An update on the general management approach to common vasculitides

An Update on Vasculitis for the General Physician

The term vasculitis is used to describe a heterogenous group of rare disease characterised by immune-mediated damage to the blood vessels resulting in downstream ischaemia, tissue injury and end-organ damage. The classification of vasculitis is based upon the size of the vessels typically affected, which results in the broad range of clinical features associated with the different forms of vasculitis. Advances in treatment of vasculitis from the emergence of corticosteroids to the modern application of targeted immunomodulatory treatments have resulted in lower mortality associated with vasculitis but it is still associated with high healthcare resources and disease-related morbidity. Vasculitis is typically managed by rheumatologists working alongside a broad multi-disciplinary team with input from a range of medical and surgical specialties, reflecting its truly multisystem nature. Vasculitis will often present on general medical wards, with diagnosis sometimes delayed as more common infective and malignant diseases are excluded. General physicians require an understanding of the clinical features of vasculitis and have knowledge of the relevant practical approaches to investigation and management of suspected vasculitis. The present review shall provide an over-arching summary of the different forms of vasculitis and a practical approach to investigation and management aimed at the general physician.

Rapidly Progressive, Symmetrical, Acute Cutaneous Necrosis of Bilateral Lower Limbs: A Rare Presentation of Polyarteritis Nodosa

Acute cutaneous necrosis is a rare presentation of polyarteritis nodosa (PAN). In this study, we report a presentation with symmetrical cutaneous necrosis of the lower limbs, which ascended upward at a rapid rate. A 47-year-old man presented with a fever of one day and pain in the feet for six days. He had no history of claudication. Upon examination, he was febrile, and subtle bluish discoloration was observed on the sole of his foot. There was a bilateral stocking-type paresthesia up to the ankle joint. His blood pressure on admission was 210/120 mmHg. Eight hours later, the pain subsided, but a left-sided foot drop was noted along with the paresthesia extending up both feet to approximately 10 cm above the medial malleolus. The feet turned black, and dark discoloration spread rapidly upward over the next 16 hours, and the skin became necrosed. A clinical diagnosis of vasculitis was established, and the patient received IV methylprednisolone at a daily dosage of 1 g for three days, effectively stopping the advancement of necrosis. This was followed by treatment with IV cyclophosphamide. A conclusive diagnosis of PAN was made, and the patient underwent wound debridement. After three months of physiotherapy, a successful skin graft was performed. Prompt identification of the underlying etiology is crucial to prevent the advancement of necrosis and save the limbs. When vasculitis is suspected, ruling out infectious causes is essential before starting early immunosuppressive treatment.

Updates in cutaneous manifestations of systemic vasculitis

PURPOSE OF REVIEW

The main purpose of this review is to present newly reported cutaneous manifestations of systemic vasculitis, updates in investigations to verify systemic involvement in cases with cutaneous vasculitis and new therapeutic guidelines. The spectrum of COVID-19-related vasculitis is also covered.

RECENT FINDINGS

Only a few reports highlighted new cutaneous presentations or associations with some systemic vasculitic entities. For example, the association of inflammatory disorders with Takayasu arteritis, the importance of considering Kawasaki disease in febrile children with erythema nodosum, the development of necrotic ulcers on fingers and toes in Behçet's disease and the possible presence of polyarteritis nodosa-like pathological features in vulvar ulcers of Behçet's disease. New attempts to classify cutaneous manifestations of giant cell arteritis (GCA) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and the diagnostic investigations for cutaneous vasculitis cases to verify systemic involvement are discussed. Treatment of systemic vasculitis with cutaneous vasculitis should be tailored according to disease status. A plethora of reports in the past 2 years focused on the broad spectrum of COVID-19 vasculitic manifestations.

SUMMARY

Although newly reported cutaneous manifestations of systemic vasculitis are relatively uncommon, the plethora of reports in the past 2 years on COVID-19 vasculitis necessitates the expansion of the classification of vasculitis associated with probable cause to include severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) vasculitis.