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Padoan R, Campaniello D, Gatto M, Schiavon F, Doria A. Current clinical and therapeutic approach to tumour-like mass lesions in granulomatosis with polyangiitis. Autoimmun Rev 2021; 21:103018. [PMID: 34902605 DOI: 10.1016/j.autrev.2021.103018] [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: 11/23/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disorder classified among the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and characterized by a triad of upper and lower respiratory tract disease, systemic vasculitis involving small-to-medium vessels and renal manifestations. Mass lesions, also described as inflammatory lesions, pseudotumor or tumour-like masses, are uncommon manifestations of GPA and are often called granuloma since histology examination shows granulomatous inflammation and rarely vasculitis. Masses could represent a localized manifestation of GPA or develop as part of a systemic disease. Unusual clinical presentation together with nonspecific radiological and histological features may delay the correct diagnosis leading to disease progression and organ damage. Diagnosis of GPA in such cases may be challenging and malignancy or infections must be considered as alternative diagnostic options. Here we reviewed all the different sites where mass lesions were reported in GPA, focusing on atypical localization, and summarized current therapeutic options and their different outcomes. We retrieved and discussed the cases reported since 2010, bearing in mind the advances in the therapeutic management of AAV patients in the last decade, namely biological therapy such as rituximab. Despite treatment regimens with glucocorticoids and immunosuppressive agents, mass lesions have a refractory course in a high proportion of patients. Invasive surgical procedures may be considered only when drug therapy fails.
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Affiliation(s)
- Roberto Padoan
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Debora Campaniello
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Franco Schiavon
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine DIMED, University of Padova, Italy.
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Bahrami B, Juniat V, Davis G, Selva D. Pachymeningeal enhancement on magnetic resonance imaging in granulomatosis with polyangiitis. Can J Ophthalmol 2020; 55:e181-e182. [PMID: 32439195 DOI: 10.1016/j.jcjo.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/24/2020] [Accepted: 04/08/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Bobak Bahrami
- University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia.
| | - Valerie Juniat
- University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Garry Davis
- University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Dinesh Selva
- University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
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Durel CA, Hot A, Trefond L, Aumaitre O, Pugnet G, Samson M, Abad S, Belot A, Blanchard-Delaunay C, Cohen P, Cohen-Aubard F, Cottin V, Crestani B, Moreuil CD, Durupt S, Garzaro M, Girszyn N, Godeau B, Hachulla E, Jamilloux Y, Jego P, Killian M, Lazaro E, Le Gallou T, Liozon E, Martin T, Papo T, Perlat A, Pillet P, Guillevin L, Terrier B. Orbital mass in ANCA-associated vasculitides: data on clinical, biological, radiological and histological presentation, therapeutic management, and outcome from 59 patients. Rheumatology (Oxford) 2019; 58:1565-1573. [DOI: 10.1093/rheumatology/kez071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Objective
Orbital mass is a rare and sight-threatening manifestation of ANCA-associated vasculitides, which remains a therapeutic challenge. We aimed to describe the presentation, therapeutic management and outcome of ANCA-associated vasculitides-related orbital mass.
Methods
We conducted a French nationwide retrospective study of patients with orbital mass in the setting of ANCA-associated vasculitides according to ACR criteria and/or Chapel Hill Consensus Conference definitions.
Results
Fifty-nine patients [33 women, median age 46 (range 7–90) years] were included. Fifty-six (95%) patients had granulomatosis with polyangiitis, two eosinophilic granulomatosis with polyangiitis and one microscopic polyangiitis. Orbital mass was unilateral in 47 (80%) cases, and seemed to develop from ENT involvement in most cases. Orbital mass biopsy was available in 32 (54%) patients, showing lymphoplasmacytic infiltration in 65%, fibrosis in 55%, granulomas in 48% and vasculitis in 36%. All patients but one received glucocorticoids as first-line therapy associated with immunosuppressive agents in 82%, mainly cyclophosphamide. Response to therapy was noted in 52% of patients treated with cyclophosphamide compared with 91% of those treated with rituximab. Twenty-seven (46%) patients required a second-line therapy because of relapse (59%) or refractory course (41%). Sequelae included visual impairment in 28%, with definitive blindness in 17%. Refractory course was associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
Conclusion
Orbital mass is associated with refractory course and high frequency of sequelae, especially blindness. Refractory course is associated with PR3-ANCA positivity, visual loss and contiguous pachymeningitis.
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Affiliation(s)
| | - Arnaud Hot
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon
| | - Ludovic Trefond
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Olivier Aumaitre
- Department of Internal Medicine, Hôpital Gabriel Montpied, Clermont-Ferrand
| | - Gregory Pugnet
- Department of Internal Medicine, Hôpital Purpan, Toulouse
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon
| | - Sébastien Abad
- AP-HP, Hôpital Avicennes, Department of Internal Medicine, Université Paris 13, Sorbonne, Paris Cité, Faculté de Médecine Bobigny, Paris
| | - Alexandre Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, National Referral Center for Inflammatory Rheumatism and Autoimmune Diseases, Hôpital Femme Mère Enfant, Bron
| | | | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris
| | - Fleur Cohen-Aubard
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Lyon
| | | | - Claire De Moreuil
- Department of Internal Medicine, Hôpital de la Cavale Blanche, Brest
| | - Stéphane Durupt
- Department of Internal Medicine, Centre Hospitalier Lyon Sud, Lyon
| | | | - Nicolas Girszyn
- Department of Internal Medicine, Hôpital Charles Nicolle, Rouen
| | - Bertrand Godeau
- Department of Internal Medicine, Referral Center for Adult Autoimmune Cytopenias, Hôpital Henri Mondor, Créteil
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, National Referral Center for Systemic Autoimmune Diseases North and North-West of France, Université de Lille, Lille
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Lyon
| | - Patrick Jego
- Department of Internal Medicine, Hôpital Sud, Rennes
| | - Martin Killian
- Department of Internal Medicine, Hôpital Nord, Saint-Etienne
| | - Estibaliz Lazaro
- Department of Internal Medicine, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac
| | | | - Eric Liozon
- Department of Internal Medicine, Hôpital de Limoges, Limoges
| | - Thierry Martin
- Department of Clinical Immunology, HIV, and Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases RESO, Nouvel Hôpital Civil, Strasbourg
| | - Thomas Papo
- Department of Internal Medicine, Hôpital Bichat, Paris
| | | | - Pascal Pillet
- Department of Medical Pediatrics, CHU de Bordeaux – GH Pellegrin, Bordeaux
| | - Loïc Guillevin
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Hôpital de la Pitié-Salpêtrière, Paris
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Paris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
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Dziedzic T, Wojciechowski J, Nowak A, Marchel A. Hypertrophic pachymeningitis. Childs Nerv Syst 2015; 31:1025-31. [PMID: 25771924 DOI: 10.1007/s00381-015-2680-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases. CASE DESCRIPTION We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.
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Affiliation(s)
- Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland,
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Wallace ZS, Carruthers MN, Khosroshahi A, Carruthers R, Shinagare S, Stemmer-Rachamimov A, Deshpande V, Stone JH. IgG4-related disease and hypertrophic pachymeningitis. Medicine (Baltimore) 2013; 92:206-216. [PMID: 23793110 PMCID: PMC4553969 DOI: 10.1097/md.0b013e31829cce35] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hypertrophic pachymeningitis (HP) is an inflammatory condition in which the dura mater of the cranium or spine becomes thickened, leading to symptoms that result from mass effect, nerve compression, or vascular compromise. The differential diagnosis of HP includes immune-mediated conditions such as rheumatoid arthritis and vasculitis, malignancies, and infections. Many times, no diagnosis is reached; in such cases, the disease has been described as idiopathic HP. IgG4-related disease (IgG4-RD) is a recently described inflammatory condition known to cause tumefactive lesions at myriad anatomical locations. Both IgG4-RD and idiopathic HP share similar demographics, histopathology, and natural history. We hypothesized that IgG4-RD is a common cause of idiopathic HP.To investigate this hypothesis, we identified all pathology specimens diagnosed as noninfectious HP during 25 years at our institution. Fourteen cases had stained slides and paraffin blocks to permit review of the original hematoxylin and eosin stained slides as well as immunostaining of cell blocks. Recently published consensus guidelines describing characteristic histopathology and the necessary quantity of IgG4+ plasma cell infiltrate were used to diagnose IgG4-RD.Four cases (66.6%) that had been regarded previously as representing idiopathic HP were diagnosed as IgG4-RD; of all the reviewed cases, IgG4-RD represented 29% of cases. Of the remaining cases, 3 cases were associated with granulomatosis with polyangiitis (GPA), 2 with lymphoma, and 1 each with rheumatoid arthritis, giant cell arteritis, and sarcoidosis. Two of the cases could not be diagnosed more precisely and were classified as undifferentiated HP. Clinical history, serologic tests, cerebrospinal fluid studies, and radiology alone could not identify the cause of HP. Rather, biopsy with histopathology and immunostaining was necessary to reach an accurate diagnosis. Significant IgG4+ plasma cell infiltrates were observed in rheumatoid arthritis, granulomatosis with polyangiitis, and lymphoma, underscoring the importance of histopathology in making the diagnosis of IgG4-RD.This case series demonstrates that IgG4-RD may be the most common etiology of noninfectious HP and highlights the necessity of biopsy for accurate diagnosis.
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Affiliation(s)
- Zachary S Wallace
- From Department of Medicine (ZSW, MNC, AK, JHS); Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology (MNC, AK, JHS); Department of Neurology (RC); and Department of Pathology (SS, ASR, VD); Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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