Predictors of medications-free and long-term remission in anti-neutrophil cytoplasmic antibody-associated vasculitis: Real-world evidence

BACKGROUND AND AIM

In this study, we report the outcomes of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in daily practice based on Connective Tissue Diseases Research Center-Vasculitis Registry (CTDRC-VR) data.

METHODS

Patients were included if they were 18 years or older, had a diagnosis of the groups of AAV based on 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis and microscopic polyangiitis, and were followed for a period longer than 2 years or were died. Complete clinical remission was defined as granulomatosis with polyangiitis (BVAS/GPA) of 0. Sustained remission was defined as a complete clinical remission for at least six months and tapering prednisolone dose to ≤ 7.5 mg/d. Long-term remission was defined as complete clinical remission for ≥ 5 years and tapering prednisolone dose to ≤ 7.5 mg/d. Medications-free remission was defined as complete clinical remission and discontinuation of glucocorticoids, cytotoxic medications and biologics.

RESULTS

Sixty patients with AAV were enrolled in this study. Sustained and long-term remission were developed in 91.7 and 72.1 percent of patients, respectively. Relapse was developed in 27 (45%) patients. Medications-free remission was developed in 23 (33.3%) patients. Vasculitis induced damage was developed in 40 (66.7%) patients. Patients with damage had significantly lower age and higher BVAS at the baseline. Upper airway and renal involvement, and non-adherence in patients with damage was significantly more common.

CONCLUSIONS

Induction therapy leads to long-term and medications-free remission in 72% and 38% of patients with AAV, respectively.

Unexpected Relapse: Insights Into Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is a rare vasculitis that can pose a significant mortality risk given its multiorgan involvement and is the most common of the three anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. Cardinal pathological features include necrotizing granulomas of the respiratory tract, small and medium vessel vasculitis, and glomerulonephritis. Early treatment is imperative to reduce permanent organ damage such as end-stage kidney disease. We describe the first case of GPA relapse 38 years after the initial pulmonary presentation. The patient previously had isolated lung involvement with preserved renal function, but presented with an acute kidney injury, uremia, and several constitutional symptoms. The patient was treated with corticosteroids and intermittent hemodialysis and initiated on immunosuppressants; the clinical course is highlighted by eventual renal recovery. Our purpose is to highlight the importance of treating patients to complete immunological recovery, particularly in GPA vasculitis, to prevent unnecessary relapse and further loss of renal function.

Hypertrophic Pachymeningitis: An Unusual Cause of Headache

Hypertrophic pachymeningitis (HP) is a rare condition characterized by inflammation and thickening of the dura mater. It can be idiopathic or secondary to various causes, including infections, tumors, or systemic inflammatory diseases. Diagnosis is challenging due to its rarity and the overlap of symptoms with other conditions. We present the case of a 42-year-old Hispanic woman with diabetes mellitus type 2 and end-stage kidney disease who presented with chest pain, dry cough, mild dyspnea, and chronic occipital headaches. Physical examination revealed cranial VI nerve palsy. Imaging showed pulmonary cavitary lesions and mediastinal lymphadenopathy. Elevated inflammatory markers and positive autoimmune tests, including rheumatoid factor and antineutrophil cytoplasmic antibody (ANCA), led to further investigation. Brain imaging revealed dural thickening, confirming HP. The patient's medical history revealed double ANCA positivity and a lung biopsy confirmed granulomatous pneumonitis. A diagnosis of ANCA-associated vasculitis (granulomatosis with polyangiitis (GPA)) was established, and treatment with rituximab and high-dose corticosteroids led to symptom improvement. GPA rarely involves meningeal inflammation, but severe and persistent headaches are common early symptoms. Inflammatory markers are often elevated, and around two-thirds of HP cases related to GPA have positive serum ANCA. MRI is the primary diagnostic tool, with characteristic findings of dural thickening and contrast enhancement. This case highlights HP as a rare cause of chronic headaches and the importance of a comprehensive medical history in diagnosis. Early recognition and treatment are crucial for improving outcomes in GPA-related HP.

A Rare Case of Autoimmune Disorder as a Trigger for Atypical Hemolytic Uremic Syndrome

Autoimmune diseases may act as a trigger for atypical hemolytic uremic syndrome (aHUS). Triggers for aHUS may include autoimmune diseases, infections, metabolic conditions, pregnancy, and transplants. aHUS-mediated injury to various organs, especially kidneys, can be life-threatening. Here, we present the case of a young female who had perinuclear antineutrophil cytoplasmic antibody (p-ANCA)-associated vasculitis and was diagnosed with aHUS. We consider underlying autoimmune p-ANCA-associated vasculitis as a trigger for aHUS in this case.

The Association Between Age at Diagnosis and Disease Characteristics and Damage in Patients With ANCA-Associated Vasculitis

OBJECTIVE

This study examined the relationship between age at diagnosis and disease characteristics and damage in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

Analysis of a prospective longitudinal cohort of patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA) in the Vasculitis Clinical Research Consortium (2013-2021). Disease cohorts were divided by age at diagnosis (years): children (<18), young adults (18-40), middle-aged adults (41-65), and older adults (>65). Data included demographics, ANCA type, clinical characteristics, Vasculitis Damage Index (VDI) scores, ANCA Vasculitis Index of Damage (AVID) scores, and novel disease-specific and non-disease-specific damage scores built from VDI and AVID items.

RESULTS

Analysis included data from 1020 patients with GPA/MPA and 357 with EGPA. Female predominance in GPA/MPA decreased with age at diagnosis. AAV in childhood was more often GPA and proteinase 3-ANCA positive. Children with GPA/MPA experienced more subglottic stenosis and alveolar hemorrhage; children and young adults with EGPA experienced more alveolar hemorrhage, need for intubation, and gastrointestinal involvement. Older adults (GPA/MPA) had more neurologic manifestations. After adjusting for disease duration, medications, tobacco, and ANCA, all damage scores increased with age at diagnosis for GPA/MPA (P < 0.001) except the disease-specific damage score, which did not differ (P = 0.44). For EGPA, VDI scores increased with age at diagnosis (P < 0.009), whereas all other scores were not significantly different.

CONCLUSION

Age at diagnosis is associated with clinical characteristics in AAV. Although VDI and AVID scores increase with age at diagnosis, this is driven by non-disease-specific damage items.

Evolution of Therapy for ANCA-Associated Vasculitis with Kidney Involvement

ANCA-associated vasculitis (AAV) belongs to a group of small vessel systemic vasculitides characterized by granulomatous and neutrophilic inflammation of various tissues. Patients often have circulating autoantibodies targeting neutrophilic antigens. Although AAV was once associated with severe end-organ damage and extremely high mortality rates, the use of glucocorticoids and cyclophosphamide led to a paradigm change in its treatment. Over the past 20 years, significant progress in understanding the immunopathogenesis of AAV has enabled development of targeted immunotherapies, providing a much better prognosis for patients. This review describes the evolution of treatment of AAV, particularly for patients with kidney involvement.

Hydralazine-Induced Vasculitis: Case Insights and Literature Review for Informed Clinical Recognition and Management

Hydralazine, a commonly prescribed medication for hypertension, has been associated, albeit rarely, with the development of vasculitis. The case presentation involves a 51-year-old female with diabetes and hypertension who presented with a distinctive rash, pancytopenia, and positive findings for various antibodies. A collaborative approach involving rheumatology, hematology, and dermatology was crucial in diagnosing leukocytoclastic vasculitis attributed to hydralazine. Prompt discontinuation of hydralazine and the initiation of a tailored treatment plan led to favorable outcomes. The study sheds light on the clinical manifestations, diagnostic challenges, and management strategies associated with this rare side effect, providing valuable insights for healthcare providers. Increased awareness of hydralazine-induced vasculitis is crucial for early recognition and proper management, ultimately contributing to improved patient outcomes in hypertension management.

A Tangled Autoimmune Trio: Multiple Sclerosis, Systemic Lupus Erythematosus and Antineutrophil Cytoplasmic Antineutrophil Cytoplasmic Antibody Vasculitis

The coexistence of multiple autoimmune diseases in the same individual is unusual and has received little attention in the literature. We present a young female patient with multiple sclerosis, systemic lupus erythematosus, and biopsy-proven renal proteinase 3 antineutrophil cytoplasmic antibodyassociated vasculitis who responded well to intravenous rituximab clinically and serologically.

Low-Dose Intravenous Methylprednisolone in Remission Induction Therapy for ANCA-Associated Vasculitis

Key Points

The contribution of IV methylprednisolone to glucocorticoid toxicity is often overlooked with limited evidence supporting its use. Markedly reduced cumulative glucocorticoid dosing for remission induction therapy in AAV is safe and effective. Reduced IV methylprednisolone and radical steroid avoidance strategies have not been shown to have any significant adverse effect on outcomes.

Background

Glucocorticoids (GCs) remain integral to the management of ANCA-associated vasculitis (AAV), but are associated with significant adverse effects. Recent studies have shown reduced oral GC dosing to be safe and effective; however, data guiding the use of intravenous (IV) methylprednisolone (MTP) are limited.

Method

A single-center retrospective cohort of patients with AAV were divided into two groups: low-dose GC (patients receiving 250 mg of IV MTP, followed by a tapering course of 30 mg of prednisolone daily) versus high-dose GC (1.5 g of IV MTP, followed by a tapering course of 40–60 mg of prednisolone daily). Primary outcomes included ESKD and mortality, and secondary outcomes included GC-related toxicity, remission, and relapse rates. This study was applied to patients with newly diagnosed AAV, including those with severe or life-threatening disease.

Results

Sixty-five patients were included in the final analysis—34 in the high-dose treatment group and 31 in the low-dose treatment group. At diagnosis, more advanced renal impairment and histological disease were present in the low-dose cohort. The rate of ESKD was similar between the groups at 6 and 12 months (P = 0.22, P = 0.60, respectively). More deaths occurred in the high-dose group (26.5% versus 6.5%, P = 0.05), although this was not significant on multivariable analysis (P = 0.06). Remission rates were comparable, and there was no significant difference in relapses. Adverse events were seen in both groups, but patients in the high-dose group experienced a higher incidence of severe infections, weight gain, and steroid-induced diabetes.

Conclusion

We demonstrate that a markedly reduced dose of IV MTP with a lower overall cumulative dose of GCs is safe and effective in the management of severe AAV disease, with no significant difference in primary outcomes.

Unraveling the Puzzle: A Case Report Questioning the Causal Relationship Between Subarachnoid Hemorrhage and Microscopic Polyangiitis

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are small-to-medium-vessel vasculitis, which includes granulomatosis with polyangiitis, microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis. MPA predominantly affects the kidneys and lungs. Subarachnoid hemorrhage (SAH), a life-threatening condition, rarely occurs with AAV. In this case, we present a 67-year-old female who presented with a sudden-onset headache after a recent diagnosis of ANCA-associated renal vasculitis. Kidney biopsy revealed pauci-immune glomerulonephritis, and serum was positive for ANCA along with myeloperoxidase antibody. A computed tomography scan of the head revealed both SAH and intraparenchymal hemorrhage. The patient was managed medically for SAH and intraparenchymal hemorrhage. ANCA vasculitis was treated with steroids and rituximab, and the patient showed improvement.

Pulmonary Artery Aneurysm Associated With Aspergilloma in a Patient Diagnosed With Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is an autoimmune, necrotizing granulomatous disease that affects small- and medium-sized blood vessels. Aspergilloma is a fungal mass of Aspergillus and usually found in the preexisting cavity in lung parenchyma. Surgical resection is the mainstay of treatment of aspergilloma. In this article, we present a case of a 70-year-old male with GPA and aspergilloma who presented with massive, life-threatening hemoptysis. Further workup with a chest computed tomography (CT) pulmonary angiogram demonstrated a pulmonary artery pseudoaneurysm along the wall of the lung cavity which was emergently managed with embolization and required monitoring in the medical intensive care unit. This case report alerts clinicians to maintain a high level of suspicion for an aneurysm if the degree of hemoptysis is higher than expected.

A Runny Nose Leads to a Rare Diagnosis: Chronic Sinusitis as a Sole Manifestation of Limited Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated necrotizing vasculitis of small to medium-sized blood vessels. The typical presentation is the classic triad of upper airway, pulmonary, and renal involvement. However, it can rarely present with the involvement of a single organ system known as limited granulomatosis with polyangiitis. We present a case of a 53-year-old male with chronic rhinosinusitis as the only manifestation of limited GPA. The diagnosis was established incidentally based on biopsy findings from the paranasal sinuses obtained during functional endoscopic sinus surgery. Subsequent testing revealed a positive cytoplasmic antineutrophilic antibody. No evidence of systemic involvement was noted. Prednisone and azathioprine were initiated leading to significant improvement. Although upper respiratory tract involvement is common in GPA, it is rare for the condition to be limited to this organ system. Our case of limited GPA is distinct in that it represents a rare presentation of this already rare disease.

Hydralazine-Associated Vasculitis and Pulmonary Hemorrhage

Hydralazine is a potent vasodilating medication used as adjunctive therapy for the treatment of hypertension. Rarely, hydralazine may cause the development of antineutrophil cytoplasmic antibody vasculitis with the pulmonary-renal syndrome. We are presenting a case of hydralazine-associated vasculitis and pulmonary hemorrhage.

A Case of Microscopic Polyangiitis Complicated by Mucormycosis: A Dangerous Balancing Act

Microscopic polyangiitis (MPA) is a rare antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis marked by renal involvement, which often leads to rapidly progressive glomerulonephritis. Immunosuppressive treatment is necessary to prevent irreparable organ damage. On the other hand, mucormycosis is a rare and devastating opportunistic fungal infection with a high mortality rate in both immunosuppressed and immunocompetent individuals. It requires a high index of suspicion at the time of diagnosis since any delay in treatment may lead to severe morbidity or death. Here, we present the case of a diabetic patient diagnosed with MPA who received partial induction treatment, subsequently developed mucormycosis, survived, yet required continued immunosuppressive treatment for active MPA while imaging was concerning for a persistent mucormycosis infection. This case highlights the barriers to early mucormycosis detection specific to vasculitis patients, mucormycosis considerations unique to the rheumatologic population, and discusses how to balance immunosuppressive treatment in the setting of a deadly opportunistic infection.

A Meta-Analysis and Cohort Study of Histopathologic and Clinical Outcomes in ANCA-Negative versus -Positive Vasculitis

BACKGROUND

ANCA-negative pauci-immune glomerulonephritis (PIGN) represents a rare and often under-studied subgroup of the vasculitides. This study aims to investigate differences in the clinical phenotype, renal histological features, and clinical outcomes of patients with PIGN, with and without serum ANCA positivity.

METHODS

A cohort of biopsy-proven PIGN with and without detectable circulating ANCA was constructed from a single center between 2006 and 2016. Primary outcomes compared clinical presentation and histopathological features according to ANCA status, with multivariate Cox regression to compare mortality and ESKD. A systematic review and meta-analysis of the published literature was undertaken.

RESULTS

In our cohort of 146 patients, 22% (n=32) had ANCA-negative disease, with a comparatively younger mean age at diagnosis; 51.4 versus 65.6 years (P<0.001). In total, 14 studies, inclusive of our cohort, were eligible for meta-analysis, totaling 301 patients who were ANCA negative. Those with ANCA-negative disease tended to have fewer extrarenal symptoms and a higher frequency of renal-limited disease, but both failed to reach statistical significance (P=0.92 and P=0.07). The risk of ESKD was significantly higher in seronegative disease (RR, 2.28; 95% confidence interval, 1.42 to 3.65; P<0.001), reflecting our experience, with a fivefold increased risk of ESKD in ANCA-negative disease (P<0.001). No significant difference in the chronicity of histopathological findings was seen and the meta-analysis showed no difference in morality (RR, 1.22; 95% confidence interval, 0.63 to 2.38; P=0.55).

CONCLUSION

Our findings demonstrate that ANCA-negative PIGN presents in younger patients, with fewer extrarenal manifestations and higher ESKD risk, despite a lack of difference in histopathology. This study provides the impetus for further research into the pathogenesis, treatment response, and duration of immunotherapy in ANCA-negative disease. We suggest that the absence of positive ANCA serology should not discourage treatment and for clinical trials to include patients who are ANCA negative.

A case report of posterior reversible encephalopathy syndrome caused by ANCA-associated vasculitis case report and retrospective analysis

INTRODUCTION

Posterior reversible encephalopathy syndrome is a reversible syndrome clinically manifested by significant variations in neuroimaging. Early treatment is indispensable to achieve the reversibility, which requires the punctual alleviation of its inducing factors.

PATIENT CONCERNS

Most symptoms of posterior reversible encephalopathy syndrome (PRES) patients can be dispelled followed by a good prognosis after the inducement removal. The patient died due to the untimely diagnosis and treatment of the primary disease. Therefore, sufficient attention should be paid to the PRES induced by ANCA-associated vasculitis (AAV).

DIAGNOSIS AND INTERVENTIONS

The patient is a middle-aged male, with acute onset, previous history of hypertension, cholecystectomy, intestinal obstruction, spontaneous renal rupture, etc. For this complaint, the manifestations are mainly blurred vision with convulsion and transient disturbance of consciousness. In 1 day of treatment, these symptoms were relieved, and he was diagnosed as PRES combined with the cranial imaging. The AAV of the patient was confirmed by spleen pathology.

OUTCOMES

Despite the relief of most symptoms in 1 day of symptomatic treatment, it is highly likely that the patient eventually died of AAV, it is highly likely that the patient eventually died of AAV which will invade the vascular system due to the failure to treat the primary disease in time.

LESSONS

For patients diagnosed as PRES, the punctual identification of cause should be performed, so as to diagnose and correct the cause and primary disease as soon as possible, accompanied with the dynamical observation of the relevant indicators for suspected patients to avoid systemic organ failure.

A Unique Case of Myositis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare systemic small-vessel disease, with heterogeneous clinical manifestations. While arthralgia and myalgia are common in the disease course, frank myositis is exceedingly rare. Immune-mediated necrotizing myopathy (IMNM) is a subtype of idiopathic inflammatory myopathies (IIMs), characterized by severe myositis. We report herein a case of prominent diffuse myositis with shared features of AAV and IMNM.

ANCA-associated vasculitis in idiopathic pulmonary fibrosis: A case report and brief review of the literature

RATIONALE

Idiopathic pulmonary fibrosis (IPF) is a progressive disease with poor prognosis. Patients with IPF represent a heterogeneous population with several described clinical phenotypes. More recently, the development of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis in IPF patients, with an incidence higher than that in the general population, has drawn attention.

PATIENT CONCERNS

A 64-year-old woman previously diagnosed with IPF presented to the emergency department with hemoptysis and hypoxemic respiratory failure.

DIAGNOSES

High-resolution chest computed tomography revealed bilateral ground-glass opacities associated with areas of consolidation superimposed on the patient's fibrotic background pattern. Diffuse alveolar hemorrhage was confirmed by the presence of hemorrhagic bronchoalveolar lavage fluid. Hematological and biochemical investigations revealed an inflammatory syndrome, moderate anemia, and rapidly progressive glomerulonephritis. Serological analysis revealed perinuclear antineutrophil cytoplasmic antibody positivity and high levels of antimyeloperoxidase antibodies antibodies. The patient underwent kidney biopsy, which revealed necrotizing glomerulonephritis. Clinical and laboratory findings were diagnostic of microscopic polyangiitis with lung and renal involvement.

INTERVENTIONS

Cyclophosphamide in combination with methylprednisolone was administered as remission induction therapy. The maintenance therapy consisted of mycophenolate mofetil and prednisone.

OUTCOMES

The patient achieved clinical, radiological, and serological remission within six weeks of treatment.

LESSONS

The association between IPF and ANCA-associated vasculitis may represent a distinct clinical phenotype. Autoimmune testing for ANCAs should be considered part of the diagnostic work-up and follow-up of patients with IPF because of the clinical and therapeutic implications of developing vasculitis in an already vulnerable patient.

Antineutrophil cytoplasmic antibody-associated vasculitis with alveolar hemorrhage and ruptured renal aneurysm: A case report and literature review

RATIONALE

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is characterized by necrotizing damage to small-vessel vasculitis and mainly occurs in the kidney or lung. We report a rare case of AAV manifesting as alveolar hemorrhage and a renal aneurysm.

PATIENT CONCERNS

A 50-year-old Chinese man presented with repeated coughing, expectoration, fever, hypoxemia, and respiratory failure. The patient suffered from rupture of the renal aneurysm during immunosuppressive therapy.

DIAGNOSIS

Considering the clinical picture (fever, progressive hypoxemia, renal insufficiency, hemorrhagic bronchoalveolar lavage fluid, and left retroperitoneal hematoma) along with cANCA-PR3 positivity, and lung biopsy findings, the patient was finally diagnosed with granulomatosis with polyangiitis complicated by alveolar hemorrhage and renal aneurysm.

INTERVENTIONS

The patient was initially treated with immunosuppressive therapy combined with plasma exchange and subsequently with renal arterial embolization due to rupture of the renal aneurysm.

OUTCOMES

The general condition and inflammatory reaction improved with immunosuppressive therapy combined with plasma exchange. Unfortunately, the patient did not respond to treatment and eventually died of respiratory failure and acute kidney injury after the rupture of the renal aneurysm.

LESSONS

We encountered unprecedented difficulties and challenges with renal aneurysm rupture. The possibility of aneurysmal rupture should be carefully considered and frequently checked for immunosuppressive therapy for AAV.

Health-Related Quality of Life in Patients With ANCA-Associated Vasculitis and Sinonasal Involvement: A Single-Center Cross-Sectional Study

BACKGROUND/OBJECTIVE

The aim of this study was to assess the impact of sinonasal morbidity on quality of life (QoL) in antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

This cross-sectional case-control study enrolled 71 patients-44 AAV cases with (ear, nose, and throat [ENT]-AAV) or without ENT involvement (non-ENT-AAV) undergoing multidisciplinary evaluations and 27 chronic rhinosinusitis (CRS) cases. Three validated QoL questionnaires (Sino-Nasal Outcomes Test-22 [SNOT-22], Nasal Obstruction Symptom Evaluation [NOSE], and Short-Form 36) were administered, and the 3 groups were compared.

RESULTS

The ENT-AAV patients were significantly younger (p = 0.01), with less antineutrophil cytoplasmic antibody positivity frequency (p = 0.035) and lower renal involvement (p = 0.003) than the non-ENT-AAV patients.The SNOT-22 questionnaire demonstrated significantly greater sinonasal morbidity in ENT-AAV patients compared with CRS patients (p < 0.001). The NOSE score of ENT-AAV patients was comparable to those of CRS patients, but higher than that of non-ENT-AAV patients (p < 0.001). The SNOT-22 and NOSE scores positively correlated with disease activity (p = 0.037; p = 0.004, respectively). Short-Form 36 domain-by-domain analysis revealed a significantly poorer QoL in ENT-AAV patients, especially with physical functioning being progressively impaired in CRS, non-ENT-AAV, and ENT-AAV patients (p < 0.001). No significant differences in QoL came to light when AAV patients were stratified according to current systemic o local treatments.

CONCLUSIONS

The QoL in AAV patients is significantly reduced, especially in the presence of ENT involvement. The AAV-related nasal morbidity is consistent and comparable to that reported by CRS patients. It significantly affects patients' QoL and in particular social functioning, leading to limitation in daily/work activities. Organ-focused questionnaires and multidisciplinary management are warranted to pursue a treat-to-target approach in these patients.

Rare Overlap of Granulomatosis With Polyangiitis in a Patient With Rheumatoid Arthritis

Granulomatosis with polyangiitis (GPA) is a systemic small/medium-sized vessel vasculitis, which is a member of the family of antineutrophil cytoplasmic auto-antibody-associated vasculitides. This disorder affects multiple organs as it is a systemic disease, but overlapping with rheumatoid arthritis is extremely rare, with few cases reported in the medical literature. We report a case of a 55-year-old female with a history of rheumatoid arthritis who presented with recurrent upper/lower respiratory tract symptoms that responded poorly to antibiotics. The patient had elevated antiproteinase antibodies, ANCA IgG titer with a cytoplasmic staining pattern, proteinuria, hematuria, chest imaging showing cavitating and non-cavitating masses, and biopsies of lung and nasal tissue confirming the diagnosis of GPA. Our patient was given immunosuppressant therapy and improvement in lab work and clinical symptoms were seen throughout the course of treatment. This case report is unique as GPA usually rarely presents with rheumatoid arthritis (RA), but in this case, the patient had a history of rheumatoid arthritis with a new biopsy-proven GPA. This case report will help future physicians to better diagnose similar cases and help to facilitate clinical recognition and treatment for the same.

Possible Association Between COVID-19 Infection and De Novo Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

The coronavirus disease 2019 (COVID-19) has caused many different complications including immune-related conditions. Hereby, we report a case of a possible association between COVID-19 infection and de novo anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis presenting with severe pulmonary-renal syndrome as a rare complication of COVID-19 infection. We had a 53-year-old male patient who was admitted for a severe COVID-19 pneumonia complicated by septic shock and acute respiratory distress syndrome. He responded to the standard treatments and was discharged. Four months later, he was admitted with a severe acute pulmonary-renal syndrome (severe acute on chronic kidney failure with active sediment and proteinuria, and diffuse alveolar hemorrhage (DAH) requiring mechanical ventilation). Kidney biopsy confirmed pauci-immune fibro-cellular crescentic glomerulonephritis on top of glomerular sclerosis. Perinuclear-ANCA and anti-myeloperoxidase antibody came back positive. Pulse steroids and cyclophosphamide were administered. Given the chronicity of the kidney lesions, the kidney function did not improve significantly, and the patient became dialysis dependent; however, respiratory status responded dramatically, and he was discharged on room air. In conclusion, although COVID-19 infection can mimic ANCA-associated vasculitis (AAV), the growing number of case reports along with our report shows the need for awareness of a potential link between COVID-19 infection and AAV which would dramatically change the treatment strategy.

Emphysematous Cystitis in a Patient Receiving Cyclophosphamide

Emphysematous cystitis (EC) is a form of complicated urinary tract infection (UTI) well described in patients with diabetes. Other known risk factors include urinary tract obstruction, older age, and female gender. This case describes a patient who developed emphysematous cystitis while receiving induction therapy with intravenous cyclophosphamide to treat antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis that presented with rapidly progressive glomerulonephritis (RPGN). The association between cyclophosphamide therapy and emphysematous cystitis has only been reported twice in literature.

Cocaine and Levamisole Induced Vasculitis

Levamisole adulterated cocaine is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. It is increasingly diagnosed because of raised awareness; however, it is still underdiagnosed in part because of its rarity and patients not reporting cocaine use. Here we report a case of levamisole-induced vasculitis. We present a 48-year-old non-Hispanic white male with a past medical history significant for Crohn’s Disease and pneumonia who presented with acute bilateral ear pain and rash. His urinary drug screen was positive, which prompted suspicion of contamination and potential levamisole adulterated cocaine-associated vasculitis. A punch biopsy showed evidence of leukocytoclastic vasculitis and multiple fibrin thrombi further supporting contamination with levamisole. We believe this case highlights the importance of using patient history in guiding diagnostic testing in the setting of acute vasculitis. Once the history of illicit substance use was confirmed, our differential diagnosis and considerations for treatment significantly changed. 

Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis

A 60-year-old Caucasian female with sero-positive rheumatoid arthritis (RA) was evaluated as a potential kidney donor for her brother-in-law with end-stage kidney disease (ESKD) secondary to c-antineutrophil cytoplasmic antibody (c-ANCA) associated vasculitis (AAV) and membranous nephropathy (MN). With little to no data supporting or contradicting this unique scenario, in addition to the varying viewpoints expressed by the different specialists, our multidisciplinary transplant committee encountered a difficult decision of whether to approve a candidate with RA for a living kidney donation or not. As a result, we carried out a careful literature review addressing aspects of recipients' outcomes following kidney transplants from a living donor with RA, especially when the recipient has AAV, living donor's short- and long-term outcomes post kidney donation, renal disease in AAV and RA, and maintenance of disease remission.

Defining a Therapeutic Window for Rituximab Maintenance Therapy in ANCA-Associated Vasculitis: A Longitudinal Observational Study

Background/Objective:

Rituximab (RTX) has been shown to be effective at maintaining remission in patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), however, the optimal regimen has not been established. The objective of this study was to determine the association between RTX exposure and pharmacological response.

Methods:

Thirty patients with GPA (25) and MPA (5) receiving maintenance therapy with RTX were longitudinally followed in a single tertiary care center. Peripheral blood samples were collected at the trough of RTX therapy and plasma RTX concentrations were measured by ELISA.

Results:

Trough plasma RTX levels greater than 550 ng/mL were associated with B-cell depletion in 100% of the samples analyzed, compared to 51% of samples with levels less than 550 ng/mL (p<0.0001). Trough plasma RTX levels greater than 1,000 ng/mL were associated with hypogammaglobulinemia in 100% of the samples analyzed, compared to 60% of samples with levels less than 1000 ng/mL (p=0.03). There was no association between the peripheral RTX and anti-RTX antibodies. However, the presence of anti-RTX antibodies was associated with a lower risk of hypogammaglobulinemia (83% versus 56%; p=0.04).

Conclusions:

Plasma trough RTX level between 550 ng/mL and 1,000 ng/mL is associated with a higher rate of B-cell depletion while minimizing hypogammaglobulinemia in GPA and MPA patients on maintenance RTX therapy. Establishment of target RTX trough levels would allow for a personalized approach to dosing RTX. However, larger and longer-term studies will be necessary to confirm these initial findings.

Cyclophosphamide induction dose and outcomes in ANCA-associated vasculitis with renal involvement: A comparative cohort study

ABSTRACT

Treatment of ANCA-associated vasculitis (AAV) improved over the last decades but disease-unspecific agents such as cyclophosphamide are still associated with serious adverse events, including high rates of infectious complications and malignancy with increased mortality.In this comparative cohort study, we included 121 AAV patients with renal involvement from 2 German vasculitis centers. Patients were separated into subsequent groups: 2.5 to 3 g vs >3 g cumulative cyclophosphamide induction dose. We investigated if a cyclophosphamide induction dose of 2.5 to 3 g could maintain efficacy while minimizing adverse events in AAV patients with renal involvement.Patients with 2.5 to 3 g vs >3 g cumulative cyclophosphamide (median 3.0 g vs 5.5 g, P < .001) had a comparable time to remission (median 4.0 vs 3.8 months, log-rank P = .87) with 90.6% and 91.5% achieving remission after 12 months. Refractory disease was low in both groups (median 3.6% vs 6.2%, P = .68) and relapse rate did not differ (median 36% vs 42%, log-rank P = .51). Kidney function was comparable at disease onset in both groups (eGFR, mean ± SD 29 ± 20 mL/min/1.73 m2 vs 35 ± 26 mL/min/1.73 m2, P = .34) and improved after 2 years irrespective of the cyclophosphamide dose (ΔeGFR, mean ± SD +8.9 ± 1.4 mL/min/1.73 m2 vs +6.0 ± 1.1 mL/min/1.73 m2, P = .33). The 2.5-3 g group had a lower rate of leukopenia (HR = 2.73 [95% CI, 1.2-6.3], P = .014) and less infectious episodes per patient (median 1.2 vs 0.7, P = .012), especially urinary tract infections (HR = 2.15 [95% CI, 1.1-4.5], P = .032).A cyclophosphamide induction dose of 2.5 to 3 g was able to induce remission and prevent from relapses with fewer cases of leukopenia and less infectious episodes during follow-up. Especially elderly AAV patients who are particularly susceptible to infectious complications could benefit from minimizing dosing regimens with maintained efficacy to control disease activity.

From Kidney to Brain: An Uncommon Severe Relapse of Myeloperoxidase Anti-Neutrophil Cytoplasmic Antibody (MPO-ANCA) Vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of rare autoimmune diseases that affect medium and small blood vessels, with uncommon, variable central nervous system (CNS) involvement. It poses diagnosis challenges due to the limited accuracy of conventional imaging and vast differential diagnosis.

We describe the case of a 76-year-old man with a previously diagnosed myeloperoxidase (MPO)-positive AAV with exclusive renal involvement. The patient presented to our emergency department (ED) with sudden-onset weakness of the right side of the body, difficulty speaking, fever, and a history of progressive cognitive impairment in the previous three months (loss of memory, time and space disorientation, acalculia). Brain imaging showed multiple acute and subacute ischemic lesions, suggesting CNS vasculitic involvement. The patient was treated with methylprednisolone pulses, followed by rituximab, with motor and cognitive improvement.

Timely diagnosis and adequate treatment of AAV as a cause for new-onset neurological symptoms are crucial to improve outcomes. Otherwise, a higher risk of relapse remains, and extensive neurological deficits may become permanent. Evidence regarding the best treatment options in these patients is scarce and case reports provide further data on this topic.

Hypertrophic spinal pachymeningitis caused by ANCA-associated vasculitis revealed by 18F-FDG PET/CT: A case report

RATIONALE

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) can involve the central nervous system in estimatedly 15% of patients. Hypertrophic pachymeningitis causes inflammatory hypertrophy of the cranial or spinal dura mater and patients present with various neurological deficits. ANCA-associated hypertrophic spinal pachymeningitis has rarely been reported in literature. We report a case of AAV presenting with hypertrophic spinal pachymeningitis detected by 18F-FDG PET/CT.

PATIENT CONCERNS

A 66-year-old woman diagnosed with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis developed back pain, bilateral lower limb weakness, dysuria, and dysporia 1 month ago.

DIAGNOSIS

Contrast-enhanced MRI showed thickening and enhancement of the dura mater in the thoracic cord. Intraspinal hypermetabolism in the corresponding region was observed on 18F-FDG PET/CT. The patient was finally diagnosed with ANCA-associated hypertrophic spinal pachymeningitis.

INTERVENTIONS

The patient was treated with a higher dose of prednisone and cyclophosphamide.

OUTCOMES

After 2-week treatment, the patient's neurological symptoms improved rapidly and laboratory findings were ameliorated. A repeated contrast-enhanced MRI showed partial improvement of the disease in the thoracic cord.

LESSONS

18F-FDG PET/CT and contrast-enhanced MRI can aid in the clinical diagnosis and surveillance in AAV-associated hypertrophic spinal pachymeningitis and potentially facilitate early recognition and intervention to prevent irreversible neurological impairment.

Antineutrophil Cytoplasmic Antibody-Associated Glomerulonephritis in a Case of Scleroderma After Recent Diagnosis With COVID-19

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare occurrence in systemic sclerosis (SSc) patients. AAV is an inflammatory disease that can lead to kidney failure due to the infiltration of mononuclear cells and the destruction of blood vessels. Also, crescentic glomerulonephritis (GN) has rarely been reported with coronavirus disease 2019 (COVID-19) and acute tubular injury is the most common renal pathology lesion in these patients. We present a rare case of a 46-year-old woman with SSc with new onset of renal failure after a recent diagnosis of COVID-19. Her serology was positive for p-ANCA and myeloperoxidase antibodies. Kidney biopsy was done and showed crescentic GN. We suggest during this pandemic, patients with an immunological disorder that are infected with COVID-19 be closely monitored for any organ involvement.

Risk of Cardiovascular Disease and Venous Thromboembolism Among Patients With Incident ANCA-Associated Vasculitis: A 20-Year Population-Based Cohort Study

OBJECTIVE

To assess the cardiovascular disease (CVD) and venous thromboembolism (VTE) risks among patients with newly diagnosed antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).

PATIENTS AND METHODS

A population-based incident AAV cohort of 58 patients diagnosed between 1996 and 2015 in Olmsted County, MN, was identified by medical record review. For each patient, 3 age- and sex-matched non-AAV comparators were randomly selected from the same population and assigned an index date corresponding to the AAV incidence date. Medical records of cases and comparators were reviewed for CVD events, which included cardiac events (coronary artery disease, heart failure, and atrial fibrillation), cerebrovascular accidents (CVA), peripheral vascular disease (PVD), and VTE, which included deep vein thrombosis (DVT) and pulmonary embolism (PE).

RESULTS

Baseline total cholesterol, high-density lipoprotein, and current smoking rate were lower in AAV than in comparators (P=.03, P=.01, and P=.04, respectively), whereas other CVD risk factors and Framingham risk score were not significantly different between the 2 groups. The CVD events developed in 13 patients and 17 comparators, corresponding to a more than 3-fold increased risk (hazard ratio [HR], 3.15; 95% CI, 1.51-6.57). By subtypes, risks were increased for cardiac events (HR, 2.96; 95% CI, 1.42-6.15) and CVA (HR, 8.16; 95% CI, 2.45-27.15), but not for PVD. The HR for VTE was 3.26 (95% CI, 0.84-12.60), significantly increased for DVT (HR, 6.25; 95% CI, 1.16-33.60), but not for PE (HR, 1.33; 95% CI, 0.23-7.54).

CONCLUSION

Despite a similar prevalence of CVD risk factors at baseline, the risk of CVD is more than 3-fold higher and for CVA 8-fold higher in patients with incident AAV than in matched comparator subjects.

Pharmacokinetics of rituximab and clinical outcomes in patients with anti-neutrophil cytoplasmic antibody associated vasculitis

Objectives

To study the determinants of the pharmacokinetics (PK) of rituximab (RTX) in patients with ANCA-associated vasculitis (AAV) and its association with clinical outcomes.

Methods

This study included data from 89 patients from the RTX in AAV trial who received the full dose of RTX (four weekly infusions of 375 mg/m2). RTX was quantified at weeks 2, 4, 8, 16 and 24, and summarized by computing the trapezoidal area under the curve. We explored potential determinants of the PK-RTX, and analysed its association with clinical outcomes: achievement of remission at 6 months, duration of B-cell depletion and time to relapse in patients who achieved complete remission.

Results

RTX serum levels were significantly lower in males and in newly diagnosed patients, and negatively correlated with body surface area, baseline B-cell count and degree of disease activity. In multivariate analyses, the main determinants of PK-RTX were sex and new diagnosis. Patients reaching complete remission at month 6 had similar RTX levels compared with patients who did not reach complete remission. Patients with higher RTX levels generally experienced longer B-cell depletion than patients with lower levels, but RTX levels at the different time points and area under the curve were not associated with time to relapse.

Conclusion

Despite the body-surface-area-based dosing protocol, PK-RTX is highly variable among patients with AAV, its main determinants being sex and newly diagnosed disease. We did not observe any relevant association between PK-RTX and clinical outcomes. The monitoring of serum RTX levels does not seem clinically useful in AAV.

Aortic ¹⁸F-FDG uptake in patients suffering from granulomatosis with polyangiitis

PURPOSE

The objective of the study was to systematically assess aortic inflammation in patients with granulomatosis with polyangiitis (GPA) using (18)F-2-deoxy-2-[(18)F]fluoro-D-glucose (FDG) positron emission tomography (PET)/CT.

METHODS

Aortic inflammation was studied in PET/CT scans obtained from 21 patients with GPA; 14 patients with sarcoidosis were included as disease controls, 7 patients with stage I or II head and neck carcinoma ascertained during routine clinical practice were used as healthy controls (HC) and 5 patients with large vessel vasculitis (LVV) were used as positive controls. Aortic (18)F-FDG uptake was expressed as the blood-normalized maximum standardized uptake value (SUVmax), known as the target to background ratio (mean TBRmax).

RESULTS

The mean TBRmax (interquartile range) of the aorta in patients with GPA, sarcoidosis, HC and LVV were 1.75 (1.32-2.05), 1.62 (1.54-1.74), 1.29 (1.22-1.52) and 2.03 (1.67-2.45), respectively. The mean TBRmax was significantly higher in patients suffering from GPA or LVV compared to HC (p < 0.05 and p < 0.005, respectively) and tended to be higher in patients suffering from sarcoidosis, but this did not reach statistical significance (p = 0.098). The mean TBRmax of the most diseased segment was significantly higher compared to HC [1.57 (1.39-1.81)] in LVV patients [2.55 (2.22-2.82), p < 0.005], GPA patients [2.17 (1.89-2.83), p < 0.005] and patients suffering from sarcoidosis [2.04 (1.88-2.20), p < 0.05]. In GPA patients, the mean TBRmax of the aorta was significantly higher in patients with previous renal involvement [2.01 (1.69-2.53)] compared to patients without renal involvement in the past [1.60 (1.51-1.80), p < 0.05]. Interrater reproducibility with a second reader was high (all intraclass correlation coefficients >0.9).

CONCLUSION

Patients suffering from GPA show marked aortic FDG uptake.

Incidence of leukocytoclastic vasculitis, 1996 to 2010: a population-based study in Olmsted County, Minnesota

OBJECTIVE

To determine the population-based incidence of leukocytoclastic vasculitis (LCV).

PATIENTS AND METHODS

This is a retrospective population-based study of all Olmsted County, Minnesota, residents with a skin biopsy-proven diagnosis of LCV from January 1, 1996, through December 31, 2010.

RESULTS

A total of 84 patients (mean age at diagnosis, 48.3 years) with newly diagnosed skin biopsy-proven LCV (43 women and 41 men) were identified. The incidence rate (age and sex adjusted to the 2000 US white population) was 4.5 per 100,000 person-years (95% CI, 3.5-5.4). The incidence of LCV increased significantly with age at diagnosis (P<.001) and did not differ between female and male patients. Subtypes of LCV were cutaneous small-vessel vasculitis (CSVV), 38 patients (45%); IgA vasculitis, 25 (30%); urticarial vasculitis, 10 (12%); cryoglobulinemic vasculitis, 3 (4%); and antineutrophil cytoplasmic antibody-associated vasculitis, 8 (10%). LCV was idiopathic in 29 of 38 patients with CSVV (76%) and 24 of 25 patients with IgA vasculitis (96%). Thirty-nine of 84 patients (46%) had systemic involvement, with the renal system most commonly involved (17 of 39 [44%]). Twenty-four of 80 patients (30%) with follow-up data available had recurrent disease. Compared with the Minnesota white population, observed survival in the incident LCV cohort was significantly poorer than expected (P<.001), including the subset of patients with idiopathic CSVV (P=.03).

CONCLUSION

The incidence of LCV was higher than that reported in previously published studies. Idiopathic LCV was more common in our population-based cohort than that described previously. Overall survival was significantly poorer (P<.001) and should be explored further in future studies.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis: where to go?

Enormous progress has been made during the last 25 years in our understanding of the aetiopathogenesis of the anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV). This has led to improvements in early diagnosis, treatment and secondary prevention of these diseases. Nevertheless, there are still unmet needs in the AAV. With respect to diagnosis and follow-up, sensitive biomarkers that reflect disease activity, also during smouldering disease, are needed. In the field of aetiopathogenesis, genetic and epigenetic studies are being performed not only directed at the autoimmune response but also at the expression of, possibly modified, autoantigens. Environmental factors, in particular microbial factors, are also being explored. This will enable analysis of gene-environment interactions in the AAV, so elucidating further their aetiopathogenesis. Explaining the differences in clinical presentation between proteinase 3 (PR3)-associated AAV and myeloperoxidase (MPO)-associated AAV requires an adequate animal model for PR3-ANCA disease, which is currently lacking. Although many large randomized controlled trials have built a base for a rational therapeutic approach in the AAV, late morbidity and mortality is still significant. The availability of new biologicals and the development of sensitive biomarkers for disease activity could further improve prognosis for patients suffering from AAV.

Small vessel vasculitis

The pediatric small vessel vasculitides reviewed in this article are Henoch-Schönlein purpura (HSP) and the anti-neutrophil cytoplasmic antibody-associated vasculitides (AAV). The new classification criteria for HSP and Wegener's granulomatosis are now validated and will facilitate the conduct of future epidemiological studies and clinical trials. The clinical manifestations of small vessel vasculitis in children are described, and current therapies discussed. There is a lack of good clinical trial data on which to base therapy for HSP. Similarly, data based on randomized controlled trials (RCTs) for pediatric AAV are lacking, although children with AAV are for the first time now included in a RCT of mycophenolate mofetil versus cyclophosphamide. Significant challenges remain in the field of pediatric small vessel vasculitis, including the development of validated disease outcome measures and biomarkers to be used in clinical trials. Lastly, long-term outcome data are lacking in survivors of pediatric small vessel vasculitis.

Hypogalactosylation of serum IgG in patients with ANCA-associated systemic vasculitis

The triad of small vessel vasculitides (SVV) comprise Wegener's granulomatosis (WG), microscopic polyangiitis (MPA) and Churg-Strauss syndrome (CS). All three are associated with presence of circulating IgG antineutrophil cytoplasm antibodies (ANCA) which target autoantigens contained, primarily, within neutrophil azurophilic granules. The widely accepted model of pathogenesis suggests that ANCA activate cytokine-primed neutrophils within the microvasculature, leading to by-stander damage to endothelial cells, and rapid escalation of inflammation with recruitment of mononuclear cells. Activation may be initiated, in vitro, by the coligation of the PR3 or MPO antigen, translocated to the cell surface, and FcgammaRIIa/FcgammaRIIIb receptors. This suggests that the IgG subclass profile of ANCA and, possibly, its glycosylation status could influence the inflammatory mechanisms activated. The glycosylation status of total IgG isolated from the sera of patients with WG (13), MPA (6) and CSS (1) was determined by analysis of the released oligosaccharides. A deficit in IgG galactosylation is demonstrated for all patient samples, compared to controls. The mean percentage values for the agalactosylated (G0) oligosaccharides were 57% (SD +/- 9.71), 47% (SD +/- 4.25) and 28% (SD +/- 4.09) for WG, MPO and control samples, respectively. The G0 levels for polyclonal IgG isolated from the sera of both WG and MPA patients were significantly increased compared to controls (P < 0.0001). The major glycoform present therefore is agalactosylated (G0) IgG. In previous studies the G0 glycoform of IgG has been shown to bind and activate mannan binding lectin, and hence to activate the complement cascade, and to facilitate mannose receptor binding and the uptake of IgG complexes by macrophages and dendritic cells. Both of these activities could impact on the processing and presentation of self-antigens in autoimmune disease.