Paediatric Cogan Syndrome masquerading as IgA vasculitis

Paediatric Cogan Syndrome is a rare and underrecognised autoimmune vasculitis characterised by ocular inflammation and sensorineural hearing loss. Its etiopathogenesis, diagnosis, and management are not well defined. We report a 12-year-old girl who initially presented with symptoms of IgA vasculitis formerly called Henoch Schoenlein Purpura (HSP) and eventually developed anterior uveitis and bilateral sensorineural hearing loss leading to the diagnosis of atypical Cogan Syndrome. The workup for infectious etiologies and other systemic rheumatologic disorders was negative. The management was multidisciplinary involving Rheumatology, Ophthalmology, Otorhinolaryngology, and Audiology. The anterior uveitis responded well to systemic glucocorticoids and Methotrexate, but the hearing loss was grossly progressive warranting a cochlear implant. We are not aware of Paediatric Cogan Syndrome being reported as a mimicker of IgA vasculitis previously in the literature. It is an important finding as IgA vasculitis is prevalent in the paediatric age group and new-onset ocular or vestibular symptoms after IgA vasculitis should alert the clinician to the possibility of Cogan Syndrome. In the absence of well-defined diagnostic criteria, it is crucial to recognise the clinical symptoms of Paediatric Cogan Syndrome for early diagnosis and treatment since the delay in diagnosis can lead to permanent disability.

Atypical Cogan's Syndrome with Large-vessel Vasculitis Successfully Treated with Tocilizumab

A 61-year-old man presented with weight loss, bilateral ocular redness, blurred vision, and sensorineural hearing loss. Fluorodeoxyglucose-position emission tomography/computed tomography demonstrated an uptake in the ascending and descending aorta, abdominal aorta and femoral arteries. Atypical Cogan's syndrome complicated with large-vessel vasculitis (LVV) was diagnosed. He was treated with high-dose prednisolone and subcutaneous tocilizumab (162 mg/week), resulting in successful improvements in his ocular and vascular involvements. Although there is currently no established treatment strategy for LVV associated with Cogan's syndrome, our case and literature review suggest that tocilizumab is a viable treatment option for this rare but life-threatening complication.

[Vertigo and ocular inflammation: Cogan syndrome]

BACKGROUND

Cogan syndrome is a rare inflammatory condition that mainly affects adults and is characterised by inflammation of various ocular structures and by audiovestibular symptoms such as hearing loss and vertigo.

CASE DESCRIPTION

A 63-year old woman recently diagnosed with an anterior uveitis presented at A&E with vertigo, nausea, vomiting, tinnitus and headache, and she developed bilateral sudden deafness within days. Blood testing revealed elevated inflammatory parameters, without signs of infection. Additional laboratory and imaging tests showed no abnormalities. We finally diagnosed her with Cogan syndrome. Our patient started oral prednisolon and methotrexate and she gradually improved.

CONCLUSION

Cogan syndrome is a rare inflammatory condition that warrants a multidisciplinary approach by an ophthalmologist, neurologist, ENT-physician, and rheumatologist / immunologist for swift diagnosis and treatment with immunosuppressive medication. A timely recognition of the syndrome at first presentation and with new flares improves the chances of full or partial recovery.

Atypical Cogan's Syndrome Mimicking Giant Cell Arteritis Successfully Treated with Early Administration of Tocilizumab

A 49-year-old Japanese man with a 2-month history of a fever, headache, and bilateral conjunctival hyperemia was admitted. His condition fulfilled the giant cell arteritis classification criteria (new headache, temporal artery tenderness, elevated ESR) and atypical Cogan's syndrome (CS) with scleritis and sensorineural hearing loss (SNHL). The interleukin (IL)-6 serum level was extremely high. Two weeks after his insufficient response of SNHL and scleritis to oral prednisolone, we administered tocilizumab (TCZ); rapid improvements in scleritis and SNHL occurred. Early IL-6 target therapy can help prevent irreversible CS-induced sensory organ damage.

Case Report: Effective and Safe Treatment With Certolizumab Pegol in Pregnant Patients With Cogan's Syndrome: A Report of Three Pregnancies in Two Patients

Cogan's syndrome is a rare autoimmune disease characterized by ocular inflammation and audiovestibular manifestations. Treatment consists of systemic glucocorticoids and other immunosuppressive agents including methotrexate, cyclophosphamide and TNF-α-inhibitors. Due to potential ovarian or fetal toxicity immunosuppressive treatment options are limited during pregnancies. Thus far there is a paucity of reports on pregnancies in Cogan's syndrome. With minimal transplacental transfer, Certolizumab pegol is considered to be safe for the use in pregnant patients with underlying inflammatory diseases. However, there is no literature on the use of this TNF-α-inhibitor in Cogan's syndrome in general and especially during gestation. Here we report three pregnancies in two Cogan's Syndrome-patients treated with Certolizumab pegol. Treatment with Certolizumab pegol was effective and well tolerated in patients with Cogan's syndrome and seems to be a safe treatment option during pregnancy.

Off-label application of intravenous immunoglobulin (IVIG) for treatment of Cogan's syndrome during pregnancy

We report the case of a woman with Cogan's syndrome concomitant with the wish to have children. After three major flares of the disease that led to unilateral deafness, immunosuppressive therapy with prednisolone and azathioprine was started. Because of the severe side effects, an off-label therapy with intravenous immunoglobulin (IVIG) was initiated, under which our patient has since given birth to three healthy children. To our knowledge this is the first report to describe Cogan's syndrome with multiple successful pregnancies under IVIG treatment.

[Cogan syndrome – when several of our senses are affected]

Cogans syndrome is a rare systemic inflammatory disease characterized by a combination of audiovestibular and ocular symptoms. In some cases, systemic complications occur with vascular inflammation. Aortitis and large vessel vasculitis are the most common forms, but medium-sized and small vessel involvement has also been described. The autoimmune reaction can lead to blindness, deafness and in worst case death, if these patients remain untreated or if treatment is delayed. There is no specific blood test or imaging method available and the diagnosis is clinical. It should be suspected in patients presenting with both inflammatory eye symptoms and audiovestibular dysfunction, when more common autoimmune and infectious diseases have been excluded. The treatment consists of high dose systemic steroids, topical steroids for the affected eye and in some cases addition of immunosuppressive drugs. Treatment is based on the severity of the symptoms and how well the patient responds to initial systemic corticosteroids. Here we present a case of suspected Cogan's syndrome where diagnosis was considered after exclusion of other possible autoimmune and infectious diseases.

COGAN'S SYNDROME

OBJECTIVES

The objective of our study was to review the current knowledge on Cogan's syndrome, including etiology, diagnosis and treatment. Systematic review methodology: Relevant publications on Cogan's syndrome from 1945 to 2014 were studied.

CONCLUSIONS

Cogan's syndrome is a rare autoimmune vasculitis, with unknown pathogenesis. Infection was thought to have played a role in the pathogenesis of the disease, but now the autoimmunity hypothesis is considered more likely to be true. Cogan's syndrome is characterized by ocular and audiovestibular symptoms similar to those of Meniere's syndrome. Approximately 70% of the patients have systemic disease, of which vasculitis is considered the pathological mechanism. Corticosteroids are the first line of treatment; multiple immunosuppressive drugs were also used with varying degrees of success. The novelty in the treatment of the disease is tumor necrosis factor (TNF)-alpha-blockers, but more studies are necessary to establish their efficacy.

Cogan's syndrome associated with orbital inflammation

Cogan's syndrome is a relatively rare inflammatory disorder presenting with a combination of ocular and vestibuloauditory symptoms. The first cases were described by David Cogan in 1945. Typically the ocular signs involve the anterior segment; however there are no descriptions of orbital inflammation associated with Cogan's syndrome. We describe such a case. A 66-year-old immunosuppressed male patient with known Cogan's syndrome presented to the eye department with right-sided proptosis, chemosis and ocular injection. Ocular motility was reduced. Other than Cogan's syndrome there were no other systemic disorders. Medical treatment included: Azathioprine 125 mg/day and low dose Tab Prednisolone 30 mg/day. A provisional diagnosis of orbital cellulitis was made and intravenous antibiotics started. Blood investigations showed raised CRP levels 475 mg/L and raised WCC (24 × 10(9)/l). An urgent CT scan of the head and orbits ruled out orbital cellulititis. The diagnosis was revised and the patient was treated for orbital inflammatory disease. Pulsed intravenous methlyprednisolone was commenced and oral steroids were increased to 60 mg/day, the Azathioprine was continued. Over the following week, the proptosis had resolved, and oral steroids were reduced back to the maintenance dose. To our knowledge this is the first description of orbital inflammatory disease associated with Cogan's syndrome.

Cogan's syndrome: achievement of complete resolution of auditory deficit with steroids

Cogan's syndrome is a rare inflammatory disorder predominantly affecting ocular and audiovestibular apparatus. The typical ocular picture is that of a non-syphilitic interstitial keratitis, while audiovestibular features resemble Meniere's disease. The hearing deficit often does not adequately respond to systemic steroids, which are the mainstay of therapy. Cochlear implants may ameliorate this deficit, but may not be readily available because of financial constraints in the Indian subcontinent. A high index of suspicion and multispecialty coordination will help in the early initiation of therapy and reduce long-term morbidity. We report a case of this rare entity where the recovery of deficits was dramatic on initiation of high-dose steroids.

Recommendations of the Italian Society of Rheumatology for the treatment of the primary large-vessel vasculitis with biological agents

OBJECTIVES

To provide recommendations on behalf of the Italian Society for Rheumatology for the off-label use of biologic agents in the treatment of large-vessel vasculitis.

METHODS

A panel of experts performed a literature search and selected the evidence relevant to the topic. The following five large-vessel vasculitides were considered: giant cell arteritis, Takayasu arteritis, primary angiitis of the central nervous system, Cogan's syndrome, and Adamantiades-Behçet's disease.

RESULTS

A consensus was achieved regarding the indication of biologic agents for the treatment of large-vessel vasculitis. Levels of evidence were assigned to the papers retrieved, and the strength of the recommendations was graded according to the levels of evidence.

CONCLUSIONS

These recommendations may be used for guidance in deciding which patients with large-vessel vasculitis should receive biologic therapy. Further updates of these recommendations may be published on the basis of the results of new clinical studies and of data from post-marketing surveillance.

Atypical Cogan syndrome mimicking acute rheumatic fever

Cogan syndrome is a syndrome of non-syphilitic interstitial keratitis associated with vestibuloauditory deficits. We report a 10 year-old male child who presented with fever, acute polyarthritis, and unilateral red eye and was diagnosed as acute rheumatic fever. Subsequently unilateral hearing loss was detected and the child was diagnosed to have atypical Cogan syndrome.

Management of patient with Cogan's syndrome: a case report

INTRODUCTION

Cogan syndrome-CS, is a rare autoimmune disease defined as an inflammation of the eyes followed by bilateral audiovestibular symptoms.

CASE PRESENTATION

This is case report of S. A. male, born on April 18th 1986 from Elbasan, presented with the gastrointestinal, audiovestibulary and eyes disorders, weight loss and progressive fatigue. CT-scan showed an inflammation in lymph nodes in the right lower quadrant of his abdomen. MRI examination showed inner ear inflammation. Ophthalmologic examination revealed that patient was very sensitive to light and visual acuity was lowing 5/10 LE and 6/10 RE, a slit-lamp examination ascertained the interstitial keratitis, iritis and conjunctivitis.

CONCLUSION

Considering all diseases manifestations, the results of all examinations, a diagnose of CS was finally made. The treatment with steroids and immunosupresors showed an improvement of diseases but hearing loss was not reversed.