Limited granulomatosis with polyangiitis in an adolescent with Crohn's disease on infliximab therapy: cause or coincidence?

Vasculitis induced by biological agents used in rheumatology practice: A systematic review

Objectives: Biological medications have been used with an increasing frequency to treat rheumatological diseases. Autoimmune events can be induced by these drugs, such as psoriasiform lesions, alopecia, lupus and, vasculitis, which more often affects the skin (small-sized vessels) and eventually other organs. In this review, we describe the clinical profile of patients with vasculitis induced by the main biological agents used in rheumatology.

Patients and methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubMed database was used for searching eligible articles. We included case reports, case series, and letter to the editor of patients on anti-tumor necrosis factor-alpha (anti-TNF-a) molecules, as well as tocilizumab, ustekinumab, secukinumab, rituximab, and abatacept, who had vasculitis induced by these agents.

Results: Eighty-one articles were included for final analysis (n=89). Twenty-seven patients were using infliximab, 20 adalimumab, 18 etanercept, seven secukinumab, four certolizumab, four rituximab, three golimumab, three ustekinumab, two abatacept, and one tocilizumab. Unspecific leukocytoclastic vasculitis (LCV) was the most common type of vasculitis (n=37), followed by anti-neutrophil cytoplasmic antibody (ANCA)- associated vasculitis (n=16). The medication was replaced with another biological molecule in 23 cases, with only four relapses. In six cases, the biological was maintained, but vasculitis worsened/persisted in one case, being necessary drug removal.

Conclusion: Infections, infusion reaction, cancer, and autoimmune events are well-known side effects of biological therapy. This review demonstrates that vasculitis is another adverse effect of this type of therapy, particularly the anti-TNF-a molecules, and LCV the most reported type of vasculitis.

Significance of granuloma and granulomatous lymphangitis in the differential diagnosis of Crohn's disease

OBJECTIVE

To clarify the pathological characteristics of granuloma and granulomatous lymphangitis in patients with non-neoplastic bowel diseases and to compare their significance in the differential diagnosis of Crohn's disease (CD) and intestinal tuberculosis (ITB).

METHODS

Altogether 78 cases with CD, 11 with ITB and 33 suffering from other non-neoplastic bowel diseases were included. All patients underwent a partial enterectomy and histopathological examination. Pathological sections were reviewed retrospectively. Detailed morphological features and the distribution of granulomas and granulomatous lymphangitis in the three groups were analyzed and compared.

RESULTS

Significant differences in the features of granuloma were observed in CD compared with ITB, including the presence of Langhans giant cells, caseous necrosis, coalescence, hyaline change, onionskin changes, and their frequency and size. Granulomatous lymphangitis was significantly more frequent in CD than in other non-neoplastic bowel diseases (P < 0.0001). The rate was also higher than that of granuloma in CD (P = 0.0004). It more often manifested within the mucosal layer of the small bowel (55.4%) in CD whereas it tended to be located within the deep layers of the intestinal wall in other diseases. It can be divided into four types, but types 1 and 2 appeared relatively specific to CD.

CONCLUSIONS

Granuloma and granulomatous lymphangitis were not specific in CD. However, by combining morphology and distribution, their manifestations could assist in the differentiation of CD from other non-neoplastic bowel diseases. Furthermore, granulomatous lymphangitis showed better diagnostic performance than granulomas in the mucosal layer of the small bowel.