Systemic vasculitis

Systemic vasculitus
Classification and external resources
Specialty rheumatology
ICD-10 M30-M31
ICD-9-CM 446

Systemic necrotizing vasculitis (SNV)[1] is a category of vasculitis,[2] comprising vasculitides that present with necrosis.[3]

Examples include giant cell arteritis,[4] microscopic polyangiitis, and granulomatosis with polyangiitis.

ICD-10 uses the variant "necrotizing vasculopathy". ICD-9, while classifying these conditions together, doesn't use a dedicated phrase, instead calling them "polyarteritis nodosa and allied conditions".

When using the influential classification known as the "Chapel Hill Consensus Conference", the terms "systemic vasculitis" or "primary systemic vasculitides" are commonly used.[5][6][7] Although the word "necrotizing" is omitted, the conditions described are largely the same.

Classification

Large vessel vasculitis

Giant-cell arteritis and Takayasu's arteritis have much in common,[8] but usually affect patients of different ages,[9] with Takayasu's arteritis affecting younger people, and giant-cell arteritis having a later age of onset.

Aortitis can also be considered a large-vessel disease.[10]

Takayasu arteritis. Primarily affects the aorta and its main branches. At least 3 out of 6 criteria yields sensitivity and specificity of 90.5 and 97.8%:

Giant cell (temporal) arteritis. Chronic vasculitis of both large and medium vessels, primarily affecting cranial branches of the arteries arising from the aortic arch. At least 3 out of 5 criteria yields sensitivity and specificity of 95 and 91%:

Medium vessel vasculitis

These conditions are sometimes considered together with the small vessel vasculitides.[11]

Polyarteritis nodosa (PAN). Systemic necrotizing vasculitis and aneurysm formation affecting both medium and small arteries. If only small vessels are affected, it is called microscopic polyangiitis, although it is more associated with granulomatosis with polyangiitis than to classic PAN. At least 3 out of 10 criteria yields sensitivity and specificity of 82 and 87%:

Kawasaki disease. Usually in children(age<4), it affects large, medium, and small vessels, prominently the coronary arteries. Associated with a mucocutaneous lymph node syndrome. Diagnosis requires fever lasting five days or more with at least 4 out of 5 criteria:

Isolated CNS vasculitis. Affects medium and small arteries over a diffuse CNS area, without symptomatic extracranial vessel involvement. Patients have CNS symptoms as well as cerebral vasculitis by angiography and leptomeningeal biopsy.

Small vessel vasculitis

There are several vasculitides that affect small vessels.[12]

Pauci-immune

Granulomatosis with polyangiitis (GPA; formerly known as Wegener's granulomatosis). Systemic vasculitis of medium and small arteries, including venules and arterioles. Produces granulomatous inflammation of the respiratory tracts and necrotizing, pauci-immune glomerulonephritis. Most common cause of saddle nose deformity in USA (nose flattened due to destruction of nasal septum by granulomatous inflammation). Almost all patients with WG have c-ANCA, but not vice versa. Current treatment of choice is cyclophosphamide. At least 2 out of 4 criteria yields sensitivity and specificity of 88 and 92%.

Eosinophilic granulomatosis with polyangiitis (EGPA; formerly known as Churg-Strauss syndrome). Affects medium and small vessels with vascular and extravascular granulomatosis. Classically involves arteries of lungs and skin, but may be generalized. At least 4 criteria yields sensitivity and specificity of 85 and 99.7%.

Microscopic polyarteritis/polyangiitis. Affects capillaries, venules, or arterioles. Thought to be part of a group that includes granulomatosis with polyangiitis since both are associated with ANCA and similar extrapulmonary manifestations. Patients do not usually have symptomatic or histologic respiratory involvement.

Immune complex

Hypersensitivity vasculitis (allergic vasculitis). Usually due to a hypersensitivity reaction to a known drug. Drugs most commonly implicated are penicillin, sulphonamides and thiazide diuretics.[13] There is presence of skin vaculitis with palpable petechiae or purpura. Biopsy of these lesions reveal inflammation of the small vessels, termed leukocytoclastic vasculitis, which is most prominent in postcapillary venules. At least 3 out of 5 criteria yields sensitivity and specificity of 71 and 84%:

IgA vasculitis (IgAV; formerly known as Henoch-Schonlein purpura). Systemic vasculitis due to tissue deposition of IgA-containing immune complexes. Biopsy of lesions shows inflammation of small vessels. It is considered a form of hypersensitivity vasculitis but is distinguished by prominent deposits of IgA. This is the most common vasculitis in children. Presence of 3 or more criteria yielded sensitivity of 87% while less than 2 criteria yielded hypersensitivity vasculitis in 74%:

Essential cryoglobulinemic vasculitis. Most often due to hepatitis C infection, immune complexes of cryoglobulins --- proteins that consists of immunoglobulins and complement and precipitate in the cold while dissolving upon rewarming --- are deposited in walls of capillaries, venules, or arterioles. Therefore, complement will be low with histology showing vessel inflammation with immune deposits.

Other/ungrouped

Vasculitis secondary to connective tissue disorders. Usually secondary to systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), relapsing polychondritis, Behçet's disease, and other connective tissue disorders.

Vasculitis secondary to viral infection. Usually due to hepatitis B and C, HIV, cytomegalovirus, Epstein-Barr virus, and Parvo B19 virus.

Symptoms and signs

Patients usually present with systemic symptoms with single or multiorgan dysfunction. Common (and nonspecific) complaints include fatigue, weakness, fever, arthralgias, abdominal pain, hypertension, renal insufficiency, and neurologic dysfunction. The following symptoms should raise a strong suspicion of a vasculitis:

Diagnosis

A detailed history is important to elicit any recent medications, any risk of hepatitis infection, or any recent diagnosis with a connective tissue disorder such as systemic lupus erythematosus (SLE). A thorough physical exam is needed as usual.

Treatment

Treatment is targeted to the underlying cause. However, most vasculitis in general are treated with steroids (e.g. methylprednisolone) because the underlying cause of the vasculitis is due to hyperactive immunological damage. Immunosuppressants such as cyclophosphamide and azathioprine may also be given.

A systematic review of antineutrophil cytoplasmic antibody (ANCA) positive vasculitis identified best treatments depending on whether the goal is to induce remission or maintenance and depending on severity of the vasculitis.[14]

References

  1. ↑ Cruz BA, Ramanoelina J, Mahr A, et al. (October 2003). "Prognosis and outcome of 26 patients with systemic necrotizing vasculitis admitted to the intensive care unit". Rheumatology (Oxford). 42 (10): 1183–8. doi:10.1093/rheumatology/keg322. PMID 12777637.
  2. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, Mo: Elsevier Saunders. p. 534. ISBN 0-7216-0187-1.
  3. ↑ "systemic necrotizing vasculitis" at Dorland's Medical Dictionary
  4. ↑ Généreau T, Lortholary O, Pottier MA, et al. (December 1999). "Temporal artery biopsy: a diagnostic tool for systemic necrotizing vasculitis. French Vasculitis Study Group". Arthritis Rheum. 42 (12): 2674–81. doi:10.1002/1529-0131(199912)42:12<2674::AID-ANR25>3.0.CO;2-A. PMID 10616017.
  5. ↑ Jennette JC, Falk RJ, Andrassy K, et al. (February 1994). "Nomenclature of systemic vasculitides. Proposal of an international consensus conference". Arthritis Rheum. 37 (2): 187–92. doi:10.1002/art.1780370206. PMID 8129773.
  6. ↑ Sørensen SF, Slot O, Tvede N, Petersen J (June 2000). "A prospective study of vasculitis patients collected in a five year period: evaluation of the Chapel Hill nomenclature". Ann. Rheum. Dis. 59 (6): 478–82. doi:10.1136/ard.59.6.478. PMC 1753166Freely accessible. PMID 10834866.
  7. ↑ Gonzalez-Gay MA, Garcia-Porrua C, Guerrero J, Rodriguez-Ledo P, Llorca J (June 2003). "The epidemiology of the primary systemic vasculitides in northwest Spain: implications of the Chapel Hill Consensus Conference definitions". Arthritis Rheum. 49 (3): 388–93. doi:10.1002/art.11115. PMID 12794795.
  8. ↑ Churg J (September 1993). "Large vessel vasculitis". Clin. Exp. Immunol. 93 Suppl 1 (Suppl 1): 11–2. doi:10.1111/j.1365-2249.1993.tb06216.x. PMC 1554929Freely accessible. PMID 8103424.
  9. ↑ Weyand CM, Goronzy JJ (July 2003). "Medium- and large-vessel vasculitis". N. Engl. J. Med. 349 (2): 160–9. doi:10.1056/NEJMra022694. PMID 12853590.
  10. ↑ Hoffman GS (September 2003). "Large-vessel vasculitis: unresolved issues". Arthritis Rheum. 48 (9): 2406–14. doi:10.1002/art.11243. PMID 13130459.
  11. ↑ Seo P, Stone JH (December 2007). "Small-vessel and medium-vessel vasculitis". Arthritis Rheum. 57 (8): 1552–9. doi:10.1002/art.23105. PMID 18050229.
  12. ↑ Jennette JC, Falk RJ (1997). "Small-vessel vasculitis". N. Engl. J. Med. 337 (21): 1512–23. doi:10.1056/NEJM199711203372106. PMID 9366584.
  13. ↑ Axford J, O'Callaghan C, (eds). 2004. Medicine. Oxford. Blackwell Publishing.
  14. ↑ Bosch X, Guilabert A, Espinosa G, Mirapeix E (2007). "Treatment of antineutrophil cytoplasmic antibody associated vasculitis: a systematic review". JAMA. 298 (6): 655–69. doi:10.1001/jama.298.6.655. PMID 17684188.
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