C-reactive protein concentration has limited value in the diagnosis of meningoencephalitis of unknown origin in dogs

OBJECTIVES

To evaluate blood and cerebrospinal fluid (CSF) concentrations of C-reactive protein (CRP) in dogs with meningoencephalitis of unknown origin (MUO); to evaluate whether blood CRP concentration is associated with epidemiological, clinicopathologic, and MRI findings; and to investigate blood CRP predictive power in survival.

ANIMALS

30 client-owned dogs with MUO, 15 client-owned dogs with steroid-responsive meningitis arteritis (SRMA; positive control group), and 15 healthy dogs (negative control group).

METHODS

Blood CRP concentration was measured in each group, while it was performed in CSF only in the MUO and SRMA groups. The analysis of epidemiological data included breed, age, sex, duration of clinical signs, and history of seizures. Blinded analysis of MRI was performed based on a classification grid, and traditional CSF analysis parameters were assessed. The predictive power of blood CRP concentration regarding survival at 6 months was investigated.

RESULTS

Of the 30 dogs with MUO, 9 (30%) had an increased CRP concentration in blood, and 3 (10%) showed a measurable CRP in CSF. Median blood CRP concentration in dogs with MUO was 0.1 mg/L (range, 0.1 to 102 mg/L), which was not statistically different from the healthy dog group but significantly lower than the SRMA control group. Only the duration of clinical signs was positively associated with an increased blood CRP level. Blood CRP concentration was not associated with survival at 6 months.

CLINICAL RELEVANCE

Blood CRP concentration is of limited value for the diagnosis and prognosis of dogs with MUO. Chronicity of the disease may be associated with an increased concentration of blood CRP.

Nonarteritic anterior ischemic optic neuropathy and incidence of Parkinson's disease based on a nationwide population based study

This study aimed to investigate the association between nonarteritic anterior ischemic optic neuropathy (NAION) and Parkinson's disease (PD) using a retrospective, nationwide, population-based cohort in South Korea. This study utilized data from the Korean National Health Insurance database, including 43,960 NAION patients and 219,800 age- and sex-matched controls. Cox proportional hazards regression models were used to assess the risk of developing PD in the NAION group compared to the control group after adjusting for various confounding factors. Subgroup analyses were conducted based on sex, age, and comorbidities. The incidence rate of PD was higher in the NAION group (1.326 per 1000 person-years) than in the control group (0.859 per 1000 person-years). After adjusting for confounding factors, the risk of developing PD was significantly higher in the NAION group (adjusted hazard ratio [aHR] 1.516, 95% confidence interval [CI] 1.300-1.769). Subgroup analyses did not reveal a significant difference in the risk of PD development based on sex, age, or comorbidities. This retrospective, nationwide, population-based cohort study revealed a significant association between NAION and an increased risk of developing PD in a South Korean population. The incidence rate of PD was observed to be higher in individuals diagnosed with NAION than in age- and sex-matched controls even after adjusting for potential confounding variables, with the risk being approximately 51.6% higher in the NAION group. Further research is necessary to elucidate the underlying pathophysiological mechanisms linking NAION to PD and to determine whether similar associations exist in other ethnic and geographical populations.

Clinical and histopathological features of rostrolateral nasal alar arteriopathy of German shepherd dogs

BACKGROUND

Dermal arteritis of the nasal philtrum (DANP) has been described in large-breed dogs.

OBJECTIVES

To characterise clinically distinct, discrete fissures of the dorsolateral nasal alae associated with severe bleeding in German shepherd dogs (GSDs).

ANIMALS

Fourteen privately owned GSDs with linear rostrolateral nasal alar fissures and a histopathological diagnosis of nasal vasculopathy.

MATERIALS AND METHODS

Retrospective analysis of medical records and histological slides.

RESULTS

Mean age of onset was 6 years. Before biopsy, episodic arteriolar bleeding was noted in 11 of the 14 (79%) dogs. Slide analysis revealed enlarged nasal arterioles with expanded vascular tunics and luminal stenosis beneath ulcers. Histopathological lesions consistent with mucocutaneous pyoderma and/or facial discoid lupus erythematosus were present in 5 of the 14 (36%) dogs. Enlarged arterioles stained blue with Alcian blue and Masson's trichrome stains, consistent with deposition of mucin and collagen, respectively. Immunohistochemical stains (neutrophil myeloperoxidase, IBA1, CD3) were performed. CD3 was negative for all dogs, whilst neutrophil myeloperoxidase and IBA1 occasionally demonstrated intramural neutrophils (3 of the 14 dogs, 21%) or histiocytes (1 of the 14 dogs, 7%) in altered vessels, respectively. All dogs underwent medical management and/or surgical excision. Treatments included tacrolimus, prednisone, ciclosporin-modified, pentoxifylline, antimicrobials and doxycycline/niacinamide. No dogs were treated with antimicrobials alone. For seven dogs with long-term follow-up, treatment response was complete in five (71%) and partial in two (29%), with six of the seven (86%) receiving immunomodulatory treatments to maintain remission.

CONCLUSION AND CLINICAL RELEVANCE

Nasal alar arteriopathy of GSDs shares histopathological changes with DANP. It has characteristic clinical and histopathological features and appears amenable to immunomodulation.

Left Ventricular Dysfunction Caused by IgG4-related Small Intramural Coronary Periarteritis

IgG4-related disease (IgG4-RD) is a systemic autoimmune disorder known to affect multiple organs. However, IgG4-RD rarely affects the myocardium. We herein report a case of left ventricular dysfunction due to cardiac involvement of IgG4-RD.

IgG4-related Periarteritis Successfully Diagnosed by an Alternative Prostate Biopsy

A 56-year-old man was referred to our facility after developing edema in his right leg. Enhanced computed tomography (CT) revealed a periarterial soft tissue mass surrounding the right iliac artery compressing the iliac vein. His elevated serum IgG4 level indicated IgG4-related disease (IgG4-RD). Both a percutaneous and surgical biopsy of this periarterial lesion proved challenging and were not pursued. A prostate biopsy, however, finally provided a histological diagnosis of IgG4-RD. Oral steroid therapy successfully resolved his leg edema and periarterial lesion. This case illustrates the usefulness of an alternative prostate biopsy for the histological diagnosis of IgG4-RD when approaching the primary affected lesion is difficult.

Characteristics and prognosis of IgG4-related periaortitis/periarteritis: A systematic literature review

OBJECTIVE

Immunoglobulin G4 (IgG4)-related disease is a systemic chronic fibroinflammatory disease that can affect almost every organ of the body. IgG4-related periaortitis/periarteritis is a newly recognized subset of IgG4-related disease, and its characteristics and prognosis remain unclear. We investigated the clinical characteristics and prognosis of IgG4-related periaortitis/periarteritis.

METHODS

We performed a systematic literature review of IgG4-related periaortitis/periarteritis. Additionally, we have summarized the characteristics and prognosis of IgG4-related coronary arteritis.

RESULTS

We investigated 248 patients with IgG4-related periaortitis/periarteritis. All studies reported the condition in elderly patients, and male predominance was observed. The infra-renal abdominal aorta and iliac arteries were the most commonly affected sites. Most reports showed the serum C-reactive protein elevation in this disease entity, in contrast to non-vascular IgG4-related disease. Based on radiological findings observed in 27 patients with IgG4-related coronary arteritis, vasculitic lesions were classified into 3 types: stenotic (67% of patients), aneurysmal (42%), and diffuse wall thickening type (92%). Serum IgG4 level, but not C-reactive protein level, was associated with the number of affected organs in IgG4-related coronary arteritis. Corticosteroid treatment with or without cardiac surgery or percutaneous coronary intervention was effective in most patients with IgG4-related coronary arteritis; however, 33% of patients showed an unfavorable clinical course including disease progression, relapse, or death. Pre-treatment stenosis and/or aneurysms were associated with progression of stenosis or aneurysm after corticosteroid treatment.

CONCLUSION

Most clinical characteristics were similar between the IgG4-related periaortitis/periarteritis and the non-vascular IgG4-related disease groups; however, serum C-reactive protein level elevation was observed only in the former. Although corticosteroid treatment was effective, this disease can be life-threatening secondary to myocardial infarction, aortic dissection, and aneurysmal rupture. Pre-treatment evaluation of stenosis or aneurysms is important for predicting progression of stenosis or aneurysm after corticosteroid treatment.

A change in Ocular Involvement in a Patient Suffering from Ankylosing Spondylitis and Behçet's Disease

We report a case of a young man suffering from both ankylosing spondylitis and Behçet's disease in whom the character of the ocular involvement changed according to the predominant disease at a given time. When the clinical picture was one of ankylosing spondylitis, only anterior uveitis was observed, while the clinical picture of Behçet's disease occurred with panuveitis and retinal vasculitis. To the best of our knowledge, this is the first report in the English literature of two different patterns of ocular involvement in the same patient with two seronegative arthritides.

Optical coherence tomography angiography in acute arteritic and non-arteritic anterior ischemic optic neuropathy

PURPOSE

The purpose of our study was to describe the feature of acute non-arteritic or arteritic anterior ischemic optic neuropathy (NA-AION and A-AION) using optical coherence tomography angiography (OCT-A) and to compare it with fluorescein angiography (FA) and indocyanine green angiography (ICGA).

METHODS

In this retrospective, observational case-control study four NA-AION patients and one A-AION patient were examined by FA, ICGA and OCT-A within 2 weeks from disease presentation. The characteristics of the images were analyzed. Optic nerve head (ONH) and radial peripapillary capillaries (RPC) vessel densities (VDs) were compared between NA-AION and controls.

RESULTS

In two of four NA-AION cases and in the A-AION patient, OCT-A clearly identified the boundary of the ischemic area at the level of the optic nerve head, which was comparable to optic disc filling defects detected by FA. In the other two NA-AION cases, a generalized leakage from the disc was visible with FA, yet OCT-A still demonstrated sectorial peripapillary capillary network reduction. Both ONH and RPC VDs were reduced in NA-AION patients, when compared to controls.

CONCLUSIONS

OCT-A was able to identify microvascular defects and VD reduction in cases of acute optic disc edema due to NA-AION and A-AION. OCT-A provides additional information in ischemic conditions of the optic nerve head.

Association of Arterial and Lymph Node Inflammation With Distinct Inflammatory Pathways in Human Immunodeficiency Virus Infection

Importance

Human immunodeficiency virus (HIV) infection is associated with a high risk of cardiovascular disease and increased arterial inflammation. In HIV, inflammation is also increased within lymph nodes (LNs), tissues known to harbor the virus even among treated and suppressed individuals.

Objective

To test the hypothesis that arterial inflammation is linked to HIV disease activity and to inflammation within HIV-infected tissues (LNs).

Design, Setting, and Participants

For this case-control study, participants were recruited from the SCOPE (Observational Study of the Consequences of the Protease Inhibitor Era) cohort, a clinic-based cohort of individuals receiving care at San Francisco General Hospital and the San Francisco Veteran's Affairs Medical Center. Arterial and LN inflammation were measured using 18F-fluorodeoxyglucose positron emission tomography. Detailed immunophenotyping was performed, along with measurement of viral activity/persistence and of circulating inflammatory biomarkers.

Main Outcomes and Measures

Arterial and LN inflammation.

Results

A total of 74 men were studied (45 HIV-infected men with a median age of 53 years [interquartile range, 49-59 years] and 29 uninfected male controls with a median age of 52 years [interquartile range, 46-56 years]). Lymph node inflammation was higher in HIV-infected individuals and correlated with markers of viral disease activity (viral load, CD8+ T cells, and CD4/CD8 ratio) and CD4+ T-cell activation. Uninfected controls had the lowest LN activity (mean [SD] maximum axillary LN standardized uptake value, 1.53 [0.56]), the elite controller and ART-suppressed groups had intermediate levels of LN (mean [SD] maximum axillary LN standardized uptake value, 2.12 [0.87] and 2.32 [1.79], respectively), and the noncontrollers had the highest activity (mean [SD] maximum axillary LN standardized uptake value, 8.82 [3.08]). Arterial inflammation was modestly increased in HIV-infected individuals and was positively correlated with circulating inflammatory biomarkers (high-sensitivity C-reactive protein and IL-6) and activated monocytes (CD14dimCD16+; nonclassical) but not with markers of HIV. While LN and arterial inflammation were increased in HIV, inflammatory activity in these tissues was not related (r = 0.09, P = .56).

Conclusions and Relevance

While LNs and, to a lesser degree, the arterial wall are inflamed in HIV, inflammation in these tissues is not closely linked. Namely, measures of HIV disease activity are strongly associated with LN inflammation but not with arterial inflammation. These data suggest that LN and arterial inflammation do not share underlying pathways of immune activation and also that therapeutic interventions that reduce viral disease activity may not predictably reduce arterial inflammation in HIV or its downstream consequence (ie, cardiovascular disease).

[Surgical treatment of a female patient with type III nonspecific aortoarteritis]

Described herein is a case report of a severe lesion of the arterial system in non-specific aortoarteritis: lesion of the aortic arch branches, thoracoabdominal segment of the aorta, abdominal aorta, visceral and renal arteries, thus underlining a multiple nature of the lesion of the aorta and its branches in the pathology concerned. Diagnosis of lesions of the aorta and its branches was made by means of multispiral computed tomography (MSCT), being the most informative method of examination in this cohort of patients, making it possible to accurately diagnose both the degree of the lesion and its extension, to choose an optimal surgical policy, to carry out dynamic follow up of the condition of the reconstructed arterial segments.

[Surgical treatment of a female patient with non-specific aortoarteritis]

Presented herein is a case report of successful surgical treatment of a female patient with non-specific aortoarteritis. In 2004 she was endured single-stage simultaneous autovenous ileorenal prosthetic repair on the right and autovenous aortorenal prosthetic reconstruction on the left for critical stenosis of the left renal artery and occlusion of the right one. In 2007 she underwent balloon dilatation of the aorta for abdominal aortic stenosis with a good favourable therapeutic outcome. In 2013 due to lesions of the aortic arch branches she was subjected to endarterectomy from the common carotid artery on the left, autovenous carotid-subclavian shunting on the right with a favourable outcome. Presented herein are the results of check-up multislice CT-angiography (MSCT) 9 years after operation on renal arteries. Multislice CT-angiography and duplex scanning of aortic arch branches made it possible to choose an optimal surgical policy in this woman. Simultaneous endarterectomy from the common carotid artery on the left with autovenous carotid-subclavian shunting on the right in a patient with non-specific aortoarteritis was used by us for the first time. This operation made it possible to restore patency of the carotid artery and to use it as a donor artery for carotid-subclavian shunting in order to eliminate vertebral subclavian steal syndrome.

SUSAC SYNDROME

PURPOSE

To describe an atypical presentation of Susac syndrome.

METHODS

Observational case report.

RESULTS

A 44-year-old man with no significant medical history presented with inferonasal visual field loss in his left eye of several months of duration. He was found to have bilateral migratory arteritis with focal areas of arteriolar occlusion in both eyes and peripheral ischemia superotemporally in his left eye. An extensive hematologic workup was negative for autoimmune disease or coagulopathy. Magnetic resonance imaging with contrast of his brain revealed a hyperintense lesion in the splenium of the corpus callosum. Auditory testing was significant for nonspecific high-frequency hearing loss in the right ear. Given the full clinical picture, a diagnosis of Susac syndrome was made.

CONCLUSION

Susac syndrome is a multisystemic, immune-mediated occlusive endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions, and hearing loss. However, patients may present with varying degrees of this triad; thus, there should be a high index of suspicion in patients presenting with multiple artery occlusions or multifocal arteritis.

Noninvasive imaging of arterial inflammation using FDG-PET/CT

PURPOSE OF REVIEW

Noninvasive imaging of atherosclerotic plaques has substantially advanced over the past decade such that currently available imaging techniques allow for characterization of high-risk morphological features of the plaques and quantification of the biological activity within the atherosclerotic milieu. Vascular PET/CT imaging provides insights into the biological activity of atherosclerotic plaques and, in particular, plaque inflammation. Fluoro-deoxyglucose-PET/CT imaging is currently used to improve the understanding of atherosclerotic pathophysiology, facilitate the discovery of new treatments and improve clinical prognostication in humans.

RECENT FINDINGS

Several studies have evaluated the feasibility, validity and reproducibility of fluoro-deoxyglucose-PET/CT for imaging of atherosclerotic plaque inflammation. Fluoro-deoxyglucose-PET/CT imaging is demonstrated to have the potential to predict the efficacy of novel antiatherosclerotic therapeutics by using a relatively small sample size and within a relatively short time period in several multicenter trials.

SUMMARY

The currently feasible assessment of inflammation within the atherosclerotic plaques has been demonstrated to enhance assessment of clinical risk, provide a better understanding of therapeutic efficacy of novel drugs, and it may provide a window into inflammation within the coronary tree. Further technological advances in PET technology have the potential to catalyze further progress in imaging of atherosclerotic plaque biology.

Choroidal thickness in nonarteritic anterior ischemic optic neuropathy

PURPOSE

To examine choroidal thickness in nonarteritic anterior ischemic optic neuropathy (AION).

DESIGN

Retrospective case control study.

METHODS

In the eye clinic of the University Medical Center in Mannheim, Germany, we studied a group that consisted of patients with nonarteritic AION and a control group that consisted of individuals with normal fundus. Choroidal thickness was measured by the enhanced-depth imaging of spectral-domain optical coherence tomography. The main outcome measure was choroidal thickness.

RESULTS

The study group consisted of 20 patients: 11 patients with acute nonarteritic AION and an unaffected contralateral eye and 9 patients with acute unilateral nonarteritic AION and previously nonarteritic AION in the contralateral eye. The control group consisted of 58 patients (58 eyes). In multivariate analysis, thinner subfoveal choroidal thickness was associated with the diagnosis of nonarteritic AION (P = 0.001; regression coefficient B, -55.1), after adjusting for age (P < 0.001) and refractive error (P = 0.20). Similarly, unaffected eyes contralateral to eyes with acute nonarteritic AION as compared to control eyes showed thinner subfoveal choroidal thickness (P = 0.037) after adjusting for age (P = 0.001) and refractive error (P = 0.06). In a reverse manner, nonarteritic AION was associated with thinner subfoveal choroidal thickness (P = 0.007) after adjusting for age, optic disc diameter, gender, and refractive error.

CONCLUSIONS

Eyes affected by nonarteritic AION and unaffected contralateral eyes showed significantly thinner macular choroids than eyes of a control group after adjusting ocular and systemic parameters. A thin choroid may be added to the diagnostic features of nonarteritic AION. Future studies may examine the pathophysiologic meaning of the finding.

[Ultrasonography in Large-Vessel Arteritis]

Vasculitides are a group of diseases in which inflammation occurs in various vascular walls of the whole body, and ischemic symptoms are caused by stenoses and occlusions of blood vessels. Various parts of blood vessels of the whole body are affected, and the clinical manifestations are diverse. In the Chapel Hill Consensus Conference (CHCC) 2012, vasculitides are classified into seven categories. Takayasu arteritis and giant cell arteritis are included in large-vessel vasculitis. Large-vessel arteritis is defined as vasculitis affecting the aorta and its major branches more often than other vasculitides, but any sized artery may be affected. Ultrasonography has been progressing rapidly, so we can easily depict vessels of the surface of the body, in 0.1-mm units, and indicate the blood flow noninvasively. Ultrasonography has been used for the diagnosis of and estimation of the treatment for large-vessel vasculitis, and its importance has been increasing.

Granulomatous inflammation: The overlap of immune deficiency and inflammation

Pediatric granulomatous diseases constitute a heterogenous group of conditions in terms of clinical phenotypes, pathogenic mechanisms, and outcomes. The common link is the presence of multinucleated giant cells in the inflammatory infiltrate. The clinical scenario in which a tissue biopsy shows granulomatous inflammation is not an uncommon one for practicing adult and pediatric rheumatologists. Our role as rheumatologists is to develop a diagnostic plan based on a rational differential diagnostic exercise tailored to the individual patient and based mainly on a detailed clinical assessment. This chapter presents a comprehensive differential diagnosis associated with a classification developed by the authors. We describe with some detail extrapulmonary sarcoidosis, Blau syndrome, and immunodeficiency associated granulomatous inflammation, which in our view are the paradigmatic primary forms of granulomatous diseases in childhood. The other entities are presented only as differential diagnoses listing their most relevant clinical features. This chapter shows that almost all granulomatous diseases seen in adults can be found in children and that there are some entities that are essentially pediatric at onset, namely Blau syndrome and most forms of immunodeficiency associated granulomatous diseases.

Acute myocardial infarction--an unusual presentation of non-specific aortoarteritis

A 42 year old man presented with classical presentation of Acute ST elevation MI of 2 hours duration. His CAG revealed a spared LMCA with a totally occluded LAD in proximal segment, for which he underwent a successful PAMI with DES to LAD. 2 days later he developed high grade fever, elevated inflammatory markers (ESR/CRP) with a dull aching pain in root of neck. On evaluation of brachiocephalic vessels, CT Aortogram suggested a diagnosis of acute onset Non-Specific Aortoarteritis. Nonspecific Aortoarteritis in young males is an uncommon presentation, though associated coronary artery involvement is known, but its presentation as an Acute MI is a rare phenomenon.

Dyspnea due to pulmonary vessel arteritis

Pulmonary arteritis is a rare cause of pulmonary hypertension. Causes of pulmonary arteritis can be divided into primary and secondary, as well as classified according to vessel size. Only large vessel vasculitis is associated with pulmonary hypertension; primary forms include Takayasu arteritis and giant cell arteritis. The diagnosis of pulmonary arteritis can be challenging and the associated morbidity is serious without prompt, directed treatment. The authors present a case involving a 48-year-old First Nations man presenting with a six-month history of exertional dyspnea and severe stenosis of the left pulmonary artery, who was ultimately diagnosed with pulmonary arteritis related to large vessel vasculitis.

Large vessel vasculitis with myelodysplastic syndrome

A 71-year-old woman presented with a high-grade fever, neck pain, anemia and thrombocytopenia. After performing further examinations, we concluded that she had simultaneously developed large vessel vasculitis and myelodysplastic syndrome (MDS). Although glucocorticoid administration improved her clinical symptoms, the MDS transformed into acute myeloid leukemia and she died one year after receiving the diagnosis. The occurrence of immune-mediated disorders in patients with MDS is a well-known phenomenon; however, large vessel vasculitis is a rare complication of MDS. Our case suggests that the association between systemic vasculitis and MDS may result in poor outcomes.

Chronic pulmonary emboli and radiologic mimics on CT pulmonary angiography: a diagnostic challenge

Chronic pulmonary thromboembolism (CPE) is a challenging diagnosis for clinicians. It is an often-forgotten diagnosis and can be difficult to detect and easily misdiagnosed. The radiologic features on CT pulmonary angiography are subtle and can be further compounded by pathologic mimics and unusual findings observed with disease progression. Diagnosis is important because CPE can lead to progressive pulmonary hypertension, morbidity, and mortality. Moreover, chronic thromboembolic pulmonary hypertension is the only category of pulmonary hypertension with an effective curative treatment in the form of pulmonary endarterectomy. Therefore, CPE must be considered and recognized early. The features of chronic pulmonary emboli on CT scans can be categorized into vascular or parenchymal findings. Endoluminal signs include totally or partially occlusive thrombi and webs and bands. Parenchymal features such as mosaic attenuation and pulmonary infarction are also noted, in addition to features of pulmonary artery hypertension. Additional findings have been noted, including cavitation of infarcts, microbial colonization of cavities, and bronchopleural fistulae. As CPE can be diagnosed at different stages of its disease pathway, such findings may not necessarily arouse suspicion toward a causative diagnosis of chronic embolism. To aid diagnosis for clinicians, this article describes the characteristic vascular and parenchymal CT scan features of chronic emboli, as well as important ancillary findings. We also provide an illustrative case series focusing on CT pulmonary angiography specifically as an imaging modality to highlight the progressive nature of CPE and its sequelae, as well as important radiologic mimics to consider in the differential diagnosis.

[Lymphoma and arteries: peri- or intravascular?]

PURPOSE

Lymphoma is a polymorphous disease that does not spare arteries. Arterial involvement may be perivascular or intravascular, with different prognostic and therapeutic implications.

PATIENTS AND METHODS

We present here one case of perivascular lymphoma and another case of intravascular lymphoma in order to highlight the specific features of each type.

RESULTS

The first patient was a woman who presented a pseudo-aneurysmal anterior iliac artery due to a non-Hodgkin lymphoma with subsequent bilateral pyelocalyceal distension. The second patient was a man who developed intravascular lymphomatosis expressed by an aneurysm of the common femoral then the primitive iliac artery.

CONCLUSION

The distinction between perivascular and intravascular arterial involvement is based on a range of features and is essential for an optimal care of patients with lymphoma.

[Aortoarteritis in HBV-associated liver cirrhosis: diagnostics, therapeutic strategy, and prognosis]

A case of decompensated liver cirrhosis in a women with a long silent period of HBV infection is presented. The first manifestation was generalized vasculitis involving small and medium-size vessels and elastic-type arteries with the development of aortoarteritis. Proper interpretation of manifestations of viral liver cirrhosis allowed for immunosuppressive treatment in combination with effective antiviral drugs. As a result, aviremia, regression of vasculitis and portal hypertension along with considerable improvement of the prognosis were achieved.

The tropics and the crime they did not commit

Travellers to tropical destinations who seek medical attention after returning to their home country often present with fever, frequently as a result of an imported infectious disease. For this reason, clinicians initially focus on an infectious cause when a clear relationship in time exists between travel and disease onset. We present a case of a patient, who developed fever 2 weeks after his return from Ghana and who was finally diagnosed with an auto-immune disease: arteritis of the large arteries. This case illustrates that broad differential diagnostic thinking is paramount in the assessment of returned travellers.

Medullary ischemia due to vertebral arteritis associated with Behçet syndrome: a case report

Here we report an extremely rare case of Behçet syndrome (BS) that showed acute onset of Wallenberg syndrome and was treated successfully by corticosteroids. A 51-year-old woman with BS had a sudden onset of Wallenberg syndrome. Three days after the onset, she was transferred to our institute. In the magnetic resonance imaging (MRI) study on admission, T2-weighted and fluid-attenuated inversion recovery images showed a high intensity area in the left paramedian region of the medulla oblongata. Contrast-enhanced T1-weighted images showed enhancement in the vessel wall of the left vertebral artery. We diagnosed her as having Wallenberg syndrome due to the acute vertebral arteritis associated with BS. After initiation of high-dose steroid therapy, her symptoms gradually improved. Two months after admission, she was discharged from our institute with mild hemihypesthesia. We hypothesized that vertebral arteritis due to BS had caused hypoperfusion of the medullary perforators causing Wallenberg syndrome in our patient.

Electrochemical impedance spectroscopy to characterize inflammatory atherosclerotic plaques

Despite advances in diagnosis and therapy, atherosclerotic cardiovascular disease remains the leading cause of morbidity and mortality in the Western world. Predicting metabolically active atherosclerotic lesions has remained an unmet clinical need. We hereby developed an electrochemical strategy to characterize the inflammatory states of high-risk atherosclerotic plaques. Using the concentric bipolar microelectrodes, we sought to demonstrate distinct Electrochemical Impedance Spectroscopic (EIS) measurements for unstable atherosclerotic plaques that harbored active lipids and inflammatory cells. Using equivalent circuits to simulate vessel impedance at the electrode-endoluminal tissue interface, we demonstrated specific electric elements to model working and counter electrode interfaces as well as the tissue impedance. Using explants of human coronary, carotid, and femoral arteries at various Stary stages of atherosclerotic lesions (n=15), we performed endoluminal EIS measurements (n=147) and validated with histology and immunohistochemistry. We computed the vascular tissue resistance using the equivalent circuit model and normalized the resistance to the lesion-free regions. Tissue resistance was significantly elevated in the oxLDL-rich thin-cap atheromas (1.57±0.40, n=14, p<0.001) and fatty streaks (1.36±0.28, n=33, p<0.001) as compared with lesion-free region (1.00±0.18, n=82) or oxLDL-absent fibrous atheromas (0.86±0.30, n=12). Tissue resistance was also elevated in the calcified core of fibrous atheroma (2.37±0.60, n=6, p<0.001). Despite presence of fibrous structures, tissue resistance between ox-LDL-absent fibroatheroma and the lesion-free regions was statistically insignificant (0.86±0.30, n=12, p>0.05). Hence, we demonstrate that the application of EIS strategy was sensitive to detect fibrous cap oxLDL-rich lesions and specific to distinguish oxLDL-absent fibroatheroma.

Oral syphilis lesions--a diagnostic approach and histologic characteristics of secondary stage

Syphilis is among the oldest recognized sexually transmitted diseases. In the past decade, its incidence has risen significantly in the developed world. Oral syphilitic lesions, the most common extragenital sign of infection, are a diagnostic challenge to dentists, who are usually the first to examine the oral lesions. Biopsies are occasionally the first examination performed, but histologic findings are considered nonspecific. We present two new cases as well as an additional 25 published cases, suggesting that plasma cell arteritis and plasma cell neuritis is a combination that has not been reported in any other pathologic condition of the oral cavity and may be specific enough to direct the clinician toward a diagnosis of syphilis prior to clinical confirmation.

Comparison of the correlations between optic disc rim area and retinal nerve fiber layer thickness in glaucoma and nonarteritic anterior ischemic optic neuropathy

PURPOSE

To test whether comparison of the correlation between optic disc rim area and retinal nerve fiber layer thickness (rim-RNFL correlation) can differentiate eyes with nonarteritic anterior ischemic optic neuropathy (NAION) from eyes with open-angle glaucoma (OAG).

DESIGN

Prospective cross-sectional study.

METHODS

One hundred and thirteen eyes with OAG and 22 with NAION were included in this study. The rim-RNFL correlation in OAG eyes was analyzed in global and 12-clock-hour parameters using rim areas determined by Heidelberg retina tomography (HRT II) and RNFL thicknesses determined by optical coherence tomography (Cirrus OCT). The eyes with NAION were determined whether to be out of the 95% prediction interval (PI) for the rim-RNFL correlation of OAG in global and clock-hour parameters.

RESULTS

A significant linear rim-RNFL correlation was observed in global and all clock-hour sectors, except the 3-, 4-, and 9-o'clock sectors, in OAG (0.045 < r(2) < 0.64, P < .05, respectively). All eyes with NAION were outside the 95% PI of the rim-RNFL correlation of OAG in at least 1 clock-hour sector in terms of clock-hour parameters, as compared with 63.6% of eyes in terms of global parameter. All NAION eyes (n = 21) with 7- or 11-o'clock involvement had a rim-RNFL correlation outside the 95% PI of OAG for corresponding clock-hour sectors.

CONCLUSIONS

By comparison of the rim-RNFL correlation, eyes with NAION were found to be well differentiated from OAG eyes, especially in clock-hour sectors. It might be an objective approach to discriminate NAION from OAG.

Giant coronary aneurysm in a patient with systemic lupus erythematosus

Coronary aneurysm is rare in SLE and confirmation of etiology is usually made at postmortem examination. We encountered a giant aneurysm with multiple stenotic segments of the coronary arteries in a patient with SLE who had previous history of AAA/TAA. Resection of the aneurysm and coronary artery bypass graft were successfully performed. Histology of the coronary arterial wall showed severe damage of the media with inflammatory cell infiltration, indicating that the aneurysm was caused by arteritis. The aneurysm may have developed during the long course of inactive stage of SLE, emphasizing the need for screening of coronary lesions in the management of SLE.

18F-FDG positron emission tomography/computed tomography and the "underground map" appearance in imaging Horton's arteritis

A majority of the clinical use of positron emission tomography (PET)-computed tomography (CT) is related to cancer management. Its application in evaluating inflammatory diseases and pyrexia of unknown origin is becoming popular. We reviewed the fluorine-18-fluorodeoxyglucose PET-CT findings of an 80-year-old woman with nonspecific clinical presentation consisting of generalised malaise, moderately high fever and weight loss. Prior CT and magnetic resonance imaging were not helpful in providing a clinical diagnosis. The diagnosis was Horton's arteritis, and the patient responded well to high-dose steroids.

Unclassified vasculitis with acral ischemic lesions: "forme fruste" or idiopathic vasculitis?

BACKGROUND AND OBJECTIVES

While acral ischemia and necrosis represent a common problem in connective tissue diseases and other disorders, acral ischemic lesions are also occasionally encountered in primary and secondary systemic vasculitides. Here we report on the course of 4 patients with acral ischemic lesions as a hallmark of unclassified vasculitis. We compare these cases with 4 additional cases of acral ischemia complicating classified vasculitis.

OBJECTIVES

To report on our experience with cases of unclassified vasculitis and acral ischemic lesions during the past 5 years and review the literature on vasculitis and acral ischemic lesions.

METHODS

The case history of one of the patients with unclassified vasculitis and acral ischemic lesions is reported in detail. The Medical history of another 3 patients presenting with vasculitic acral ischemic lesions and unclassified vasculitis during the past 5 years in our department (Lübeck/Bad Bramstedt) is summarized and compared to the course of patients with acral ischemic lesions complicating classified vasculitides. A PubMed database review of reports on acral ischemic lesions and vasculitis from 1985 to August 2006 was performed using the following combination of keywords: "Vasculitis" [MeSH] AND ("Necrosis" [MeSH] OR "Ischemia" [MeSH] OR "Infarction" [MeSH]) AND ("Extremities" [MeSH] OR "Fingers [MeSH] OR "Toes" [MeSH] OR "limb"), yielding 1328 entries. This search was subsequently limited to "Humans, All Adult (19+ years)", yielding 904 entries. Only three (0.7%) of these entries described one (one paper) or more (n=28) patients (two papers) with idiopathic vasculitis characterized by digit necrosis in the absence of systemic manifestations (except in some cases for arthralgia) or laboratory parameters pointing to a diagnosis of an established type of vasculitis.

RESULTS

A 37-year-old female presented with acral ischemic lesions of the left forefoot, fingers and toes, and Raynaud's phenomenon. Angiography showed multiple stenoses of ulnar and digital arteries, anterior and posterior tibialis arteries, and occlusions of radial artery and occlusion of the plantar artery in the absence of large vessel abnormalities. Histological analysis of an amputation disclosed giant cell arteritis of small vessels. The patient achieved remission with immunosuppressive treatment (cyclophosphamide and prednisolone). Three other patients with acral ischemic lesions and unclassified vasculitis also lacking other manifestations and defining laboratory and technical features during initial presentation and follow-up of 4 month to 5 years are presented. Necrotizing and leukocytoclastic vasculitis were present in two other patients, respectively. In contrast, acral ischemic lesions could be attributed to rheumatoid vasculitis and essential cryoglobulinemic vasculitis in two other cases each based on the patient's history and laboratory findings at the time of presentation of acral ischemic lesions.

CONCLUSIONS

While acral ischemic lesions could represent initial or isolated (forme fruste) manifestations of a defined vasculitis, acral ischemic lesions may rarely be encountered as the predominant manifestation of an as yet unclassified vasculitis. the histological findings seem to differ. Our report includes a peculiar case of giant cell arteritis of small arteries not classifiable as giant cell arteritis of large arteries or Takayasu disease.

Nosology of primary vasculitis

PURPOSE OF REVIEW

Recent developments in the nosology of primary systemic vasculitis are placed in the context of an historical overview. The ongoing attempts to develop criteria for classification and diagnosis are discussed.

RECENT FINDINGS

Giant cell arteritis has supplanted temporal arteritis as the preferred term for chronic granulomatous arteritis in older adults. A new classification system for childhood vasculitis has been proposed by a European collaborative group. A study of idiopathic polyarteritis nodosa demonstrates greater similarity to microscopic polyangiitis in relapse rate than previously reported. Controversy has arisen over the eponym Wegener's granulomatosis because of alleged involvement of Friedrich Wegener in the Nazi regime during World War II. Diagnostic criteria for Kawasaki disease are problematic because many patients with coronary artery involvement do not fulfill current criteria at the time of presentation. Classification of antineutrophil cytoplasm autoantibody-associated small vessel vasculitis based on antineutrophil cytoplasm autoantibody specificity has been complicated by the finding that different ethnic groups may have very different clinical features relative to antigen specificity; for example, most patients with Wegener's granulomatosis in China have myeloperoxidase-antineutrophil cytoplasm autoantibodies rather than proteinase 3-antineutrophil cytoplasm autoantibodies.

SUMMARY

Within the past year, new classification systems for primary vasculitis have been proposed, new classification criteria have been developed, and the appropriateness of a longstanding eponym has been challenged.

Cannabis arteritis: a new case report and a review of literature

Cannabis arteritis manifests in cannabis users, independently of tobacco consumption. Around 50 cases were reported in the literature since the first description of this entity in 1960. We report the case of a 36-year-old man, cannabis user, without vascular risk factor who developed digital necrosis on the right foot. The pedal pulses were not palpable. He had no abnormal laboratory findings. Arteriography revealed distal segmental lesions and occlusion of popliteal artery. This arteritis was linked to cannabis use, but the patient did not stop cannabis consumption. His symptoms became even worse and he eventually developed sub-acute ischaemia in his left leg despite vascular treatments. Amputation of the right second toe and of the left leg finally became necessary. Cannabis arteritis is relatively similar to thromboangiitis obliterans in its clinical and arteriographical presentation. A parallelism can be made between the role of tobacco in thromboangiitis obliterans pathogenesis and the role of cannabis in cannabis arteritis. Cannabis use must be searched in young patients presenting with arteriopathy. Cannabis arteritis may indeed represent a frequent cause of juvenile peripheral obstructive arterial disease, but is probably under-diagnosed.

Correlations between retinal nerve fiber layer and visual field in eyes with nonarteritic anterior ischemic optic neuropathy

PURPOSE

To evaluate correlations between retinal nerve fiber layer (RNFL) thickness with visual field (VF) sensitivities in eyes with nonartertic anterior ischemic optic neuropathy (NAION).

DESIGN

Case-control study in an academic, institutional setting.

METHODS

One eye from 21 patients with NAION and 32 healthy participants were included in this prospective study. Humphrey visual field (HVF) sensitivities were obtained from standard achromatic HVF test (24-2 SITA). RNFL was measured with scanning laser polarimetry (SLP, GDx-VCC) and optical coherence tomography (OCT, StratusOCT). Correlations were evaluated between RNFL and sensitivities from global, hemifields, and regional locations of the VF pertinent to the RNFL distribution. A total of 15 NAION eyes had inferior altitudinal HVF defects, and their global and regional RNFL was compared with that of control eyes. The main outcome measure was correlation between HVF sensitivities and RNFL.

RESULTS

Correlations of global, hemifield, and sectorial HVF sensitivities with RNFL were greater when RNFL was measured with OCT than with SLP, except for nasal and inferonasal sectors. RNFL thickness was far lower in the hemiretinas corresponding to the relative unaffected hemifield in eyes with altitudinal VF defect compared with controls.

CONCLUSIONS

In patients with NAION, RNFL measured by OCT provided better correlation to HVF changes than SLP did. Both instruments showed decreased RNFL in NAION eyes with altitudinal VF defects compared with control eyes, demonstrating loss of RNFL even in sectors of the optic disk that corresponded to relatively unaffected hemifield, suggesting greater damage beyond the extent estimated by VF methods.