Vasculitis


Article Author:
Shraddha Jatwani


Article Editor:
Abdul Waheed


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/26/2019 7:39:44 PM

Introduction

Vasculitis is a heterogeneous group of pathologies characterized by inflammation if vessels. They share common links of clinical, laboratory, and pathophysiologic features. The clinical and pathological features are variable and depend on the site and type of blood vessels affected.[1] Research has identified more than 30 kinds of vasculitis.[2] Vasculitis may present as a primary process or secondary to another underlying disease. Diseases in which vasculitis is a primary process are called primary systemic vasculitides. Systemic vasculitides classify according to the 1990 American College of Rheumatology (ACR) criteria.[3] The International Chapel Hill Consensus Conference (CHCC) is the most commonly used nomenclature systems for vasculitis.[2]

Etiology

The cause of various vasculitis is unknown — there is a recognition in the literature of several risk factors that increase the incidence and prevalence of vasculitis including geography, age, ethnicity, gender, genetic and environmental factors. Behcet disease is more common among inhabitants of countries that border the ancient Silk Route.[4] Takayasu disease is more prevalent in South Asian countries than elsewhere. Kawasaki disease is a disease of young children less than five years of age,[5] whereas giant cell arteritis (GCA) is a disease of the elderly. There is evidence that the incidence of GCA has increased over the past 50 years by a factor of 2 to 5.[6]

Takayasu disease is more common in females (9 to 1 ratio) than males, while Behcet disease tends towards higher severity in men, with a higher frequency of advanced ocular disease. GCA and granulomatosis with polyangiitis (GPA) occur predominantly in the White population.[7]

Studies have found the association of human leukocyte antigen (HLA)-B51 with Behcet disease, increasing the risk of disease susceptibility and disease severity.[4] Genetic studies have indicated roles for class II HLA alleles such as HLA-DRB1*0401 and HLA-DRB1*0101, in some studies for GCA.[8]

Several medications and certain infections have well-known associations with systemic vasculitis, e.g., hepatitis B with polyarteritis nodosa (PAN), hepatitis C with mixed cryoglobulinemia, silica dust with pauci-immune vasculitis.[9]

Epidemiology

The overall incidence per annum of primary systemic vasculitis is approximately 20 to 40/million according to studies in Europe and USA.[4] GCA is the most common among the primary vasculitides with an annual incidence (in the population of individuals at least 50 years old) around 240 per million.[10] Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and Churg-Strauss syndrome have been reported at an incidence anywhere from 1 to 10 per million.[4]

Pathophysiology

The endothelium is an active player in inflammatory processes and pathogenesis of vasculitis. Cytokine-mediated changes in the expression and function of adhesion molecules coupled with inappropriate activation of leukocytes and endothelial cells are the primary factors influencing the degree and location of vessel damage in the vasculitis syndromes. Few mechanisms studied include pathogenic immune complex formation and deposition (mixed cryoglobulinemia, PAN), production of antineutrophilic cytoplasmic antibodies (in GPA, MPA and Churg-Strauss syndrome) and pathogenic T lymphocyte responses and granuloma formation.[11]

Histopathology

Histopathology of biopsies in GCA show mononuclear cell infiltrate dominated by T lymphocytes and macrophages, with the inflammatory infiltrate penetrating all layers of the arterial wall. The infiltrates can be granulomatous with the accumulation of histiocytes and multinucleated giant cells (MGC’s). Granuloma formation with multinucleated giant cells can be present in infiltrates & presence of MGC’s correlates with increased risk for ischemic complications. Remodeling of the arterial wall leads to vascular complications associated with GCA, whereas fibrinoid necrosis is the hallmark for ANCA-associated vasculitis. Renal biopsies in the AAVs show focal, segmental lysis of glomerular tufts, disruption of the basement membrane, and accumulation of fibrinoid material. Churg-Strauss syndrome usually shows a granulomatous vasculitis of small arteries and veins, associated with eosinophilic infiltration.[11]

History and Physical

Systemic vasculitides are clinically heterogonous, so it is not possible to outline a single algorithm for evaluating patients suspected with vasculitis. A thorough medical history, a complete physical examination, and laboratory testing would be helpful as vasculitides are rare, but the potential exists for severe organ damage or death. Vasculitis should be a consideration in patients who present with systemic or constitutional symptoms in combination with evidence of single or multiorgan dysfunction. Suspicious findings in history include fevers, unexplained weight loss, nasal crusting, epistaxis, upper airway disease, ocular inflammation, acute foot drop or wrist drop, limb claudication, unexplained hemoptysis, hematuria, and a history of hepatitis. Suspicious findings on the physical exam include sensory or motor neuropathy, palpable purpura, nasal septal perforation, absent, diminished or tender pulses, bruit, and blood pressure discrepancies.

Specific clinical abnormalities that when present alone or in combination, should suggest a diagnosis of vasculitis. These include palpable purpura, pulmonary infiltrates and microscopic hematuria, chronic inflammatory sinusitis, mononeuritis multiplex, unexplained ischemic events, and glomerulonephritis with evidence of multisystem disease.

In this activity, the discussion will focus on GCA and ANCA associated vasculitis (AAV).

Most common clinical manifestations for patients with GCA include fevers, weight loss, malaise, headaches, visual symptoms like amaurosis fugax, unilateral or bilateral vision loss, diplopia, jaw claudication, vertigo, scalp tenderness. Atypical manifestations include throat pain, large artery disease, aortic dissection, neurologic signs like peripheral neuropathy, transient ischemic attack, stroke, myocardial infarction, delirium, etc.

AAV can affect any organ systems, and symptoms usually depend on organ system involvement with different types of vasculitis. With GPA, patients can present with inflammation of the upper airway, with epistaxis, sinus inflammation, inflammation of trachea or nasal cartilage to lead to saddle nose deformity. Eye and orbital inflammation are common in GCA and MPA as well. Pulmonary involvement in GCA, MPA, and CSS can present as causing hemoptysis, nodules, pleuritis, alveolar hemorrhage. Neurologic manifestations in patients with AAV include peripheral neuropathy, sensorineural hearing loss, CNS vasculitis. Glomerulonephritis (GN) can present early in disease in about half of the patients with AAV. 

Evaluation

When suspecting vasculitis workup should include a complete blood cell count (CBC) (usually associated with neutrophilia, anemia, and thrombocytosis), kidney function (may be abnormal in renal involvement from GPA, Churg-Strauss etc), liver function studies, erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP), [elevation in acute phase reactants noticed in most vasculitis], serologies for viral hepatitis (hepatitis B in PAN), serum cryoglobulins, and a urinalysis with urinary sediment. Additional testing should include anti-neutrophil cytoplasmic antibodies (ANCA), anti-nuclear antibodies (ANA), complement levels (low complement levels associated with mixed cryoglobulinemia), immunoelectrophoresis (monoclonal gammopathies can occur in Hepatitis C related vasculitis) and work up to rule out vasculitis mimics including infections.

A radiographic evaluation, such as a chest x-ray or high-resolution computed tomography (HR-CT) is indicated in patients with respiratory symptoms. Biopsy of the involved tissue is essential for the diagnosis of many vasculitides. A temporal artery biopsy should always be part of the workup in cases of suspected GCA. Skin biopsy of purpuric lesions and renal biopsies in patients with glomerulonephritis have high diagnostic yields. CT imaging of the sinuses may be necessary for patients with suspected GPA. Vascular imaging, including magnetic resonance imaging (MRI), MR angiograms, CT angiograms, vascular ultrasound, and positron emission tomography (PET) may be used to detect large artery lesions.

Treatment / Management

Treatment depends on the type of vasculitis. If an offending antigen is recognized, e.g., hepatitis infection, it should be treated appropriately along with the treatment regimen of vasculitis. Treatment regimens center upon the specific diagnosis and the severity or extent of the disease. The approach to treatment for any vasculitis generally includes three components: remission induction, remission maintenance, and monitoring.

Glucocorticoids are the first-line treatment for patients with vasculitis used with or without immunosuppressive agents. The type of vasculitis guides the choice of immunosuppressive agents. Methotrexate (MTX), azathioprine (AZA), mycophenolate (MMF), cyclophosphamide (CYC), rituximab (RTX), intravenous immunoglobulin, plasma exchange, etc., have all been used in various treatment regimens in different forms of vasculitis.[12] Once the condition is in remission, slow, downward glucocorticoid titration should commence, to maintain control of disease activity and minimize the risks of drug toxicity. Patients and physicians should know the short-term and long-term toxic side effects of therapeutic agents for monitoring.

In this article, we will discuss the treatment and management of GCA, GPA, and MPA briefly.

Initial treatment for GCA includes steroids, starting at doses 40 to 60 mg a day, as single or divided doses. Glucocorticoid treatment should inititate without delay in patients with a strong suspicion for GCA. Intravenous pulse steroids are an option in patients with recent vision loss. After remission, steroid should be slowly tapered off. Methotrexate and azathioprine can serve as steroid-sparing agents. Tocilizumab has been approved recently for treatment of GCA

Patients with AAV have poor survival rates without treatment, with 81% mortality after one year of diagnosis. Current treatment regimens aim to induce remission and then maintain remission. Depending on disease severity, with organ- and life-threatening manifestations warranting the most aggressive therapy, treatments are tailored for various types of AAV. EULAR/ERA-EDTA published guidelines for the management of AAV in 2016, and the patients with the non-organ threatening disease can start on a regimen of methotrexate or mycophenolate mofetil in the combination of glucocorticoid. Patients with the life-threatening disease should start on a regimen of cyclophsphamide or rituximab with glucocorticoids. Plasma exchange can be a consideration in patients with progressive renal failure or pulmonary hemorrhage. For maintenance therapy, regimens of azathioprine, mycophenolate mofetil, or rituximab with a tapering course of steroids have demonstrated efficacy.[13]

Differential Diagnosis

Vasculitis has several mimics, so careful evaluation of differentials is necessary when evaluating such patients. Conditions that can mimic vasculitis include infections such as infective endocarditis, histoplasmosis, and gonococcal infection.  Since the treatment of vasculitis requires the use of immunosuppressive drugs, it is necessary to perform a full infection screen in all patients with suspected vasculitis. Coagulopathies like antiphospholipid syndrome & thrombotic thrombocytopenic purpura, neoplasms like atrial myoma, lymphoma and several drug toxicities like cocaine and levamisole can present with symptoms similar to vasculitis.[14]

Prognosis

Long-term survival of patients with vasculitis highly depends on the diagnosis, response to therapy, adverse effects of drugs, including the occurrence of infections. In a study assessing long-term survival in ANCA-associated vasculitis: the 1-, 2- and 5-year survival was 88%, 85%, and 78%, respectively. The mortality ratio was 2.6 compared with the general population.[15] Mortality reports derive from both active vasculitic disease and complications of therapy.

Complications

Complications of vasculitis are dependent on the type of vessel involved. Large vessel involvement with vasculitides like GCA, Takayasu, or Kawasaki can lead to complications like acute myocardial infarction, stroke including ischemia of cranial arteries like an ophthalmic artery,[16] mesenteric ischemia, aortic syndromes (including dissection or intramural hematoma) or critical extremity ischemia.[17] Life-threatening complications of small-vessel vasculitis include alveolar hemorrhage, renal failure, and intestinal ischemia.[18] Aneurysm formation is a known complication of GCA, polyarteritis nodosa, and Behcet disease.[17] Deep venous thrombosis and pulmonary embolism are more frequent in AAV and Behcet disease than in other vasculitides.[4]

Deterrence and Patient Education

A patient should consult a physician with if he/she notices any symptoms suspicious for vasculitis. If diagnosed with vasculitis, a patient will require a multi-disciplinary approach for management with the primary care physician and rheumatologist.

Enhancing Healthcare Team Outcomes

Vasculitis is a chronic systemic illness, requiring a multi-disciplinary team for its management. Shared decision making and communication are crucial elements for a good outcome. Patients, rheumatologists, primary care physicians, nephrologists, ophthalmologists, pulmonologists, and other specialties including pharmacists would need to work closely, to achieve remission and improve the quality of care and quality of life for such patients.

Nursing will also play a key role in managing vasculitis cases, from administering medication, to observing for disease or drug-related adverse effects, and reporting these to the rest of the team. The pharmacist should verify all dosing and perform medication reconciliation to prevent drug-drug interactions, also alerting the team when these are present so a therapy change can occur proactively. The ordering/prescribing physician (MD, DO NP, PA) should work in concert with these other professions so that the interprofessional team model can drive optimal patient outcomes with minimal adverse events. [Level V]


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Vasculitis - Questions

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Which of the following laboratory findings is NOT common in patients with vasculitis?



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Which of the following medications is the initial therapy for vasculitis syndromes?



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Which of the following vasculitides and their anatomic propensities is incorrect?



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An acutely ill patient presents with fever and palpable purpura. Which of the following is not in the differential diagnosis?



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A 65-year-old female presents with neck pain, sudden vision changes, and arthralgias. She also reports a history of recent onset weight loss (15 lbs), fatigue and dizziness. Vitals show blood pressure 150/90 mmHg, pulse 84/min, and respiratory rate 18/min. On physical exam, she appears lethargic but does not have any evidence of focal neurological deficits. Pulses were normal, except for temporal pulses which are feeble. Labs show white blood cells 15200/mm3, hemoglobin 10.8 g/dl, platelet 451,000 per microliter, creatinine 0.9 mg/dl, glomerular filtration rate 102 ml/min/1.73 m2, erythrocyte sedimentation rate 86 mm/hr, and C-reactive protein 2.3 mg/dl. What should be the next step in the management?



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A 35-year-old male presents to the emergency department with a history of hemoptysis for 3 days. His symptoms are accompanied by fatigue, malaise, epistaxis, dark-colored urine, and cough. Laboratory testing is significant for elevated erythrocyte sedimentation rate, c-reactive protein in elevation in creatinine (2.0 mg/dl). A chest radiograph shows a cavitary lesion. What is the most likely histopathological finding expected on kidney biopsy?



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A 17-year-old male with a past medical history of asthma and allergic rhinitis presents with cough, shortness of breath, abdominal pain, myalgias, weight loss, and malaise for six weeks. Physical exam suggests tachypnea, hypoxia, nasal crusting, and a tender subcutaneous nodule on the left elbow. Laboratory findings are significant for eosinophilia and positive antineutrophil cytoplasmic antibodies (ANCA). Chest x-ray shows pulmonary infiltrates. What is the first line treatment for this patient?



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A 40-year-old female presents to the emergency department with complaints of hemoptysis, cough, malaise, fatigue, weight loss of 20 lbs and dark colored urine. Physical exam shows conjunctival injection in the left eye, nasal crusting, and crackles on auscultation of lungs. An auto-immune process is suspected. Which of the following antibodies is most likely to be present in this patient?



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A 67-year-old male with a history of granulomatosis with polyangiitis presents to the urgent care center with complaints of blurred and double vision with redness of the eye. Physical exam shows conjunctival injection with swelling around the left eye. What ocular manifestation is most likely to be present in this patient?



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Vasculitis - References

References

Savage CO,Harper L,Cockwell P,Adu D,Howie AJ, ABC of arterial and vascular disease: vasculitis. BMJ (Clinical research ed.). 2000 May 13     [PubMed]
Hunder GG,Arend WP,Bloch DA,Calabrese LH,Fauci AS,Fries JF,Leavitt RY,Lie JT,Lightfoot RW Jr,Masi AT, The American College of Rheumatology 1990 criteria for the classification of vasculitis. Introduction. Arthritis and rheumatism. 1990 Aug     [PubMed]
Jennette JC,Falk RJ,Bacon PA,Basu N,Cid MC,Ferrario F,Flores-Suarez LF,Gross WL,Guillevin L,Hagen EC,Hoffman GS,Jayne DR,Kallenberg CG,Lamprecht P,Langford CA,Luqmani RA,Mahr AD,Matteson EL,Merkel PA,Ozen S,Pusey CD,Rasmussen N,Rees AJ,Scott DG,Specks U,Stone JH,Takahashi K,Watts RA, 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis and rheumatism. 2013 Jan     [PubMed]
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Sneller MC,Fauci AS, Pathogenesis of vasculitis syndromes. The Medical clinics of North America. 1997 Jan     [PubMed]
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Suresh E, Diagnostic approach to patients with suspected vasculitis. Postgraduate medical journal. 2006 Aug     [PubMed]
Flossmann O,Berden A,de Groot K,Hagen C,Harper L,Heijl C,Höglund P,Jayne D,Luqmani R,Mahr A,Mukhtyar C,Pusey C,Rasmussen N,Stegeman C,Walsh M,Westman K, Long-term patient survival in ANCA-associated vasculitis. Annals of the rheumatic diseases. 2011 Mar     [PubMed]
Guyer DR,Miller NR,Auer CL,Fine SL, The risk of cerebrovascular and cardiovascular disease in patients with anterior ischemic optic neuropathy. Archives of ophthalmology (Chicago, Ill. : 1960). 1985 Aug     [PubMed]
Nuenninghoff DM,Hunder GG,Christianson TJ,McClelland RL,Matteson EL, Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years. Arthritis and rheumatism. 2003 Dec     [PubMed]
Seo P,Stone JH, The antineutrophil cytoplasmic antibody-associated vasculitides. The American journal of medicine. 2004 Jul 1     [PubMed]
Weyand CM,Hunder NN,Hicok KC,Hunder GG,Goronzy JJ, HLA-DRB1 alleles in polymyalgia rheumatica, giant cell arteritis, and rheumatoid arthritis. Arthritis and rheumatism. 1994 Apr;     [PubMed]
Yates M,Watts RA,Bajema IM,Cid MC,Crestani B,Hauser T,Hellmich B,Holle JU,Laudien M,Little MA,Luqmani RA,Mahr A,Merkel PA,Mills J,Mooney J,Segelmark M,Tesar V,Westman K,Vaglio A,Yalçındağ N,Jayne DR,Mukhtyar C, EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Annals of the rheumatic diseases. 2016 Sep;     [PubMed]

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