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Thomas C, Zubair T, Monteagudo L, Lotfi-Emran S, Yamanuha J. Cryoglobulin-Associated Retinal Vasculitis: Retrospective Case Series. J Vitreoretin Dis 2024; 8:181-185. [PMID: 38465357 PMCID: PMC10924588 DOI: 10.1177/24741264231203788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Purpose: To highlight clinical and imaging features of 5 patients diagnosed with retinal vasculitis and cryoglobulins. Methods: This retrospective case series describes clinical and angiographic features of retinal vasculitis and serum cryoglobulins and is the most extensive series to our knowledge. Results: Five female patients were diagnosed with retinal vasculitis and serum cryoglobulins. The average age at time of cryoglobulin identification was 46 years (range, 28-72 years), although retinal vasculitis had been present for various durations. Fluorescein angiograms demonstrated large-vessel and small-vessel segmental leakage in 3 patients, only large-vessel segmental leakage in 1 patient, and only small-vessel segmental leakage in 1 patient. Treatment included topical steroids, intraocular steroid injections, oral corticosteroids, oral antimetabolites, and biologic therapy. At the time of this report, 4 of 5 patients had persistent angiographic leakage; however, none had retinal vascular occlusions. Conclusions: Various treatments were efficacious, although resolution was difficult. No patient experienced retinal vascular occlusions or other types of end-organ compromise.
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Affiliation(s)
- Claire Thomas
- University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA
| | - Talhah Zubair
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Luke Monteagudo
- Division of Rheumatic and Autoimmune Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sahar Lotfi-Emran
- Division of Rheumatic and Autoimmune Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Justin Yamanuha
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
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2
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Diaz MJ, Liu V, Forouzandeh M, Motaparthi K. Type III cryoglobulinemia associated with monoclonal gammopathy of uncertain significance and presenting with retiform purpura. JAAD Case Rep 2024; 44:34-37. [PMID: 38292579 PMCID: PMC10824683 DOI: 10.1016/j.jdcr.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Affiliation(s)
- Michael J. Diaz
- University of Florida College of Medicine, Gainesville, Florida
| | - Vivian Liu
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Mahtab Forouzandeh
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
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3
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Ponomarev AB, Pashayeva KR, Feyziyeva NY. [Comparative analysis of the development mechanisms of cryoglobulinemic vasculitis and Sjögren's syndrome]. Arkh Patol 2024; 86:52-56. [PMID: 38319273 DOI: 10.17116/patol20248601152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Cryoglobulinemic vasculitis is a disease characterized by damage of small vessels and in some cases can be a manifestation of mixed cryoglobulinemia. Mixed cryoglobulinemia is a condition in which immunoglobulins in the blood serum form precipitates at temperatures below 37 °C and dissolve again when it rises. Currently, hepatitis C (HCV) is considered the most common etiological factor of mixed cryoglobulinemia. In addition, mixed cryoglobulinemia may be associated with other infectious agents, as well as autoimmune and lymphoproliferative diseases. In the absence of such association, we can talk about essential mixed cryoglobulinemia. To understand how different nosologies in their clinical and morphological picture lead to the development of mixed cryoglobulinemia, it is necessary to carefully analyze the mechanisms of the development of some of them, namely, HCV-associated cryoglobulinemic vasculitis and Sjögren's syndrome. It is noteworthy that mixed cryoglobulinemia in relation to Sjögren's syndrome can be perceived both as its consequence and as a manifestation of the underlying disease. Such an ambiguous nature of mixed cryoglobulinemia makes it currently impossible to select clear diagnostic criteria. For this reason, it is necessary to carry out a comparison between different immunopathogenesis of mixed cryoglobulinemia in order to identify the features that form its classical manifestations.
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Affiliation(s)
- A B Ponomarev
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - K R Pashayeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
| | - N Yu Feyziyeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
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4
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Covic A, Caruntu ID, Burlacu A, Giusca SE, Covic A, Stefan AE, Brinza C, Ismail G. Therapeutic Potential of Rituximab in Managing Hepatitis C-Associated Cryoglobulinemic Vasculitis: A Systematic Review. J Clin Med 2023; 12:6806. [PMID: 37959271 PMCID: PMC10648453 DOI: 10.3390/jcm12216806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
(1) Background. Hepatitis C infection often leads to extrahepatic manifestations, including cryoglobulinemic vasculitis. This systematic review aimed to assess the efficacy and safety of rituximab in treating hepatitis C-associated cryoglobulinemic vasculitis. (2) Methods. Following PRISMA guidelines, databases were searched for relevant studies. Eligibility criteria included studies on hepatitis C-associated cryoglobulinemic vasculitis treated with rituximab. (3) Results. Nine studies met the eligibility criteria and were included in this analysis. Rituximab was commonly administered at 375 mg/m2 weekly for one month. The results consistently demonstrated the efficacy of rituximab, whether as a standalone treatment or as part of a therapeutic regimen. The combination of rituximab with Peg-IFN-α and ribavirin significantly increased the complete response rate compared to Peg-IFN-α and ribavirin alone (54.5% vs. 33.3%, p < 0.05). The 3-year sustained response rate was notably higher in the rituximab combination group (83.3% vs. 40%). In another trial, rituximab achieved remission in 83.3% of patients at 6 months, compared to only 8.3% in the control group. The efficacy of rituximab was supported by long-term experience, with clinical benefits in patients with severe cryoglobulinemic vasculitis, including those resistant to standard therapies. Mild adverse events were generally reported, with rare severe reactions in some studies. (4) Conclusions: In conclusion, rituximab appeared to be effective and safe in managing hepatitis C-associated cryoglobulinemic vasculitis, either alone or with antiviral therapy.
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Affiliation(s)
- Andreea Covic
- Nephrology Department, Dialysis and Renal Transplant Center, “Dr. C.I. Parhon” University Hospital, 700503 Iasi, Romania; (A.C.); (A.C.); (A.E.S.)
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
| | - Irina Draga Caruntu
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
- Department of Morpho-Functional Sciences I—Histology, Pathology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandru Burlacu
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
- Department of Interventional Cardiology, Cardiovascular Diseases Institute “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania
| | - Simona Eliza Giusca
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
- Department of Morpho-Functional Sciences I—Histology, Pathology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adrian Covic
- Nephrology Department, Dialysis and Renal Transplant Center, “Dr. C.I. Parhon” University Hospital, 700503 Iasi, Romania; (A.C.); (A.C.); (A.E.S.)
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
| | - Anca Elena Stefan
- Nephrology Department, Dialysis and Renal Transplant Center, “Dr. C.I. Parhon” University Hospital, 700503 Iasi, Romania; (A.C.); (A.C.); (A.E.S.)
| | - Crischentian Brinza
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine, 700115 Iasi, Romania; (I.D.C.); (A.B.); (C.B.)
- Department of Interventional Cardiology, Cardiovascular Diseases Institute “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania
| | - Gener Ismail
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
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Houben E, de Groot PF, Vegting Y, Vos JMI, Nur E, Hilhorst ML, Hak AE(L, Kwakernaak AJ. Not Everything Is as It Seems: A Case Series and Overview of Diseases Mimicking Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Clin Med 2023; 12:6144. [PMID: 37834788 PMCID: PMC10573599 DOI: 10.3390/jcm12196144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare heterogeneous disease in which treatment must be initiated early to prevent irreversible organ damage and death. There are several diseases that can mimic AAV, even in the presence of positive ANCA serology and/or histological evidence of vasculitis, as demonstrated in this case series. We reflect on the diagnostic approach of patients with AAV and provide an overview of AAV-mimicking diseases that can be considered in patients with atypical disease presentation or course.
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Affiliation(s)
- Eline Houben
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Pieter F. de Groot
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Yosta Vegting
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Josephine M. I. Vos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marc L. Hilhorst
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - A. E. (Liesbeth) Hak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arjan J. Kwakernaak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Gragnani L, Visentini M, Lorini S, Santini SA, Lauletta G, Mazzaro C, Urraro T, Quartuccio L, Cacciapaglia F, Ruscitti P, Tavoni A, Marri S, Cusano G, Petraccia L, Naclerio C, Treppo E, del Frate G, Di Cola I, Raimondo V, Scorpiniti D, Monti M, Puccetti L, Elia G, Fallahi P, Basili S, Scarpato S, Iannone F, Casato M, Antonelli A, Zignego AL, Ferri C. COVID-19 and Mixed Cryoglobulinemia Syndrome: Long-Term Survey Study on the Prevalence and Outcome, Vaccine Safety, and Immunogenicity. J Clin Immunol 2023; 43:680-691. [PMID: 36795264 PMCID: PMC9933006 DOI: 10.1007/s10875-023-01444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE Mixed cryoglobulinemia syndrome (MCs) is a rare immunoproliferative systemic disorder with cutaneous and multiple organ involvement. Our multicenter survey study aimed to investigate the prevalence and outcome of COVID-19 and the safety and immunogenicity of COVID-19 vaccines in a large MCs series. METHODS The survey included 430 unselected MCs patients (130 M, 300 F; mean age 70 ± 10.96 years) consecutively collected at 11 Italian referral centers. Disease classification, clinico-serological assessment, COVID-19 tests, and vaccination immunogenicity were carried out according to current methodologies. RESULTS A significantly higher prevalence of COVID-19 was found in MCs patients compared to Italian general population (11.9% vs 8.0%, p < 0.005), and the use of immunomodulators was associated to a higher risk to get infected (p = 0.0166). Moreover, higher mortality rate was recorded in MCs with COVID-19 compared to those without (p < 0.01). Patients' older age (≥ 60 years) correlated with worse COVID-19 outcomes. The 87% of patients underwent vaccination and 50% a booster dose. Of note, vaccine-related disease flares/worsening were significantly less frequent than those associated to COVID-19 (p = 0.0012). Impaired vaccination immunogenicity was observed in MCs patients compared to controls either after the first vaccination (p = 0.0039) and also after the booster dose (p = 0.05). Finally, some immunomodulators, namely, rituximab and glucocorticoids, hampered the vaccine-induced immunogenicity (p = 0.029). CONCLUSIONS The present survey revealed an increased prevalence and morbidity of COVID-19 in MCs patients, as well an impaired immunogenicity even after booster vaccination with high rate of no response. Therefore, MCs can be included among frail populations at high risk of infection and severe COVID-19 manifestations, suggesting the need of a close monitoring and specific preventive/therapeutical measures during the ongoing pandemic.
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Affiliation(s)
- Laura Gragnani
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Serena Lorini
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | - Stefano Angelo Santini
- Department of Basic, Clinical, Intensive and Perioperative Biotechnological Sciences, Catholic University School of Medicine, Rome, Italy ,Synlab Lazio, Roma, Italy
| | - Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro” Medical School, Bari, Italy
| | - Cesare Mazzaro
- Clinical Experimental Onco-Haematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Teresa Urraro
- Rheumatology Unit, “M. Scarlato” Hospital, Scafati (SA), Italy
| | - Luca Quartuccio
- Rheumatology Clinic Department of Medicine (DAME), ASUFC, University of Udine, Udine, Italy
| | - Fabio Cacciapaglia
- UO Reumatologia – Department of Precision and Regenerative Medicine-Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological & Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Silvia Marri
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | - Giuseppina Cusano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luisa Petraccia
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | | | - Elena Treppo
- Rheumatology Clinic Department of Medicine (DAME), ASUFC, University of Udine, Udine, Italy
| | - Giulia del Frate
- Rheumatology Clinic Department of Medicine (DAME), ASUFC, University of Udine, Udine, Italy
| | - Ilenia Di Cola
- Rheumatology Unit, Department of Biotechnological & Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Vincenzo Raimondo
- Rheumatology Clinic ‘Madonna dello Scoglio’ Cotronei, Crotone, Italy
| | | | - Monica Monti
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | | | - Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, School of Medicine, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research & New Technologies in Medicine and Surgery, University of Pisa, School of Medicine, Pisa, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Florenzo Iannone
- UO Reumatologia – Department of Precision and Regenerative Medicine-Ionian Area, University of Bari “Aldo Moro”, Bari, Italy
| | - Milvia Casato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, School of Medicine, Pisa, Italy
| | - Anna Linda Zignego
- MASVE Interdepartmental Hepatology Center, Department of Experimental and clinical Medicine, University of Florence, Center for Research and Innovation CRIA-MASVE, AOU Careggi, Florence, Italy
| | - Clodoveo Ferri
- Rheumatology Clinic 'Madonna dello Scoglio' Cotronei, Crotone, Italy. .,Rheumatology Unit, University of Modena and Reggio Emilia, School of Medicine, Modena, Italy.
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Sunderkötter C, Golle L, Pillebout E, Michl C. Pathophysiology and clinical manifestations of immune complex vasculitides. Front Med (Lausanne) 2023; 10:1103065. [PMID: 36936215 PMCID: PMC10020193 DOI: 10.3389/fmed.2023.1103065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Immune complex (IC) vasculitides present inflammations of vessel walls associated with perivascular deposition of immunoglobulins (Igs), mostly ICs. They encompass systemic and skin-limited variants of IgA vasculitis (IgAV), cryoglobulinemic vasculitis (CV), rheumatoid, lupus, and hypocomplementemic vasculitides, serum sickness cutaneous IgM/IgG (non-IgA) vasculitis, and recurrent macular (hypergammaglobulinemic or exertion-induced) vasculitis. Serum sickness and CV fulfill the criteria of a type III hypersensitivity immune reaction as large lattices of the IC precipitate at vessel walls and activate polymorphonuclear neutrophils (PMNs). Immunoglobulin-A vasculitis differs with regard to the causes of perivascular deposition of ICs since here many IgA1 molecules are hypoglycosylated (Gd-IgA1), which appears to facilitate their perivascular deposition in skin and mesangium (via e.g. CD71). The reasons for increased generation of immunoglobulins or formation of IC and their perivascular deposition in either skin or systemic organs are different and not fully explored. A common denominator of OC vasculitides is the activation of PMNs near the vessel wall via Fcy or Fcα receptors. Acute episodes of IgAV additionally require PMNs to become preactivated by IgA1 or by IC already in circulation. This intravascular priming results in increased adherence and subsequently vessel-destructive NETosis when they encounter IgA deposited at the vessel walls. Binding of IgA1 to PMNs in blood stream is associated with increased serum levels of hypogalactosidated IgA1. The characteristic clinical picture of IgAV (and also of so-called IgG/IgM vasculitis) comprises palpable or retiform purpura with a clear predilection for lower legs, probably due to stasis-related reduction in blood velocity, while in other IC vasculitides, additional factors influence the sites of vasculitides. Our knowledge of distinct forms and different pathophysiological pathways of IC vasculitides may lead to in efficacious or targeted therapies. Antibodies to complement components or intestinal budesonide for IgAV are promising agents (the latter suppresses the pathophysiologically related IgA nephropathy by reducing the generation of mucosal IgA.
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Affiliation(s)
- Cord Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- *Correspondence: Cord Sunderkötter
| | - Linda Golle
- Department of Dermatology and Venereology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Evangéline Pillebout
- Laboratory Nephrology Unit, Saint Louis Hospital, INSERM 1149, CRI, Paris, France
| | - Christiane Michl
- Department of Dermatology and Venereology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Ishitoku M, Yoshida Y, Matsubara T, Fujii K, Yorishima A, Oka N, Masuda S, Sugimoto T, Mokuda S, Masaki T, Hirata S. Cryoglobulinemic Vasculitis Associated with Monoclonal Gammopathy of Undetermined Significance Developed after Sustained Virologic Response of Hepatitis C: A Case Report. Intern Med 2022. [PMID: 36384905 PMCID: PMC10372272 DOI: 10.2169/internalmedicine.9768-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old woman had a history of chronic hepatitis C virus (HCV) infection previously treated with interferon to achieve a sustained virologic response. Thereafter, she developed polyarthritis and purpura of the lower extremities as well as progressive renal dysfunction with hypertension and proteinuria that had occurred in the last three months. Laboratory investigations revealed seropositivity for cryoglobulin but negative findings for HCV RNA. She was ultimately diagnosed with cryoglobulinemic glomerulonephritis complicated by monoclonal gammopathy of undetermined significance (MGUS) based on the pathological findings of the kidney and bone marrow, indicating that MGUS-induced cryoglobulinemic vasculitis may occur even after HCV elimination.
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Affiliation(s)
- Michinori Ishitoku
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Toshiki Matsubara
- Postgraduate Clinical Training Center, Hiroshima University Hospital, Japan
| | - Kenji Fujii
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Ai Yorishima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Naoya Oka
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Sho Masuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
- Department of Rheumatology, Medical Corporation JR Hiroshima Hospital, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Japan
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Vornicu A, Berechet A, Frățilă G, Obrişcă B, Jurcuţ C, Ismail G. Relapse of cryoglobulinemic vasculitis with new-onset severe renal involvement in two patients following mRNA COVID-19 vaccination: A case report. Medicine (Baltimore) 2022; 101:e29431. [PMID: 35687780 PMCID: PMC9276277 DOI: 10.1097/md.0000000000029431] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/20/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Since mass-scale severe acute respiratory syndrome coronavirus 2 vaccination, there have been case reports of several immune-mediated reactions, including new-onset and flares of glomerular disorders following immunization with mRNA coronavirus disease 2019 vaccines. Here, we report two cases, the first to our knowledge, of relapsing cryoglobulinemic vasculitis with new-onset severe renal involvement following mRNA coronavirus disease 2019 vaccination. PATIENT CONCERNS The relapse of the cutaneous and the new onset of severe renal involvement of cryoglobulinemic vasculitis occurred three weeks after the second dose of the mRNA Moderna coronavirus disease 2019 vaccination and two days after the first dose of mRNA Pfizer coronavirus disease 2019 vaccination in the first and second patient, respectively. DIAGNOSIS Kidney biopsies were performed. The first pacient's kidney biopsy showed a membranoproliferative pattern of glomerular injury with extensive mesangial and endocapillary hypercellularity, while severe endothelial swelling, loss of fenestrations and widening of subendothelial space were identified by electron-microscopy. The second patient's kidney biopsy was consistent with cryoglobulin associated membrano-proliferative pattern of glomerular injury. INTERVENTIONS Our patients were managed with a combination of immunosuppressants consisting of corticosteroids, Cyclophosphamide and Rituximab with a favourable outcome at the end of the induction period. OUTCOMES Clinical and immunological response was achieved in both patients after four months of follow-up. LESSONS The temporal association of the relapse of the cryoglobulinemic vasculitis to mRNA coronavirus disease 2019 vaccination suggest that the vaccine might have been a trigger for the reactivation of the disease in our cases. This possible association should be acknowledged by physicians in order to provide optimal monitoring and treatment in case of reactivation of the disease post-immunization.
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Affiliation(s)
- Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Berechet
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Georgiana Frățilă
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Obrişcă
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Ciprian Jurcuţ
- Department of Internal Medicine, “Dr. Carol Davila” Central University Emergency Military Hospital, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
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10
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Chang ML, Cheng JS, Chuang YH, Pao LH, Wu TS, Chen SC, Chang MY, Chien RN. Evolution of Cryoglobulinemia in Direct-Acting Antiviral-Treated Asian Hepatitis C Patients With Sustained Virological Responses: A 4-Year Prospective Cohort Study. Front Immunol 2022; 13:823160. [PMID: 35371039 PMCID: PMC8964347 DOI: 10.3389/fimmu.2022.823160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background How cryoglobulinemia evolves after sustained virological response (SVR) following direct-acting antiviral (DAA) treatment in Asian hepatitis C virus (HCV)-infected patients remains elusive. Methods A prospective cohort study was conducted in 422 Taiwanese patients (358 completed DAA therapy and 353 experienced SVRs). Serum cryoglobulins were surveyed at baseline and every 3-6 months posttherapy. Results Of 422, 227 (53.8%) had cryoglobulinemia, 8 (1.89%) had cryoglobulinemic vasculitis. Of 227, 54 (23.8%), 57 (25.1%) and 116 (51.1%) had 1, 2 and 3 cryoglobulins, respectively; those with 3 cryoglobulins had the highest alanine aminotransferase, immunoglobulin G (IgG) and fibrosis-4 index. During a 4-year follow-up, among SVR patients, cryoglobulinemia rates decreased from 56.4% to 15.4%, single cryoglobulin rates increased (21.6% to 63.9%) and 3 cryoglobulin rates decreased (55.7% to 11.1%). Compared with baseline values, among SVR patients with baseline cryoglobulinemia, complement component 4 levels increased, and IgG and IgM levels decreased until 48 weeks posttherapy for those without posttherapy cryoglobulinemia. All 8 cryoglobulinemic vasculitis patients exhibited SVRs; 5 (62.5%) achieved complete clinical response 12 weeks posttherapy, of whom, 2 (40%) experienced clinical relapse 24~48 weeks posttherapy. Baseline IgM levels were associated with posttherapy cryoglobulinemia in SVR patients (cut-off values at 12, 24, 48 weeks and 4 years posttherapy: 130, 105, 118 and 168 mg/dL, respectively). Conclusions Among DAA-treated SVR patients, in 4 years, cryoglobulinemia rates decreased from 56.4% to 15.4%, multiple cryoglobulin rates decreased, cryoglobulinemia signals reversed, 62.5% of cryoglobulinemic vasculitis patients achieved complete clinical response (40% had relapse), and baseline IgM levels indicated posttherapy cryoglobulinemia.
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Affiliation(s)
- Ming-Ling Chang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jur-Shan Cheng
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ya-Hui Chuang
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Chang Gung Memorial Hospital, Taipei and Linkou, Taiwan
| | - Li-Heng Pao
- Graduate Institute of Health-Industry Technology, Chang Gung University of Science and Technology, Taoyuan, Taiwan.,Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Ting-Shu Wu
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Shiang-Chi Chen
- Department of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Ming-Yu Chang
- Division of Pediatrics, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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11
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Edmonds N, Mannschreck D, Flowers RH. A rare case of type II cryoglobulinemic vasculitis with renal and pulmonary involvement in a patient with underlying lymphoplasmacytic lymphoma. Int J Dermatol 2022; 62:e302-e303. [PMID: 35383893 DOI: 10.1111/ijd.16183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/03/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Nicole Edmonds
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
| | - Diana Mannschreck
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
| | - R Hal Flowers
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
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12
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Sy-Go JPT, Thongprayoon C, Herrera Hernandez LP, Zoghby Z, Leung N, Manohar S. Rituximab-Associated Flare of Cryoglobulinemic Vasculitis. Kidney Int Rep 2021; 6:2840-2849. [PMID: 34805636 PMCID: PMC8589694 DOI: 10.1016/j.ekir.2021.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patients with cryoglobulinemic vasculitis (CV) can develop disease flare after rituximab administration. The objective of our study was to describe the prevalence, clinical characteristics, predisposing factors, and outcomes of patients with rituximab-associated flare of CV. Methods We conducted a retrospective study in a tertiary referral center until March 25, 2020. Results Among 64 patients with CV who received rituximab therapy in our center, 14 (22%) developed disease flare. Median age was 67.5 years. Seven patients (50%) had type II CV and the other half had either type I (n = 6) or type III (n = 1). Twelve patients (86%) had an underlying B-cell lymphoproliferative disorder as the cause of their CV. CV flare occurred after a median time of 5.5 days (range: 2–8 days). The organ systems most involved were the skin (n = 10), kidneys (n = 5), and peripheral nerves (n = 3). Five patients (36%) developed acute kidney injury (AKI), 3 of whom presented with nephritic syndrome secondary to biopsy-proven membranoproliferative glomerulonephritis. Treatment was directed against the underlying disease in addition to supportive care. Patients who developed flare were more likely to have B-cell lymphoproliferative disorder as the underlying etiology of their CV (P = 0.03). Eight patients (57%) died after a median time of 27 months. Conclusions Rituximab-associated flare can occur in all types of CV, tends to arise approximately 2 days and less than 1 week after rituximab administration, and is more likely to happen in patients with an underlying B-cell lymphoproliferative disorder. It does not indicate treatment failure, and rituximab should not be abandoned altogether. AKI is a common manifestation, and mortality rate at 2 years is high.
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Affiliation(s)
- Janina Paula T Sy-Go
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Loren P Herrera Hernandez
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ziad Zoghby
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sandhya Manohar
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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13
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Tabb ES, Duncan LM, Nazarian RM. Eosinophilic granulomatosis with polyangiitis: Cutaneous clinical and histopathologic differential diagnosis. J Cutan Pathol 2021; 48:1379-1386. [PMID: 34019312 DOI: 10.1111/cup.14065] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, but severe systemic vasculitis that can affect skin and other organ systems. Diagnostic criteria have evolved, and many attempts have been made to classify the vasculitides based on clinical and/or histopathologic features, with an aim to develop standardized criteria. According to the EGPA Consensus Task Force recommendations, EGPA is a syndrome of asthma, eosinophilia, pulmonary infiltrates, and extrapulmonary vasculitis (such as cutaneous involvement with purpura). Histopathologic evidence of vasculitis in EGPA may be associated with eosinophilic infiltration and/or perivascular granulomatous inflammation. We review clinicopathologic criteria of this enigmatic vasculopathy.
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Affiliation(s)
- Elisabeth S Tabb
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lyn M Duncan
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rosalynn M Nazarian
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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14
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Maltseva N, Borzova E, Fomina D, Bizjak M, Terhorst‐Molawi D, Košnik M, Kulthanan K, Meshkova R, Thomsen SF, Maurer M. Cold urticaria - What we know and what we do not know. Allergy 2021; 76:1077-1094. [PMID: 33249577 DOI: 10.1111/all.14674] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
Cold urticaria (ColdU) is a common form of chronic inducible urticaria characterized by the development of wheals, angioedema or both in response to cold exposure. Recent research and guideline updates have advanced our understanding and management of ColdU. Today, its pathophysiology is thought to involve the cold-induced formation of autoallergens and IgE to these autoallergens, which provoke a release of proinflammatory mediators from skin mast cells. The classification of ColdU includes typical and atypical subtypes. We know that cold-induced wheals usually develop on rewarming and resolve within an hour and that anaphylaxis can occur. The diagnosis relies on the patient's history and cold stimulation testing. Additional diagnostic work-up, including a search for underlying infections, should only be done if indicated by the patient's history. The management of ColdU includes cold avoidance, the regular use of nonsedating antihistamines and the off-label use of omalizumab. However, many questions regarding ColdU remain unanswered. Here, we review what is known about ColdU, and we present important unanswered questions on the epidemiology, underlying pathomechanisms, clinical heterogeneity and treatment outcomes. Our aim is to guide future efforts that will close these knowledge gaps and advance the management of ColdU.
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Affiliation(s)
- Natalya Maltseva
- Center of Allergy and Immunology Clinical State Hospital 52 Moscow Ministry of Healthcare Moscow Russian Federation
| | - Elena Borzova
- Department of Dermatology and Venereology I.M. Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Daria Fomina
- Center of Allergy and Immunology Clinical State Hospital 52 Moscow Ministry of Healthcare Moscow Russian Federation
- Department of Clinical Immunology and Allergology I.M.Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Mojca Bizjak
- University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
| | - Dorothea Terhorst‐Molawi
- Dermatological Allergology Allergie‐Centrum‐Charité Department of Dermatology and Allergy Charité – Universitätsmedizin Berlin Berlin Germany
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
| | - Kanokvalai Kulthanan
- Department of Dermatology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Raisa Meshkova
- Smolensk State Medical University Smolensk Russian Federation
| | - Simon Francis Thomsen
- Department of Dermatology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Marcus Maurer
- Dermatological Allergology Allergie‐Centrum‐Charité Department of Dermatology and Allergy Charité – Universitätsmedizin Berlin Berlin Germany
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15
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Yagi N, Yoshimura T, Nakamae H, Hayashi D, Tanaka Y, Ichikawa Y, Hino M. Severe cryoglobulinemia with cerebral infarction successfully treated with steroid and rituximab: A case report. Clin Case Rep 2021; 9:543-546. [PMID: 33489212 PMCID: PMC7813025 DOI: 10.1002/ccr3.3578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/06/2022] Open
Abstract
We report the case of severe cryoglobulinemia with cerebral infarction and ischemic cardiac disease successfully treated with steroid and rituximab.
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Affiliation(s)
- Naoko Yagi
- Department of HematologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
- Present address:
Department of HematologyOsaka City General HospitalOsaka cityJapan.
| | - Takuro Yoshimura
- Department of HematologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
- Present address:
Department of HematologyOsaka City General HospitalOsaka cityJapan.
| | - Hirohisa Nakamae
- Department of HematologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
| | - Daisuke Hayashi
- Department of DermatologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
| | - Yasuyuki Tanaka
- Department of DermatologyOsaka Minami Medical CenterOsaka cityJapan
| | - Yoshitaka Ichikawa
- Department of CardiologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
| | - Masayuki Hino
- Department of HematologyGraduate School of MedicineOsaka City UniversityOsaka cityJapan
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16
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Perkins GB, Kim J, Coates PT. Going rogue: how autoantibodies become pathogenic. Kidney Int 2020; 99:800-802. [PMID: 33347920 DOI: 10.1016/j.kint.2020.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Griffith B Perkins
- Department of Molecular and Biomedical Science, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Juewan Kim
- Discipline of Medicine, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - P Toby Coates
- Discipline of Medicine, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; Central Northern Adelaide Renal and Transplantation Service (CNARTS), The Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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17
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Lorini S, Gragnani L, Zignego AL. The Relevance of MicroRNAs in the Pathogenesis and Prognosis of HCV-Disease: The Emergent Role of miR-17-92 in Cryoglobulinemic Vasculitis. Viruses 2020; 12:E1364. [PMID: 33260407 DOI: 10.3390/v12121364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 11/27/2020] [Indexed: 12/26/2022] Open
Abstract
Hepatitis C virus (HCV) is a major public health problem. HCV is a hepatotropic and lymphotropic virus that leads to hepatocellular carcinoma (HCC) and lymphoproliferative disorders such as cryoglobulinemic vasculitis (CV) and non-Hodgkin's lymphoma (NHL). The molecular mechanisms by which HCV induces these diseases are not fully understood. MicroRNAs (miRNAs) are small non-coding molecules that negatively regulate post-transcriptional gene expression by decreasing their target gene expression. We will attempt to summarize the current knowledge on the role of miRNAs in the HCV life cycle, HCV-related HCC, and lymphoproliferative disorders, focusing on both the functional effects of their deregulation as well as on their putative role as biomarkers, based on association analyses. We will also provide original new data regarding the miR 17-92 cluster in chronically infected HCV patients with and without lymphoproliferative disorders who underwent antiviral therapy. All of the cluster members were significantly upregulated in CV patients compared to patients without CV and significantly decreased in those who achieved vasculitis clinical remission after viral eradication. To conclude, miRNAs play an important role in HCV infection and related oncogenic processes, but their molecular pathways are not completely clear. In some cases, they may be potential therapeutic targets or non-invasive biomarkers of tumor progression.
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18
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Nwannunu CE, Shah R, Limmer AL. Management of Primary Small-Vessel Vasculitis. Skin Therapy Lett 2020; 25:5-8. [PMID: 32510891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Small-vessel vasculitides (SVV) are a group of disorders that occur due to primarily systemic inflammation or as sequelae of an infection, malignancy, or other rheumatic disease. Arising in any organ including the skin, the clinical features of SVV encompass a variety of manifestations. A comprehensive diagnostic assessment should be performed as management protocols widely differ. Although rare, physicians should be familiar with the common types of SVV to ensure prompt management and prevention of severe, life-threatening end-organ damage. Given the variable manifestations and associated etiologies of SVV, the following review aims to discuss the pathogenesis of more prevalent SVVs, highlight distinguishing features to aid in patient evaluation and diagnosis, and examine evidence-based management options for treatment and care.
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Affiliation(s)
- Crystal E Nwannunu
- Department of Dermatology, McGovern Medical School, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Radhika Shah
- Texas A&M University College of Medicine, Dallas, TX, USA
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19
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Ajiboye O, Vohra I, Attar B, Katiyar V, Mba B. Cryoglobulinemic Vasculitis Masquerading as Bilateral Carpal Tunnel Syndrome. Cureus 2019; 11:e6423. [PMID: 31988822 PMCID: PMC6970103 DOI: 10.7759/cureus.6423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/15/2019] [Indexed: 11/05/2022] Open
Abstract
Cryoglobulinemic vasculitis (CV) is a systemic inflammatory syndrome involving small- to medium-sized vessels. Almost half of hepatitis C-infected patients have detectable cryoglobulins levels, but only very few develop clinical manifestations. In this case report, we bring forth a diagnostic challenge of CV. A 52-year-old man with untreated hepatitis C (high viral load), diabetes mellitus, hypertension, and chronic kidney disease 4 (CKD) with solitary left kidney presented with one month of bilateral hand pain that started in his right hand, progressed to involve the left with numbness more on the palmer aspects and lateral three fingers. Physical exam was significant for bilateral positive Phalen and Tinel's sign. CV occurs due to precipitation of immune complexes within the vessels. Palpable purpura, arthralgia, and weakness have been described as the core symptoms of CV. However, progressive acute to subacute neuropathy, especially bilateral, should raise concerns for vasculitic neuropathy.
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Affiliation(s)
- Oyintayo Ajiboye
- Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Ishaan Vohra
- Internal Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Bashar Attar
- Gastroenterology and Hepatology, Rush University Medical Center, Chicago, USA
| | - Vatsala Katiyar
- Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Benjamin Mba
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
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20
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Abstract
AIM To investigate risk factors of unfavorable prognosis in patients with chronic hepatitis C (CHC), including liver cirrhosis (LC), decompensated cirrhosis, hepatocellular carcinoma (HCC), cryoglobulinemic vasculitis (CryoVas) and B-cell non-Hodgkin's lymphoma. MATERIALS AND METHODS This was a retrospective study using data of 824 patients with CHC hospitalized between 2010 and 2016 in clinic named after E.M. Tareev. We used multivariate analysis including logistic regression to calculate odds ratios (ORs) for potential risk factors/predictors associated with unfavorable outcomes in patients with CHC. RESULTS The rate of LC, decompensated LC, HCC, serious CryoVas and B-cell lymphoma in patients with CHC was 39.1% (322/824), 14.0% (115/824), 2.8% (23/824), 5.2% (43/824) and 1.2% (10/824), respectively. After adjustment for sex and age the rate of LC, decompensated LC, HCC was 22.8, 8.0 and 1.5%, respectively. Annual rate of LC in patients with CHC was 1.5%; in cirrhotic patients annual rate of decompensated LC and HCC was 2.9 and 1%, respectively. Risk factors independently associated with development of LC were elevated body mass index (OR 1.43), immunosuppressive therapy (OR 1.67), diabetes type 2 (OR 2.03), absence of antiviral therapy (OR 2.15), alcohol abuse (OR 2.34), duration of infection ≥20 years (ОR 2.74) and an absence of sustained virological responce (SVR) (OR 2.98). Independent risk factors for decompensation in cirrhotic patients included diabetes type 2 (OR 1.47), alcohol abuse (OR 1.53), an absence of antiviral therapy (OR 2.36) and an absence of SVR (OR 1.94). An episode of decompensation was the independent predictor of HCC in cirrhotic patients (OR 3.99). Genotype 1b (OR 1.66) and an absence of antiviral therapy (OR 3.31) were independently associated with serious CryoVas. Two prognostic scales were offered for risk evaluation of LC and its complications. CONCLUSION Multivariate analysis showed several factors independently associated with higher risk for LC, decompensation of LC, HCC, serious CryoVas in patients with CHC. The rate of unfavorable outcomes of CHC is found, including rare extrahepatic manifestations.
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Affiliation(s)
- S E Shchanitcyna
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - E Z Burnevich
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,City Clinical Hospital №24, Moscow, Russia
| | - E N Nikulkina
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - A L Filatova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - S V Мoiseev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,M.V. Lomonosov Moscow State University, Moscow, Russia
| | - N A Мukhin
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,M.V. Lomonosov Moscow State University, Moscow, Russia
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21
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Abstract
RATIONALE Concomitant cryoglobulinemic vasculitis and cold agglutinin disease (CAD) is an extremely uncommon clinical scenario. The role of bortezomib in the treatment of cryoglobulinemic vasculitis needs further investigation. PATIENT CONCERNS A 72-year-old Chinese woman presented with a 25-year history of cyanosis of the extremities after cold exposure, which worsened and was accompanied with purpuric skin lesions and proteinuria in recent years. Laboratory data demonstrated hemolysis. Cold agglutinin and cryoglobulin tests were positive. There was no evidence for malignancies after blood, image, and pathologic tests. DIAGNOSES Concomitant cryoglobulinemic vasculitis and CAD. INTERVENTIONS The patient was treated with bortezomib-based regimen, including bortezomib, cyclophosphamide, and dexamethasone. OUTCOMES The patient responded well to the treatment. Both symptoms and laboratory tests significantly improved. The patient's condition was in a state of sustained remission in the 6-month follow-up. LESSONS This rare case promotes further understanding of these 2 diseases and suggests that bortezomib is a promising treatment in type I cryoglobulinemic vasculitis.
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Affiliation(s)
| | | | - Fan Jin
- Department of Infectious Diseases
| | - Meng Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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22
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Toriu N, Sawa N, Oguro M, Mizuno H, Oshima Y, Hasegawa E, Sumida K, Suwabe T, Kawada M, Ueno T, Hayami N, Sekine A, Hiramatsu R, Yamanouchi M, Hoshino J, Takaichi K, Ohashi K, Fujii T, Yanagita M, Ubara Y. Renal-limited Cryoglobulinemic Vasculitis: Two Case Reports. Intern Med 2018; 57:1879-1886. [PMID: 29962417 PMCID: PMC6064702 DOI: 10.2169/internalmedicine.0131-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022] Open
Abstract
Cryoglobulinemic vasculitis (CV) presents with systemic manifestations, including renal disease, arthritis, peripheral neuropathy, and muscle weakness. We encountered two patients who developed severe nephrotic range proteinuria; however, extrarenal manifestations were not noted during the clinical course. A renal biopsy revealed typical membranoproliferative glomerulonephritis (MPGN) with huge thrombus-like endothelial deposits and predominant IgM positivity, but electron microscopy did not reveal any definite microtubules. Immunosuppressive therapy and plasmapheresis were only partially effective, and the improvement was not durable. Biological therapy with rituximab (RTX) had no effect. Renal-limited CV should be recognized as a subset of essential CV.
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Affiliation(s)
- Naoya Toriu
- Nephrology Center, Toranomon Hospital, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City Hospital, Japan
| | | | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Japan
- Okinaka Memorial Institute for Medical Research, Japan
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23
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Mahmood T, Puckrin R, Sugar L, Naimark D. Staphylococcus-Associated Glomerulonephritis Mimicking Henoch-Schönlein Purpura and Cryoglobulinemic Vasculitis in a Patient With an Epidural Abscess: A Case Report and Brief Review of the Literature. Can J Kidney Health Dis 2018; 5:2054358118776325. [PMID: 29900000 PMCID: PMC5985547 DOI: 10.1177/2054358118776325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/29/2018] [Indexed: 01/31/2023] Open
Abstract
Rationale Staphylococcus-associated glomerulonephritis (SAGN) is a rare immune complex-mediated glomerulonephritis associated with active Staphylococcus infection. We report a case illustrating the importance of clinical history and kidney biopsy findings in establishing the correct diagnosis. Presenting concerns of the patient We report the case of a 64-year-old man with alcohol-associated cirrhosis, type 2 diabetes mellitus, and hypertension who presented to hospital with lower back and abdominal pain, rectal bleeding, a purpuric lower extremity rash, and oliguric acute kidney injury with microscopic hematuria and nephrotic-range proteinuria. Diagnoses Skin biopsy revealed IgA leukocytoclastic vasculitis. Serum cryoglobulins were positive and there was hypocomplementemia with a low C3 level. Magnetic resonance imaging of the lumbar spine revealed septic discitis and epidural abscesses caused by a recent Staphylococcus aureus bacteremia. Kidney biopsy showed IgA-dominant and C3-dominant proliferative glomerulonephritis with subepithelial humps in keeping with SAGN. Interventions Urgent hemodialysis was initiated along with a prolonged course of intravenous cefazolin. Outcomes Remarkably, the patient demonstrated a complete recovery of renal function after 2 months of dialysis dependence and successful treatment of the epidural abscesses. Lessons learned This case shows that SAGN can closely mimic the clinical, laboratory, and histological presentation of Henoch-Schönlein Purpura or cryoglobulinemic vasculitis. Clinical history and kidney biopsy, particularly electron microscopic analysis, are essential to establishing the correct diagnosis to avoid the unnecessary and potentially harmful administration of immunosuppression. Despite the typically poor prognosis of SAGN, this case report illustrates that full renal recovery remains possible with supportive care and eradication of the underlying infection.
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Affiliation(s)
- Tahrin Mahmood
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Robert Puckrin
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Linda Sugar
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Institute of Health Policy, Management and Evaluation, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Giuggioli D, Sebastiani M, Colaci M, Fallahi P, Gragnani L, Zignego AL, Antonelli A, Ferri C. Treatment of HCV-Related Mixed Cryoglobulinemia. Curr Drug Targets 2018; 18:794-802. [PMID: 26302805 DOI: 10.2174/1389450116666150825112105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/13/2015] [Accepted: 07/15/2015] [Indexed: 11/22/2022]
Abstract
Mixed cryoglobulinemia syndrome (MCs) is a systemic vasculitis, involving skin, joints, peripheral nerves, and several internal organs. Hepatitis C virus (HCV) is recognized as the etiologic agent for the majority of MCs patients, as well as of number of autoimmune, lymphoproliferative, and neoplastic disorders. In this context, HCV-related MCs represents an important model autoimmune/ neoplastic disease triggered by a virus in humans. With regard the therapeutic strategies of MCs, we can treat these patients at different steps by means of etiological (antivirals), pathogenetic, symptomatic drugs (mainly immunosuppressors, corticosteroids, plasmapheresis). In the majority of individuals, MCs shows a mild, slow-progressive clinical course needing only symptomatic treatments, generally low doses of corticosteroids. Considering the etiopathogenesis of MCs, the eradication of HCV should be considered the gold standard in the treatment of MCs. The use of combined peg-interferon- α/ribavirin and/or novel antiviral drugs may lead to HCV eradication in a significant percentage of cases with possible remission of MCs. On the other hand, the presence of rapidly progressive, diffuse vasculitis with multiple organ involvement may be successfully treated with aggressive immunosuppressive and anti-inflammatory therapies, mainly based on cyclophosphamide or rituximab, high dose corticosteroids, and plasma aphaeresis. Moreover, sequential/combined antiviral or immunosuppressive treatments could represent an useful therapeutic strategy particularly in MCs patients with major clinical manifestations. The treatment of MCs should be decided for every patient according to the severity of clinical picture. Thus, a careful follow-up of the disease is necessary, with particular attention to the possibility of cancers onset, such as B-cell lymphoma. The present review focuses on the different therapeutic strategies in patients with MCs, including the treatment of cryoglobulinemic skin ulcers, which represents one of the most discouraging complications of the disease.
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Affiliation(s)
- Dilia Giuggioli
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero- Universitaria, Policlinico di Modena, Modena, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero- Universitaria, Policlinico di Modena, Modena, Italy
| | - Michele Colaci
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero- Universitaria, Policlinico di Modena, Modena, Italy
| | - Poupak Fallahi
- Department of Internal Medicine, School of Medicine, University of Pisa, Pisa, Italy
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MASVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MASVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Antonelli
- Department of Internal Medicine, School of Medicine, University of Pisa, Pisa, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, Department of Internal Medicine, University of Modena and Reggio E., Policlinico di Modena, via del Pozzo, 71, 41100 Modena, Italy
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Ignatova TM, Kozlovskaya LV, Gordovskaya NB, Chernova OA, Milovanova SY, Novikov PI, Nekrasova TP, Beketova TV, Mukhin NA. [Hepatitis C virus-associated cryoglobulinemic vasculitis: A 20-year experience with treatment]. TERAPEVT ARKH 2017. [PMID: 28631698 DOI: 10.17116/terarkh201789546-52] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM To summarize the experience of a multidisciplinary therapy hospital in treating patients with hepatitis C virus (HCV)-associated cryoglobulinemic vasculitis (CV). SUBJECTS AND METHODS Seventy-two patients (mean age, 49.4±10.3 years) with HCV-associated CV were examined and followed up for an average period of 2.8±3.6 years. The efficiency of traditional (corticosteroids ± cyclophosphamide) and selective (rituximab) immunosuppressive therapy (IST) was estimated in 31 and 15 observations, respectively, and that of antiviral therapy (AVT) in 25. Vasculitis activity was assessed using the Birmingham vasculitis activity score (BVAS). The patients' survival was studied; multivariate logistic regression analysis was carried out. RESULTS 24 (33.4%) of the 72 patients had a stage of liver cirrhosis (LC). The pretreatment mean BVAS was 11.9±7.2 (range 2 to 36). Severe CV (BVAS ≥15) was present in 30.6% of the patients. AVT was accompanied by achievement of sustained virologic response in 48% of the patients, clinical remission in 68% and had an advantage over IST in relation to long-term treatment results. Rituximab was significantly more effective than traditional immunosuppressants (remission rates of 73 and 13%, respectively). Combined therapy (rituximab and AVT) was most effective in patients with severe forms of vasculitis. Sixteen patients died from complications of vasculitis (37.5%), infection (37.5%), and LC (25%). The factors adversely affecting prognosis were age >55 years (odds ratio (OR), 4.49), the presence of LC (OR, 3.68), renal failure (OR, 4.66) and the use of glucocorticosteroids (OR, 3.91). CONCLUSION HCV-associated CV can determine the prognosis of chronic HСV infection. AVT is the treatment of choice in all patients with HСV-associated CV. AVT must be combined with rituximab therapy in patients with severe forms of vasculitis.
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Affiliation(s)
- T M Ignatova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - L V Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - N B Gordovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - O A Chernova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - S Yu Milovanova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - P I Novikov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - T P Nekrasova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - T V Beketova
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - N A Mukhin
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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26
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Ferri C, Colaci M, Fallahi P, Ferrari SM, Antonelli A, Giuggioli D. Thyroid Involvement in Hepatitis C Virus-Infected Patients with/without Mixed Cryoglobulinemia. Front Endocrinol (Lausanne) 2017; 8:159. [PMID: 28736547 PMCID: PMC5500622 DOI: 10.3389/fendo.2017.00159] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/23/2017] [Indexed: 12/23/2022] Open
Abstract
Thyroid involvement is a common condition that can be recorded during the natural course of different systemic rheumatic diseases, including the mixed cryoglobulinemia (MC) syndrome or cryoglobulinemic vasculitis. MC is triggered by hepatitis C virus (HCV) chronic infection in the majority of cases; it represents the prototype of autoimmune-lymphoproliferative disorders complicating a significant proportion of patients with chronic HCV infection. HCV is both hepato- and lymphotropic virus responsible for a great number of autoimmune/lymphoproliferative and/or neoplastic disorders. The complex of HCV-related hepatic and extrahepatic manifestations, including MC and thyroid involvement, may be termed "HCV syndrome." Here, we describe the prevalence and clinico-serological characteristics of thyroid involvement, mainly autoimmune thyroiditis and papillary thyroid cancer, in patients with HCV syndrome with or without cryoglobulinemic vasculitis.
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Affiliation(s)
- Clodoveo Ferri
- Chair and Rheumatology Unit, Azienda Ospedaliero-Universitaria di Modena, Medical School, University of Modena and Reggio Emilia, Modena, Italy
- *Correspondence: Clodoveo Ferri,
| | - Michele Colaci
- Chair and Rheumatology Unit, Azienda Ospedaliero-Universitaria di Modena, Medical School, University of Modena and Reggio Emilia, Modena, Italy
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dilia Giuggioli
- Chair and Rheumatology Unit, Azienda Ospedaliero-Universitaria di Modena, Medical School, University of Modena and Reggio Emilia, Modena, Italy
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27
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Artoni E, Sighinolfi GL, Gatti AM, Sebastiani M, Colaci M, Giuggioli D, Ferri C. Micro and nanoparticles as possible pathogenetic co-factors in mixed cryoglobulinemia. Occup Med (Lond) 2016; 67:64-67. [PMID: 27694373 DOI: 10.1093/occmed/kqw134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mixed cryoglobulinemia (MC) is a rare multisystem disease whose aetiopathogenesis is not completely understood. Hepatitis C virus (HCV) infection may have a causative role, and genetic and/or environmental factors may also contribute. AIMS To investigate the presence and possible role of environmental agents in MC. METHODS We recruited 30 HCV-infected MC patients with different clinical manifestations and a control group of 30 healthy, sex-/age-matched volunteers. We collected serum samples from each patient and incubated at 4°C for 7 days to obtain cryoprecipitate samples. We used environmental scanning electron microscopy (ESEM) and energy dispersive X-ray spectroscopy microanalysis to verify the presence of microparticles (MPs) and nanoparticles (NPs) in serum and cryoprecipitate samples. We evaluated environmental exposure using a medical and occupational history questionnaire for each subject. RESULTS MC patients had a significantly higher risk of occupational exposure (OR 5.6; 95% CI 1.84-17.50) than controls. ESEM evaluation revealed a significantly higher concentration, expressed as number of positive spots (NS), of serum inorganic particles in MC patients compared with controls (mean NS 18, SD = 16 versus NS 5.4, SD = 5.1; P < 0.05). Cryoprecipitate samples of MC patients showed high concentrations of inorganic particles (mean NS 49, SD = 19). We found a strong correlation between NS and cryocrit (i.e. percentage of cryoprecipitate/total serum after centrifugation at 4°C) levels (P < 0.001). CONCLUSIONS In addition to HCV infection, MPs and NPs might play an important role in the aetiopathogenesis of MC.
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Affiliation(s)
- E Artoni
- Department of Neuroscience, Biomedical and Metabolic Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy.,Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy
| | - G L Sighinolfi
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy,
| | - A M Gatti
- Institute for Advanced Sciences Convergence and International Clean Water Institute, Herndon, VA 20171, USA
| | - M Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy
| | - M Colaci
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy
| | - D Giuggioli
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy
| | - C Ferri
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena 41124, Italy
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28
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Zignego AL, Gragnani L, Piluso A, Sebastiani M, Giuggioli D, Fallahi P, Antonelli A, Ferri C. Virus-driven autoimmunity and lymphoproliferation: the example of HCV infection. Expert Rev Clin Immunol 2015; 11:15-31. [PMID: 25534977 DOI: 10.1586/1744666x.2015.997214] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
HCV chronic infection is characterized by possible development of both hepatic and extrahepatic manifestations. The infection by this both hepatotropic and lymphotropic virus is responsible for polyoligoclonal B-lymphocyte expansion, leading to several immune-mediated disorders. Mixed cryoglobulinemia syndrome that in some cases may evolve to frank B-cell non-Hodgkin's lymphoma is the prototype of HCV-driven autoimmune and lymphoproliferative disorders. The HCV oncogenic potential has been suggested by several clinicoepidemiological and laboratory studies; it includes hepatocellular carcinoma, B-cell non-Hodgkin's lymphoma and papillary thyroid cancer. The definition HCV syndrome refers to the complex of HCV-driven diseases; these latter are characterized by heterogeneous geographical distribution, suggesting a role of other important genetic and/or environmental cofactors. The natural history of HCV syndrome is the result of a multifactorial and multistep pathogenetic process, which may evolve from mild manifestations to systemic autoimmune disorders, and less frequently to malignant neoplasias. The present updated review analyzes the clinical and pathogenetic aspects of the main HCV-associated diseases.
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Affiliation(s)
- Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MASVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Conteduca V, Sansonno D, Russi S, Pavone F, Dammacco F. Therapy of chronic hepatitis C virus infection in the era of direct-acting and host-targeting antiviral agents. J Infect 2013; 68:1-20. [PMID: 24012819 DOI: 10.1016/j.jinf.2013.08.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 08/07/2013] [Accepted: 08/22/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Chronic hepatitis C virus (HCV) infection represents a leading worldwide medical and social problem. The expanding knowledge of HCV lifecycle has led to the development of novel antiviral agents that: a) specifically target a viral function (direct-acting antivirals), or b) specifically inhibit viral replication. The present review describes the novel anti-HCV drugs that have been better studied at the time of this writing and the current two types of treatment, namely interferon-based and interferon-free regimens. In addition, predictive factors, virological responses, side-effects, and resistance mechanisms of the novel agents are summarized. CONCLUSIONS The introduction of novel antiviral agents is remarkably changing the therapeutic combinations aimed at improving virological responses both for easy-to-cure and difficult-to-treat patients. Since additional, effective drugs are under advanced development, it seems reasonable to expect that further therapeutic and prognostic improvements will be achieved in the near future.
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Affiliation(s)
- Vincenza Conteduca
- Section of Internal Medicine and Clinical Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
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30
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Sharma A, Sharma K. Hepatotropic viral infection associated systemic vasculitides-hepatitis B virus associated polyarteritis nodosa and hepatitis C virus associated cryoglobulinemic vasculitis. J Clin Exp Hepatol 2013; 3:204-12. [PMID: 25755502 PMCID: PMC4216827 DOI: 10.1016/j.jceh.2013.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/09/2013] [Indexed: 12/12/2022] Open
Abstract
Two hepatotropic viruses have been shown to have causal relationship with systemic vasculitis-hepatitis B with classical polyarteritis nodosa and hepatitis C with cryoglobulinemic vasculitis. The present paper provides an updated overview on the clinical presentations and management of these vasculitides. HBV associated PAN patients have higher weight loss, peripheral neuropathy, mononeuritis multiplex, abdominal pain, gastrointestinal manifestations requiring surgery, cardiomyopathy, orchitis, hypertension, and/or elevated transaminase levels. Microaneurysms are also more common in mesenteric artery. Skin manifestations, however are less common. These patients also have a severe disease as suggested by higher five factor score and higher BVAS. Though relapses are less common, mortality is higher in patients with HBV PAN as compared to non HBV PAN. Plasmapheresis has a role in treatment in clearing off immune complexes. The common clinical manifestations of HCV associated cryoglobulinemic vasculitis are skin lesions, peripheral neuropathy, glomerulonephritis, arthritis, and sicca symptoms. Though combination therapy comprising of pegylated interferon α and ribavirin is the first line of management, immunotherapy is needed for severe or life threatening manifestations. Recent randomized trials have shown the efficacy of rituximab in such situations.
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Key Words
- ANCA, anti neutrophilic cytoplasmic antibodies
- BVAS, Birmingham vasculitis activity score
- CHCC, Chapel Hill Consensus classification criteria
- FFS, five factor score
- FVG, French vasculitis group
- HBV
- HBV, hepatitis b virus
- HBV, hepatitis c virus
- HCV
- MPA, microscopic polyangiitis
- MPO, myeloperoxidase
- PAN, polyarteritis nodosa
- PE, plasma exchange
- cryoglobulinemic vasculitis
- polyarteritis nodosa
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Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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31
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Zaidan M, Mariotte E, Galicier L, Arnulf B, Meignin V, Vérine J, Mahr A, Azoulay É. Vasculitic emergencies in the intensive care unit: a special focus on cryoglobulinemic vasculitis. Ann Intensive Care 2012; 2:31. [PMID: 22812447 PMCID: PMC3488028 DOI: 10.1186/2110-5820-2-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/24/2012] [Indexed: 12/25/2022] Open
Abstract
Vasculitis is characterized by the infiltration of vessel walls by inflammatory leukocytes with reactive damage and subsequent loss of vessel integrity. The clinical course of systemic vasculitis may be punctuated by acute life-threatening manifestations that require intensive care unit (ICU) admission. Furthermore, the diagnosis may be established in the ICU after admission for a severe inaugural symptom, mostly acute respiratory failure. Among the systemic vasculitides, cryoglobulinemic vasculitis (CV) has been rarely studied in an ICU setting. Severe CV-related complications may involve the kidneys, lungs, heart, gut, and/or central nervous system. The diagnosis of CV in the ICU may be delayed or completely unrecognized. A high level of suspicion is critical to obtain a timely and accurate diagnosis and to initiate appropriate treatment. We describe severe acute manifestations of CV based on six selected patients admitted to our ICU. That all six patients survived suggests the benefit of prompt ICU admission of patients with severe CV.
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Affiliation(s)
- Mohamad Zaidan
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Eric Mariotte
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Bertrand Arnulf
- Department of Immuno-Hematology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Jérôme Vérine
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Alfred Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Élie Azoulay
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
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