Overlap syndrome of systemic sclerosis with antineutrophil cytoplasmic antibody-associated vasculitis according to 2022 ACR/EULAR criteria

BACKGROUND/AIMS

This study applied the 2022 American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) criteria for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) to patients with systemic sclerosis (SSc) and investigated the frequency of overlap syndrome of SSc and AAV (SSc-AAV-OS).

METHODS

Among the 232 patients diagnosed with SSc, 105 with signs suggestive of small- or medium-vessel vasculitis, which were defined as the present of interstitial lung disease (ILD), peripheral neuropathy, or suspected renal vasculitis, were included in this study and analyzed.

RESULTS

Among the 105 SSc patients, the detection rate of ANCA was 19.0%. When the 2022 ACR/EULAR criteria were applied, the frequency of SSc-AAV-OS was 20.0%, which was much higher than 1.7% reported with previous criteria for AAV. ANCA positivity contributed to the reclassification of SSc-AAV-OS more than ANCA negativity in SSc patients with signs suggestive of small- or medium-vessel vasculitis.

CONCLUSION

The frequency of SSc-AAV-OS in SSc patients with signs suggestive of small- or medium-vessel vasculitis at diagnosis was 20.0%. Therefore, we suggest that physicians should perform ANCA tests in SSc patients exhibiting signs suggestive of small- or medium-vessel vasculitis and apply the new criteria for AAV.

Clinical characteristics of patients with vasculitis positive for anti-neutrophil cytoplasmic antibody targeting both proteinase 3 and myeloperoxidase: a retrospective study

Anti-neutrophil cytoplasmic antibody (ANCA) may target proteinase 3 (PR3) or myeloperoxidase (MPO). Although a few patients with vasculitis have both MPO- and PR3-ANCA, the details of their clinical characteristics are not known. The objective of this study was to analyze the characteristics of patients with dual MPO- and PR3-ANCA-positive vasculitis. The medical records of patients with ANCA and vasculitis confirmed by biopsy were reviewed. The age at diagnosis, sex, and data on organ involvement of the kidney, lung, upper airways, skin, nervous system, and gastrointestinal tract were collected. Clinical variables were analyzed according to ANCA specificity. Of 85 patients with ANCA and vasculitis included in this study, 67 (78.8%) had MPO-ANCA, 10 (11.8%) had PR3-ANCA, and 8 (9.4%) had both MPO- and PR3-ANCA. Patients with MPO- PR3 + ANCA-associated vasculitis (AAV) were younger at diagnosis (median, 54.4 years; p < 0.05) than patients with MPO + PR3- AAV (67.0 years) or dual-ANCA AAV (MPO + PR3 + , 68.5 years). The initial glomerular filtration rate in patients with MPO + PR3- AAV (22.0 ml/min) was significantly lower than that in patients with MPO- PR3 + AAV (108.6 ml/min, p < 0.05), but was not different from that in dual-ANCA AAV patients (16.5 ml/min). Upper airway involvement also differed with ANCA type (MPO+ PR3- , 35.8% vs. MPO- PR3 + , 70.0% vs. MPO + PR3+ , 75.0%, p < 0.05). The involvement of other organs did not differ according to ANCA type. Age at diagnosis, kidney involvement, and upper airway involvement were associated with ANCA type. Patients with dual-ANCA-positive vasculitis had considerably more kidney dysfunction than patients with MPO- PR3+ AAV. They also had more upper airway involvement than patients with MPO+ PR3- AAV.

[Differentiated laboratory diagnostics of rheumatic diseases]

Laboratory diagnostics of rheumatic diseases include examinations to confirm the diagnosis, estimate prognosis, assess disease activity as well as recognition and avoidance of complications. Although detection and clinical classification of serological signs of inflammation are the first and often decisive steps in the diagnosis of inflammatory rheumatic diseases, a lack of humoral signs of inflammation does not rule out an inflammatory rheumatic disease. Rheumatological and immunological laboratory diagnostics should always be assessed in the context of the clinical issue and other clinical and technical findings.

[The 461th case: fever, hematuria, and right lumbar pain]

A 56-year-old female was admitted to the Department of Rheumatology, Peking Union Medical College Hospital with complaint of recurrent fever and acute lumbar pain. Fever was complicated with malaise, cough and occasional blood-streaked sputum. Lab tests showed elevated white blood cell count, increased serum creatinine, erythrocyte sedimentation rate and C-reactive protein. Other lab findings included severe anemia, hematuria, and proteinuria. Immunological examinations were positive for antinuclear antibodies, antineutrophil cytoplasmic antibodies and antiglomerular basement membrane antibody. Ultrasonography and CT scan detected a huge spontaneous perirenal hematoma at right side. Angiography revealed multiple microaneurysms on bilateral renal arteries and branches. A diagnosis of systemic vasculitis was suggested. Under the combination therapy of corticosteroids and cyclophosphamide, the patient presented sustained remission for one year. This case indicates that prompt and sufficient treatment of primary disease is essential to a promising outcome.

[Prognosis and its risk factors in ANCA-associated glomerulonephritis patients treated with initial renal replacement therapy]

Objective: To explore the prognosis and its risk factors in anti-neutrophil cytoplasmic antibodies (ANCA)-associated glomerulonephritis (AAGN) patients who needed initial renal replacement therapy (RRT). Methods: One hundred patients [54 females, 46 males, with a median age of 54(41, 60) years] with biopsy-proven AAGN and requiring initial RRT between January 1996 and December 2016 in Nanjing Jinling Hospital were included. Intensive immunotherapy indicated that the patients received corticosteroids in combination with cyclophosphamide or mycophenolate mofetil, or immunoadsorption (IA) or double filtration plasmapheresis (DFPP). The clinical and histological risk factors for renal survival were analyzed. Results: Forty-one patients were free of RRT after a median time of 1 (0.5, 2) month treatment (dialysis-independent group), and the remaining 59 patients were on maintenance dialysis (dialysis-dependent group). The multivariate logistic analysis revealed that the proportion of normal glomeruli <8% (OR=5.95, P=0.002) and global sclerotic glomeruli ≥50% (OR=4.87, P=0.003), and not receiving intensive immunotherapy (OR=7.81, P=0.004) were the risk factors for the renal recovery in these patients. During a median follow-up time of 22 (10, 50) months, 15 patients(36.6%) in the dialysis-independent group progressed into maintenance dialysis, and the 1 and 3 year renal survival rate were 86% and 60%, respectively. During a median follow-up time of 6 (2, 24) months, 12 (12%) patients died, among whom four patients died of therapy. The multivariate Cox regression analysis revealed that IA/DFPP treatment (HR=10.85, P=0.034) and low albumin level (HR=1.26, P=0.009) significantly associated with a higher risk of therapy-related death. Conclusions: The renal recovery rate in AAGN patients with initial RRT was low. The proportion of normal and global sclerotic glomeruli, receiving intensive immunotherapy or not were associated with renal outcome, and IA/DFPP treatment as well as lower albumin level were independently associated with therapy-related death.

[The significances of peripheral neutrophils CD(55) and myeloperoxidase expression in patients with myeloperoxidase-specific anti-neutrophil cytoplasmic antibody associated vasculitis]

Objective: To investigate the expression of CD(55) and myeloperoxidase (MPO) on neutrophils in patients with MPO-specific anti-neutrophil cytoplasmic antibody associated vasculitis(MPO-AAV), and analyze the relationship between the expression and clinical manifestation. Methods: Forty untreated patients with active MPO-AAV (patient group) and 30 healthy volunteers (control group) were enrolled in this study. The CD(55) on neutrophils and both membrane and cytoplasmic MPO were detected by flow cytometry. Serum fragment-from the activated complement factor B(Ba) and MPO were measured by ELISA. The clinical activity of vasculitis was valued by Birmingham vasculitis activity score-version 3(BVAS-V3). The significance of laboratory data was evaluated by Spearman correlation test and multivariate linear regression analysis. Results: (1)The mean fluorescence intensity(MFI) of CD(55) expressed on neutrophils was significantly higher than that in control group[4 068.6±2 306.0 vs 2 999.5±1 504.9, P=0.033]. Similar results of serum MPO and Ba in patient group were found compared to controls [500.0(381.0, 612.7) IU/L vs 286.9(225.5, 329.1) IU/L, P<0.001; 35.2(25.2, 79.5) ng/L vs 18.0(15.0, 28.0) ng/L, P<0.001], respectively. However, MIF of cytoplasmic MPO in patients was significantly lower than that of control group(1 577.1±1 175.9 vs 3 105.3±2 323.0, P=0.003) . (2) In patient group, cytoplasmic intensity of MPO was negatively associated with the serum levels of MPO(r=-0.710, P<0.001) and Ba (r=-0.589, P=0.001). Moreover, serum MPO was positively associated with serum Ba(r=0.691, P<0.001). Membrane intensity of CD(55) on neutrophils was positively correlated with patient age (r=0.514, P=0.001), C reactive protein (r=0.376, P=0.018), peripheral neutrophils count (r=0.485, P=0.001) and BVAS-V3 (r=0.484, P=0.002), whereas negative correlation between membrane CD(55) and disease duration was seen (r=-0.403, P=0.01). (3) The result of multiple linear regression analysis showed there was statistically significant positive correlation between MFI of CD(55) expressed on neutrophils and BVAS-V3 (β=0.001, P=0.027). Conclusions: In MPO-AAV, CD(55) expression on neutrophils is markedly enhanced, which is one of the independent risk factors related to disease activity. It might protect neutrophils from attacking AAV, CD(55) expression on neutrophils is markedly enhanced, which is one of the independent risk factors related to disease activity. It might protect neutrophils from attacking by complement alternative pathway. Activated neutrophils release more MPO and lysosome to intensify the inflammation reaction and aggravate the disease. Thus CD(55) might become a new potential target for the treatment of this disease in the future.

Clinical features and prognostic factors of Churg-Strauss syndrome

BACKGROUND/AIMS

Churg-Strauss syndrome (CSS) is a rare systemic necrotizing small-vessel vasculitis, with accompanying bronchial asthma, eosinophilia, and eosinophilic infiltration of various tissues. The purposes of our study were to characterize the clinical features of CSS and to identify factors associated with CSS prognosis in Koreans.

METHODS

Medical records were reviewed retrospectively for all physician-diagnosed CSS patients in the Seoul National University Hospital between January 1990 and March 2011.

RESULTS

Data from 52 CSS patients were analyzed. The respiratory tract was the most commonly involved organ (90.4%). Renal involvement was less frequent in antineutrophilic cytoplasmic antibody (ANCA)(-) patients than in ANCA(+) patients (p = 0.048). Clinical remission occurred in 95.3% of patients, but 16.3% of them relapsed. Patients who maintained remission for more than 6 months were relatively older (median, 51 years) at diagnosis (p = 0.004), had been diagnosed in earlier stages (p = 0.027), showed more frequent respiratory involvement (p = 0.024) and generalized symptoms (p = 0.039), and showed less frequent cutaneous involvement (p = 0.030) than those who did not achieve persistent (> 6 months) remission. Patients who achieved persistent remission also showed higher C-reactive protein (CRP) levels (p = 0.031) than those who did not.

CONCLUSIONS

ANCA(-) CSS patients showed less frequent renal involvement. Characteristics of good responders were older age, diagnosis at earlier stages, less cutaneous involvement, more respiratory involvement, high CRP values, and more generalized symptoms.