Vasculitis

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Vasculitis
Other namesVasculitides [1]
Vasculitis.JPG
Petechia and purpura on the lower limb due to medication-induced vasculitis
Pronunciation
Specialty Rheumatology, Immunology
Symptoms Weight loss, fever, myalgia, purpura
Complications Gangrene, Myocardial infarction

Vasculitis is a group of disorders that destroy blood vessels by inflammation. [2] Both arteries and veins are affected. Lymphangitis (inflammation of lymphatic vessels) is sometimes considered a type of vasculitis. [3] Vasculitis is primarily caused by leukocyte migration and resultant damage. Although both occur in vasculitis, inflammation of veins (phlebitis) or arteries (arteritis) on their own are separate entities.

Contents

Signs and symptoms

Possible signs and symptoms include: [4] [5]

Causes

There are several different etiologies for vasculitides. Although infections usually involve vessels as a component of more extensive tissue damage, they can also directly or indirectly cause vasculitic syndromes through immune-mediated secondary events. Simple vascular thrombosis usually only affects the luminal process, but through the process of thrombus organization, it can also occasionally cause a more chronic vasculitic syndrome. The autoimmune etiologies, a particular family of diseases characterized by dysregulated immune responses that produce particular pathophysiologic signs and symptoms, are more prevalent. [6]

Classification

Primary systemic, secondary, and single-organ vasculitis are distinguished using the highest classification level in the 2012 Chapel Hill Consensus Conference nomenclature. [7]

Primary systemic vasculitis

Primary systemic vasculitis is catogized by the size of the vessels mainly involved. Primary systemic vasculitis includes large-vessel vasculitis, medium-vessel vasculitis, small-vessel vasculitis, and variable-vessel vasculitis. [7]

Large-vessel vasculitis

The 2012 Chapel Hill Consensus Conference defines large vessel vasculitis (LVV) as a type of vasculitis that can affect any size artery, but it usually affects the aorta and its major branches more frequently than other vasculitides. [7] Takayasu arteritis (TA) and giant cell arteritis (GCA) are the two main forms of LVV. [8]

Medium vessel vasculitis

Medium vessel vasculitis (MVV) is a type of vasculitis that mostly affects the medium arteries, which are the major arteries that supply the viscera and their branches. Any size artery could be impacted, though. [7] The two primary types are polyarteritis nodosa (PAN) and Kawasaki disease (KD). [8]

Small vessel vasculitis

Small vessel vasculitis (SVV) is separated into immune complex SVV and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). [7]

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis linked to MPO-ANCA or PR3-ANCA that primarily affects small vessels and has few or no immune deposits. AAV is further classified as eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA), granulomatosis with polyangiitis (Wegener's) (GPA), and microscopic polyangiitis (MPA). [7]

Immune complex small vessel vasculitis (SVV) is vasculitis that primarily affects small vessels and has moderate to significant immunoglobulin and complement component deposits on the vessel wall. [7] Normocomplementemic urticarial vasculitis (HUV) (anti-C1q vasculitis), cryoglobulinemic vasculitis (CV), IgA vasculitis (Henoch-Schönlein) (IgAV), and anti-glomerular basement membrane (anti-GBM) disease are the categories of immune complex SVV. [8]

Variable vessel vasculitis

Variable vessel vasculitis (VVV) is a kind of vasculitis that may impact vessels of all sizes (small, medium, and large) and any type (arteries, veins, and capillaries), with no particular type of vessel being predominantly affected. [7] This category includes Behcet's disease (BD) and Cogan's syndrome (CS). [8]

Secondary vasculitis

The subset of illnesses known as secondary vasculitis are those believed to be brought on by an underlying ailment or exposure. Systemic illnesses (such as rheumatoid arthritis), cancer, drug exposure, and infection are the primary causes of vasculitis; however, there are still few factors that have a conclusively shown pathogenic relationship to the condition. [9] Vasculitis frequently coexists with infections, and several infections, including hepatitis B and C, HIV, infective endocarditis, and tuberculosis, are significant secondary causes of vasculitis. [10] Except for rheumatoid vasculitis, the majority of secondary vasculitis forms are exceedingly rare. [11]

Single-organ vasculitis

Single-organ vasculitis, formerly known as "localized," "limited," "isolated," or "nonsystemic" vasculitis, refers to vasculitis that is limited to one organ or organ system. Examples of this type of vasculitis include gastrointestinal, cutaneous, and peripheral nerve vasculitis. [9]

Diagnosis

Micrograph showing a vasculitis (eosinophilic granulomatosis with polyangiitis). H&E stain. Churg-Strauss syndrome - very high mag.jpg
Micrograph showing a vasculitis (eosinophilic granulomatosis with polyangiitis). H&E stain.
Severe vasculitis of the major vessels, displayed on FDG-PET/CT Vasculitis FDG PET-CT.png
Severe vasculitis of the major vessels, displayed on FDG-PET/CT
  • Some types of vasculitis display leukocytoclasis, which is vascular damage caused by nuclear debris from infiltrating neutrophils. [12] It typically presents as palpable purpura. [12] Conditions with leucocytoclasis mainly include hypersensitivity vasculitis (also called leukocytoclastic vasculitis) and cutaneous small-vessel vasculitis (also called cutaneous leukocytoclastic angiitis).
Laboratory Investigation of Vasculitic Syndromes [15]
DiseaseSerologic testAntigenAssociated laboratory features
Systemic lupus erythematosusANA including antibodies to dsDNA and ENA [including SM, Ro (SSA), La (SSB), and RNP]Nuclear antigensLeukopenia, thrombocytopenia, Coombs' test, complement activation: low serum concentrations of C3 and C4, positive immunofluorescence using Crithidia luciliae as substrate, antiphospholipid antibodies (i.e. anticardiolipin, lupus anticoagulant, false-positive VDRL)
Goodpasture's diseaseAnti-glomerular basement membrane antibodyEpitope on noncollagen domain of type IV collagen
Small vessel vasculitis
Microscopic polyangiitisPerinuclear antineutrophil cytoplasmic antibodyMyeloperoxidaseElevated CRP
Granulomatosis with polyangiiitisCytoplasmic antineutrophil cytoplasmic antibodyProteinase 3 (PR3)Elevated CRP
Eosinophilic granulomatosis with polyangiitisperinuclear antineutrophil cytoplasmic antibody in some casesMyeloperoxidaseElevated CRP and eosinophilia
IgA vasculitis (Henoch-Schönlein purpura)None
CryoglobulinemiaCryoglobulins, rheumatoid factor, complement components, hepatitis C
Medium vessel vasculitis
Classical polyarteritis nodosaNoneElevated CRP and eosinophilia
Kawasaki's DiseaseNoneElevated CRP and ESR

In this table: ANA = antinuclear antibodies, CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, dsDNA = double-stranded DNA, ENA = extractable nuclear antigens, RNP = ribonucleoproteins; VDRL = Venereal Disease Research Laboratory

Treatment

Treatments are generally directed toward stopping the inflammation and suppressing the immune system. Typically, corticosteroids such as prednisone are used. Additionally, other immune suppression medications, such as cyclophosphamide and others, are considered. In case of an infection, antimicrobial agents including cephalexin may be prescribed. Affected organs (such as the heart or lungs) may require specific medical treatment intended to improve their function during the active phase of the disease.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Giant cell arteritis</span> Medical condition

Giant cell arteritis (GCA), also called temporal arteritis, is an inflammatory autoimmune disease of large blood vessels. Symptoms may include headache, pain over the temples, flu-like symptoms, double vision, and difficulty opening the mouth. Complication can include blockage of the artery to the eye with resulting blindness, as well as aortic dissection, and aortic aneurysm. GCA is frequently associated with polymyalgia rheumatica.

<span class="mw-page-title-main">Granulomatosis with polyangiitis</span> Medical condition

Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis (WG), after the Nazi German physician Friedrich Wegener, is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is an autoimmune disease and a form of vasculitis that affects small- and medium-size vessels in many organs but most commonly affects the upper respiratory tract, lungs and kidneys. The signs and symptoms of GPA are highly varied and reflect which organs are supplied by the affected blood vessels. Typical signs and symptoms include nosebleeds, stuffy nose and crustiness of nasal secretions, and inflammation of the uveal layer of the eye. Damage to the heart, lungs and kidneys can be fatal.

<span class="mw-page-title-main">Henoch–Schönlein purpura</span> Medical condition

Henoch–Schönlein purpura (HSP), also known as IgA vasculitis, is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children. In the skin, the disease causes palpable purpura, often with joint pain and abdominal pain. With kidney involvement, there may be a loss of small amounts of blood and protein in the urine, but this usually goes unnoticed; in a small proportion of cases, the kidney involvement proceeds to chronic kidney disease. HSP is often preceded by an infection, such as a throat infection.

<span class="mw-page-title-main">Eosinophilic granulomatosis with polyangiitis</span> Medical condition

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as allergic granulomatosis, is an extremely rare autoimmune condition that causes inflammation of small and medium-sized blood vessels (vasculitis) in persons with a history of airway allergic hypersensitivity (atopy).

<span class="mw-page-title-main">Polyarteritis nodosa</span> Medical condition

Polyarteritis nodosa (PAN) is a systemic necrotizing inflammation of blood vessels (vasculitis) affecting medium-sized muscular arteries, typically involving the arteries of the kidneys and other internal organs but generally sparing the lungs' circulation. Small aneurysms are strung like the beads of a rosary, therefore making this "rosary sign" an important diagnostic feature of the vasculitis. PAN is sometimes associated with infection by the hepatitis B or hepatitis C virus. The condition may be present in infants.

<span class="mw-page-title-main">Takayasu's arteritis</span> Medical condition

Takayasu's arteritis (TA), also known as aortic arch syndrome, nonspecific aortoarteritis, and pulseless disease, is a form of large vessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowing, most commonly affecting young or middle-aged women of Asian descent, though anyone can be affected. It mainly affects the aorta and its branches, as well as the pulmonary arteries. Females are about 8–9 times more likely to be affected than males.

<span class="mw-page-title-main">Arteritis</span> Medical condition

Arteritis is a vascular disorder characterized by inflammation of the walls of arteries, usually as a result of infection or autoimmune responses. Arteritis, a complex disorder, is still not entirely understood. Arteritis may be distinguished by its different types, based on the organ systems affected by the disease. A complication of arteritis is thrombosis, which can be fatal. Arteritis and phlebitis are forms of vasculitis.

<span class="mw-page-title-main">Anti-neutrophil cytoplasmic antibody</span> Group of autoantibodies

Anti-neutrophil cytoplasmic antibodies (ANCAs) are a group of autoantibodies, mainly of the IgG type, against antigens in the cytoplasm of neutrophils and monocytes. They are detected as a blood test in a number of autoimmune disorders, but are particularly associated with systemic vasculitis, so called ANCA-associated vasculitides (AAV).

<span class="mw-page-title-main">Cryoglobulinemia</span> Medical condition

Cryoglobulinemia is a medical condition in which the blood contains large amounts of pathological cold sensitive antibodies called cryoglobulins – proteins that become insoluble at reduced temperatures. This should be contrasted with cold agglutinins, which cause agglutination of red blood cells.

<span class="mw-page-title-main">Nephritic syndrome</span> Medical condition

Nephritic syndrome is a syndrome comprising signs of nephritis, which is kidney disease involving inflammation. It often occurs in the glomerulus, where it is called glomerulonephritis. Glomerulonephritis is characterized by inflammation and thinning of the glomerular basement membrane and the occurrence of small pores in the podocytes of the glomerulus. These pores become large enough to permit both proteins and red blood cells to pass into the urine. By contrast, nephrotic syndrome is characterized by proteinuria and a constellation of other symptoms that specifically do not include hematuria. Nephritic syndrome, like nephrotic syndrome, may involve low level of albumin in the blood due to the protein albumin moving from the blood to the urine.

Microscopic polyangiitis is an autoimmune disease characterized by a systemic, pauci-immune, necrotizing, small-vessel vasculitis without clinical or pathological evidence of granulomatous inflammation.

Cerebral vasculitis is vasculitis involving the brain and occasionally the spinal cord. It affects all of the vessels: very small blood vessels (capillaries), medium-size blood vessels, or large blood vessels. If blood flow in a vessel with vasculitis is reduced or stopped, the parts of the body that receive blood from that vessel begins to die. It may produce a wide range of neurological symptoms, such as headache, skin rashes, feeling very tired, joint pains, difficulty moving or coordinating part of the body, changes in sensation, and alterations in perception, thought or behavior, as well as the phenomena of a mass lesion in the brain leading to coma and herniation. Some of its signs and symptoms may resemble multiple sclerosis. 10% have associated bleeding in the brain.

Pauci-immune vasculitis is a form of vasculitis that is associated with minimal evidence of hypersensitivity upon immunofluorescent staining for IgG. Often, this is discovered in the setting of the kidney.

Necrotizing vasculitis, also called systemic necrotizing vasculitis, is a category of vasculitis, comprising vasculitides that present with necrosis. Examples include giant cell arteritis, microscopic polyangiitis, and granulomatosis with polyangiitis. ICD-10 uses the variant "necrotizing vasculopathy". ICD-9, while classifying these conditions together, does not use a dedicated phrase, instead calling them "polyarteritis nodosa and allied conditions".

<span class="mw-page-title-main">Cutaneous small-vessel vasculitis</span> Medical condition

Cutaneous small-vessel vasculitis (CSVV), is inflammation of small blood vessels, usually accompanied by small lumps beneath the skin. The condition is also known as hypersensitivity vasculitis, cutaneous leukocytoclastic vasculitis, hypersensitivity angiitis, cutaneous leukocytoclastic angiitis, cutaneous necrotizing vasculitis and cutaneous necrotizing venulitis,

<span class="mw-page-title-main">Retinal vasculitis</span> Medical condition

Retinal vasculitis is inflammation of the vascular branches of the retinal artery, caused either by primary ocular disease processes, or as a specific presentation of any systemic form of vasculitis such as Behçet's disease, sarcoidosis, multiple sclerosis, or any form of systemic necrotizing vasculitis such as temporal arteritis, polyarteritis nodosa, and granulomatosis with polyangiitis, or due to lupus erythematosus, or rheumatoid arthritis. Eales disease, pars planitis, birdshot retinochoroidopathy, and Fuchs heterochromic iridocyclitis (FHI) can also cause retinal vasculitis. Infectious pathogens such as Mycobacterium tuberculosis, visceral larva migrans can also cause retinal vasculitis. Drug-induced vasculitis may involve retina as well, as seen in methamphetamine induced vasculitis.

<span class="mw-page-title-main">Palpable purpura</span> Medical condition

Palpable purpura is characterized by firm, elevated hemorrhagic plaques or papules that can measure several centimeters in diameter. These are typically found on dependent surfaces, like the back of a recumbent patient or the lower legs. The center of a lesion may become ulcerative, pustular, vesicular, necrotic, or nodular. They tend to be asymptomatic, but when nodular or ulcerative, they can become tender. Palpable purpura is the most common cutaneous lesion among individuals with inflammatory vascular injury, whereas nonpalpable purpura typically indicates bleeding caused by a platelet or coagulation disorder.

Vasculitic neuropathy is a peripheral neuropathic disease. In a vasculitic neuropathy there is damage to the vessels that supply blood to the nerves. It can be as part of a systemic problem or can exist as a single-organ issue only affecting the peripheral nervous system (PNS). It is diagnosed with the use of electrophysiological testing, blood tests, nerve biopsy and clinical examination. It is a serious medical condition that can cause prolonged morbidity and disability and generally requires treatment. Treatment depends on the type but it is mostly with corticosteroids or immunomodulating therapies.

Retiform purpura is the result of total vascular blockage and damage to the skin's blood vessels. These lesions can appear due to intravascular issues where clots, proteins, or emboli block skin vessels. They can also result from direct harm to the vessel walls, as seen in conditions like vasculitis, calciphylaxis, and certain severe opportunistic infections.

References

  1. "Vasculitis — Definition". Merriam-Webster Online Dictionary. Archived from the original on 1 July 2016. Retrieved 8 January 2009.
  2. "Glossary of dermatopathological terms. DermNet NZ". Archived from the original on 20 December 2008. Retrieved 8 January 2009.
  3. "Vasculitis" "at Dorland's Medical Dictionary
  4. "The Johns Hopkins Vasculitis Center — Symptoms of Vasculitis". Archived from the original on 27 February 2009. Retrieved 7 May 2009.
  5. "Vasculitis — Symptoms | NHLBI, NIH". www.nhlbi.nih.gov. 22 May 2023. Retrieved 23 October 2023.
  6. Seidman, M.A. (2014). "Vasculitis". Pathobiology of Human Disease. Elsevier. pp. 2995–3005. doi:10.1016/b978-0-12-386456-7.05506-4. ISBN   978-0-12-386457-4.
  7. 1 2 3 4 5 6 7 8 Jennette, J. C.; Falk, R. J.; Bacon, P. A.; Basu, N.; Cid, M. C.; Ferrario, F.; Flores-Suarez, L. F.; Gross, W. L.; Guillevin, L.; Hagen, E. C.; Hoffman, G. S.; Jayne, D. R.; Kallenberg, C. G. M.; Lamprecht, P.; Langford, C. A.; Luqmani, R. A.; Mahr, A. D.; Matteson, E. L.; Merkel, P. A.; Ozen, S.; Pusey, C. D.; Rasmussen, N.; Rees, A. J.; Scott, D. G. I.; Specks, U.; Stone, J. H.; Takahashi, K.; Watts, R. A. (27 December 2012). "2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides". Arthritis & Rheumatism. Wiley. 65 (1): 1–11. doi: 10.1002/art.37715 . ISSN   0004-3591. PMID   23045170.
  8. 1 2 3 4 Jennette, J. Charles (27 September 2013). "Overview of the 2012 revised International Chapel Hill Consensus Conference nomenclature of vasculitides". Clinical and Experimental Nephrology. Springer Science and Business Media LLC. 17 (5): 603–606. doi:10.1007/s10157-013-0869-6. ISSN   1342-1751. PMC   4029362 . PMID   24072416.
  9. 1 2 Mahr, Alfred; de Menthon, Mathilde (2015). "Classification and classification criteria for vasculitis". Current Opinion in Rheumatology. Ovid Technologies (Wolters Kluwer Health). 27 (1): 1–9. doi:10.1097/bor.0000000000000134. ISSN   1040-8711. PMID   25415531. S2CID   24318541.
  10. Suresh, E (1 August 2006). "Diagnostic approach to patients with suspected vasculitis". Postgraduate Medical Journal. Oxford University Press (OUP). 82 (970): 483–488. doi:10.1136/pgmj.2005.042648. ISSN   0032-5473. PMC   2585712 . PMID   16891436.
  11. Luqmani, Raashid Ahmed; Pathare, Sanjay; Kwok-fai, Tony Lee (2005). "How to diagnose and treat secondary forms of vasculitis". Best Practice & Research Clinical Rheumatology. Elsevier BV. 19 (2): 321–336. doi:10.1016/j.berh.2004.11.002. ISSN   1521-6942. PMID   15857799.
  12. 1 2 A Brooke W Eastham, Ruth Ann Vleugels and Jeffrey P Callen (12 July 2021). "Leukocytoclastic Vasculitis". Medscape . Updated: Oct 25, 2018
  13. Maffioli L, Mazzone A (2014). "Giant-Cell Arteritis and Polymyalgia Rheumatica". NEJM. 371 (17): 1652–1653. doi:10.1056/NEJMc1409206. PMC   4277693 . PMID   25337761.
  14. Dellavedova L, Carletto M, Faggioli P, Sciascera A, Del Sole A, Mazzone A, Maffioli LS (2015). "The prognostic value of baseline 18F-FDG PET/CT in steroid-naïve large-vessel vasculitis: introduction of volume-based parameters". European Journal of Nuclear Medicine and Molecular Imaging. 55 (2): 340–8. doi:10.1007/s00259-015-3148-9. PMID   26250689. S2CID   21446786.
  15. Burtis CA, Ashwood ER, Bruns DE (2012). Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 5th edition. Elsevier Saunders. p. 1568. ISBN   978-1-4160-6164-9.