis, and natural killer or T-cell lymphoma [NKTL]). The conclusion of our work is that all patients with midline destructive lesions should undergo histologic and molecular studies to be evaluated for mucosal leishmaniasis, particularly patients whose clinical history suggests this possibility. In cases of uvular involvement, biopsy of this region might be a possible alternative to nasal biopsy.
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Affiliation(s)
- R Crovetto-Martínez
- Department of Stomatology II, University of the Basque Country / EHU, Spain.
| | - J M Aguirre-Urizar
- Department of Stomatology II, University of the Basque Country / EHU, Spain
| | - C Orte-Aldea
- Department of Otorhinolaryngology, Miguel Servet Hospital, Zaragoza, Spain
| | - I Araluce-Iturbe
- Department of Otorhinolaryngology, Basurto University Hospital (UPV/EHU), Bilbao, Vizcaya, Spain
| | - J Whyte-Orozco
- Department of Anatomy and Histology, University of Zaragoza, Spain
| | - M A Crovetto-De la Torre
- Department of Otorhinolaryngology, Basurto University Hospital (UPV/EHU), Bilbao, Vizcaya, Spain
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