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Jedlowski PM, Jedlowski MF. Coronavirus disease 2019-associated immunoglobulin A vasculitis/Henoch-Schönlein purpura: A case report and review. J Dermatol 2021; 49:190-196. [PMID: 34741345 PMCID: PMC8652426 DOI: 10.1111/1346-8138.16211] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 09/05/2021] [Revised: 09/20/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
Immunoglobulin A (IgA) vasculitis or Henoch–Schönlein purpura is a predominantly pediatric disease occurring after a triggering viral or bacterial infection. Conversely, drug exposure is the most common inciting event in adult cases of IgA vasculitis. Recently, data has suggested a temporal association between coronavirus disease 2019 (COVID‐19) and the development of IgA vasculitis in children and adults. Here, we describe a case of IgA vasculitis with nephritis in a 70‐year‐old man with COVID‐19 and perform a comprehensive review of eight reported cases of suspected COVID‐19‐associated IgA vasculitis. When compared to classical IgA vasculitis, COVID‐19‐associated IgA vasculitis exclusively affects males (p < 0.00002) and is more common in adults (p < 0.005). Among cases of COVID‐19‐associated IgA vasculitis, adult cases were associated with significantly more arthralgia than pediatric cases (p = 0.04). In cases where skin biopsy was obtained, direct immunofluorescence (DIF) was negative for IgA in 50% of cases; thereafter, kidney biopsy DIF was positive for IgA in all cases. With this study, we provide support for an association between IgA vasculitis and severe acute respiratory syndrome coronavirus 2 infection and provide clinical information differentiating its manifestations from classical IgA vasculitis.
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Affiliation(s)
- Patrick M Jedlowski
- Division of Dermatology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mahdieh F Jedlowski
- Division of Dermatology, University of Arizona College of Medicine, Tucson, Arizona, USA
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Mohamoud M, Horgan C, Eworuke E, Dee E, Bohn J, Shapira O, Munoz MA, Stojanovic D, Sansing-Foster V, Ajao A, La Grenade L. Complementary Use of U.S. FDA's Adverse Event Reporting System and Sentinel System to Characterize Direct Oral Anticoagulants-Associated Cutaneous Small Vessel Vasculitis. Pharmacotherapy 2020; 40:1099-1107. [PMID: 33090530 DOI: 10.1002/phar.2468] [Citation(s) in RCA: 2] [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: 10/23/2022]
Abstract
BACKGROUND Cutaneous small vessel vasculitis (CSVV) has been reported after exposure to direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban. OBJECTIVE We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to describe clinical characteristics associated with CSVV among DOAC-exposed patients. Furthermore, we characterized this signal in the Sentinel System to relate the clinical data from the individual FAERS cases to population-based electronic healthcare data. METHODS We queried FAERS for all cases of CSVV associated with DOACs from U.S. approval date of each DOAC through March 16, 2018. Within the Sentinel System, we identified incident CSVV cases using ICD-9 and ICD-10 diagnosis codes among adults aged ≥ 30 years who received a DOAC in the prior 90 days between January 1, 2010, and June 30, 2018. We excluded patients with evidence of select autoimmune diagnoses in the 183 days prior to their CSVV diagnoses and reported patient characteristics in the 183-day period prior to CSVV diagnoses. RESULTS In FAERS, we identified 50 cases of CSVV reported with rivaroxaban (n=26), apixaban (n=14), dabigatran (n=9), and edoxaban (n=1). Approximately 50% of the cases reported time to onset within 10 days after DOAC exposure. When specified, the predominant type of CSVV reported was leukocytoclastic vasculitis (n=31), followed by Henoch-Schonlein purpura (n=4). Hospitalization occurred in most of the cases (n=37). Switching of the offending agent after the development of CSVV was reported (n=26). Three rivaroxaban (n=3) cases and one dabigatran case (n=1) reported positive rechallenge. In the Sentinel system, we identified 3659 CSVV cases with prior DOAC exposure, with 85% of events occurring within 10 days. CONCLUSIONS The assessment of FAERS cases, combined with the temporal clustering of the Sentinel System cases suggest a possible causal relationship of DOACs and CSVV. Future efforts should characterize the risk of CSVV among the various DOAC users.
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Affiliation(s)
- Mohamed Mohamoud
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Casie Horgan
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Efe Eworuke
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elizabeth Dee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Justin Bohn
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Oren Shapira
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Monica A Munoz
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Danijela Stojanovic
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Veronica Sansing-Foster
- Division of Epidemiology, Office of Clinical Evaluation and Analysis, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Adebola Ajao
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lois La Grenade
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Gehlhausen JR, Wetter DA, Nelson C, Ramachandran S, McNiff JM, Ko CJ. A detailed analysis of the distribution, morphology, and histopathology of complex purpura in hospitalized patients: A case series of 68 patients. J Am Acad Dermatol 2020; 84:1188-1196. [PMID: 32376433 DOI: 10.1016/j.jaad.2020.04.149] [Citation(s) in RCA: 2] [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] [Received: 02/10/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Purpura in inpatients commonly leads to dermatologic consultation. The differential diagnosis is broad and algorithms are intricate. OBJECTIVE We evaluated inpatient consultations for complex purpura to document the most common diagnoses and to validate the true diagnostic utility of histopathology, clinical morphology, and distribution. METHODS We reviewed a case series of 68 inpatients during a 4-year period with a dermatologic consultation for purpura and biopsy findings of vasculitis or microvascular occlusion. RESULTS Key features of complex purpura are nonbranching (round) versus branching (retiform) morphology, dependent versus acral or generalized distribution, and leukocytoclastic vasculitis versus microvascular occlusion (with emphasis on depth of involvement). Dependent nonbranching purpura with only superficial vessels involved by leukocytoclastic vasculitis was most often due to IgA vasculitis or cutaneous single-organ small-vessel vasculitis. In contrast, deeper involvement by leukocytoclastic vasculitis was suggestive of systemic disease (eg, antineutrophil cytoplasmic antibody-associated vasculitis). Branching purpura was concerning, with greater than 90% sensitivity and specificity for microvascular occlusion and associated high mortality (≈50%). The majority of patients who died had acral branching lesions. LIMITATIONS Small sample size, inpatients at a tertiary care center, and retrospective nature are some limitations. CONCLUSION Nonbranching dependent purpura corresponded to leukocytoclastic vasculitis, with the most common diagnoses being IgA vasculitis or skin-limited small-vessel vasculitis; patients with deep involvement often had systemic diseases. In this series, branching purpura was due to microvascular occlusion rather than medium-vessel vasculitis, and had associated high mortality.
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Affiliation(s)
- Jeff R Gehlhausen
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | - David A Wetter
- Mayo Clinic Department of Dermatology, Rochester, Minnesota
| | - Caroline Nelson
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | | | - Jennifer M McNiff
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut
| | - Christine J Ko
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut.
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Abstract
Cutaneous and other vasculitides are specific inflammations of the blood vessel wall that can take place in any organ system of the body including the skin. Vasculitis has been traditionally divided according to the size of the vessel involved (small, medium, and large). Vasculitis is more of a reaction pattern rather than a specific disease entity. Therefore, the clinical presentation of vasculitis (most commonly palpable purpura on the lower extremities) dictates a thorough history, review of systems, and a meticulous physical examination. The diagnosis of vasculitis relies also on the histopathological and immunofluorescence studies. Wound care specialist may face with vasculitis-associated ulcers along with a spectrum of other cutaneous presentations associated with vasculitis. The focus of this article is to update the types, etiology, pathogenesis, and management options for cutaneous vasculitis.
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Affiliation(s)
- Eran Shavit
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Alavi
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - R Gary Sibbald
- 1 Women's College Hospital, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
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