Haemodialysis and transplantation in Wegener's granulomatosis.

Two men with Wegener''s disease began immunosuppressive treatment during severe renal insufficiency. Despite an initial temporary remission new lesions appeared and renal failure progressed. Haemodialysis was started, cytotoxic drugs were stopped, and steroid dosage was reduced. All extrarenal manifestations of the disease remitted, however, suggesting a favourable effect of either the immunosuppression induced by terminal renal failure or the haemodialysis itself. Renal transplantation was then undertaken in both patients. Thirteen and 55 months after the operations respectively renal function was satisfactory and no signs of reactivation of Wegener''s disease had appeared. These results show that whatever the activity of Wegener''s disease and its initial response to immunosuppressive agents, dialysis and transplantation are fully warranted once irreversible renal failure is established.     

Pulmonary renal syndromes--a review.

Several systemic diseases share clinical, pathologic and radiologic characteristics. This article emphasizes similarities and differences in the clinical and chest radiographic manifestations of six diseases with both pulmonary and renal abnormalities-Goodpasture''s syndrome, Wegener''s granulomatosis, lymphomatoid granulomatosis, Churg-Strauss syndrome, systemic lupus erythematosus, and scleroderma.     

Pulmonary renal syndromes. II. Etiology and pathogenesis.

Numerous systemic diseases share immunopathogenic mechanisms. This article reviews the proposed etiologies and immunopathogenic mechanisms of a group of diseases which share pulmonary and renal abnormalities. Specifically, we discuss the following diseases: Good-pasture''s syndrome, systemic lupus erythematosus, progressive systemic sclerosis, Wegener''s granulomatosis, lymphomatoid granulomatosis, and Churg-Strauss syndrome.     

Antineutrophil cytoplasmic autoantibody in renal disease

ANCA are an important marker for identifying pauci-immune necrotizing and crescentic glomerulonephritis and systemic vasculitis. Patients with ANCA-associated renal disease have a spectrum of illness ranging from renal-limited disease to widespread vasculitis, including the clinicopathologic syndromes of polyarteritis nodosa and Wegener's granulomatosis. ANCA may be directly involved in the pathogenesis of pauci-immune glomerulonephritis and necrotizing systemic vasculitis.     

Wegener's Granulomatosis: A Review of Three Cases

Clinical and autopsy features in three cases of Wegener''s granulomatosis are presented. The disease is characterized by the triad of necrotizing granulomatous lesions of the respiratory tract, segmental necrotizing angiitis of arteries and veins, and necrotizing glomerulitis commonly terminating in uremia. Correct antemortem diagnosis was made in two of the three cases-in one by recognition of the characteristic triad and in the other by a biopsy from the antrum. Pathological lesions were chiefly in respiratory tract, spleen, kidneys and blood vessels. Necrotizing granulomatous lesions were present in the lungs. Glomerular lesions were particularly severe and wide-spread in two of the three patients, leading to uremia. Trabeculitis of the spleen, an unusual lesion, was a noticeable feature in all three. Fibrinoid necrosis, with little or no inflammatory infiltration, was the prevailing type of vascular necrosis. The characteristics of the disease process suggest a hypersensitivity mechanism. Similarities to, but significant differences from, polyarteritis nodosa are recognized.     

Enhanced allergic tissue injury in Goodpasture's syndrome by intercurrent bacterial infection.

Studies of 16 relapses in seven patients receiving treatment for Goodpasture''s syndrome showed that intercurrent bacterial infection seemed to be the precipitating event in 13 cases, whereas a rising antibody titre to glomerular basement membrane was responsible in only one. This association between infection and relapse in Goodpasture''s syndrome has several implications for the pathogenesis of antibody-mediated tissue damage, and, clearly, more experiments are needed. Whatever the explanation, however, prevention and early diagnosis and treatment of infection in anti-GBM disease are important.     

Towards a more rapid diagnosis of rapidly progressive glomerulonephritis.

An attempt was made to provide simple practical guidelines to alert general practitioners to the diagnosis of rapidly progressive glomerulonephritis and lead to early referral to hospital. The duration of illness before referral to this hospital and its effect on outcome in patients with crescentic nephritis were assessed retrospectively from the case notes of 24 patients referred over two years. Four patients had Goodpasture''s syndrome, 11 Wegener''s granulomatosis, seven microscopic polyarteritis, and two idiopathic progressive glomerulonephritis. The duration of symptoms before referral to the local hospital was similar in the four groups of patients and varied from one week to 28 months (mean 10 months). The duration of stay in the local hospital was two, nine, 11, and 180 days in the patients with Goodpasture''s syndrome and a mean of four days (range one to eight) in those with Wegener''s granulomatosis and 10 days (one to 18 days) in those with microscopic polyarteritis. In the local hospital the diagnosis was based on the results of renal biopsy and detection of antibodies to glomerular basement membrane in two patients with Goodpasture''s syndrome and on the results of renal biopsy in seven of the other patients aided by the detection of antibodies to the cytoplasm of neutrophils (ANCA) in 10. Three of the 24 patients died and four required maintenance haemodialysis. Patients who present to their general practitioners with persistent non-specific symptoms should have a urine dipstick test and then blood tests and emergency referral to hospital if necessary. Hospital physicians should be aware of the speed and accuracy with which current assays can confirm a diagnosis of rapidly progressive glomerulonephritis.     

Ocular disease in patients with ANCA-positive vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis—the term recently applied to Wegener's granulomatosis—is a rare multi-system inflammation characterized by necrotizing granulomas and vasculitis. We investigated the ocular manifestations of this disease in a group of patients drawn from five inflammatory eye disease clinics across the United States. Of 8,562 persons with ocular inflammation, 59 individuals were diagnosed with ANCA-positive vasculitis; 35 males and 21 females, aged 16 to 96 years, were included in this study. Ocular diagnoses were scleritis (75.0%), uveitis (17.9%), and other ocular inflammatory conditions (33.9%) including peripheral ulcerative keratitis and orbital pseudotumor. Mean duration of ocular disease was 4.6 years. Oral corticosteroids and other systemic immunosuppressive agents were used by 85.7% and 78.5% of patients, respectively. Over time, patients with ANCA-positive vasculitis experienced 2.75-fold higher mortality than other patients with inflammatory eye disease.     

Anti-proteinase 3 anti-neutrophil cytoplasm autoantibodies recapitulate systemic vasculitis in mice with a humanized immune system

Evidence is lacking for direct pathogenicity of human anti-proteinase-3 (PR3) antibodies in development of systemic vasculitis and granulomatosis with polyangiitis (GPA, Wegener''s granulomatosis). Progress in study of these antibodies in rodents has been hampered by lack of PR3 expression on murine neutrophils, and by different Fc-receptor affinities for IgG across species. Therefore, we tested whether human anti-PR3 antibodies can induce acute vasculitis in mice with a human immune system. Chimeric mice were generated by injecting human haematopoietic stem cells into irradiated NOD-scid-IL2Rγ^−/− mice. Matched chimera mice were treated with human IgG from patients with: anti-PR3 positive renal and lung vasculitis; patients with non-vasculitic renal disease; or healthy controls. Six-days later, 39% of anti-PR3 treated mice had haematuria, compared with none of controls. There was punctate bleeding on the surface of lungs of anti-PR3 treated animals, with histological evidence of vasculitis and haemorrhage. Anti-PR3 treated mice had mild pauci-immune proliferative glomerulonephritis, with infiltration of human and mouse leukocytes. In 3 mice (17%) more severe glomerular injury was present. There were no glomerular changes in controls. Human IgG from patients with anti-PR3 autoantibodies is therefore pathogenic. This model of anti-PR3 antibody-mediated vasculitis may be useful in dissecting mechanisms of microvascular injury.     

Commentary: assessing the effects of environmental pollution when people know that they have been exposed.

OBJECTIVE: To examine the effectiveness of routine clinic review in detecting relapse after treatment for Hodgkin''s disease. DESIGN: Review of hospital records. SETTING: Regional centre for cancer treatment and research. SUBJECTS: 210 patients with Hodgkin''s disease recruited to a chemotherapy trial protocol between 1984 and the end of 1990 who had achieved a complete or partial remission after treatment. MAIN OUTCOME MEASURES: The number of clinic visits made by patients over the period of observation, the number of relapses occurring during that time, and the route by which relapse was detected. RESULTS: The 210 patients generated 2512 outpatient reviews, and 37 relapses were detected. Thirty relapses (81%) were diagnosed in patients who described symptoms, which in 15 cases had resulted in an earlier appointment being arranged. In only four cases (11%; 95% confidence interval 4% to 25%) was relapse detected as a result of routine physical examination on investigation of a patient who did not have symptoms. CONCLUSIONS: Relapse of Hodgkin''s disease after treatment is usually detected as a result of the investigation of symptoms rather than by routine screening of asymptomatic patients. It is therefore proposed that the frequency of routine follow up visits should be reduced and greater emphasis placed on patient education. This should underline the importance of symptoms and encourage patients to arrange an earlier appointment if these develop.     

The Leeuwenhoek Lecture, 1997. Marek's disease herpesvirus: oncogenesis and prevention.

There are a number of neoplasias for which a herpesvirus is an essential part of the aetiology. Of these, Marek''s disease is the most common and provides excellent opportunities for the study of a herpesvirus-induced tumour both experimentally and under natural conditions in the field. Marek''s disease is caused by an alpha herpesvirus; it differs from the other oncogenic herpesviruses which are gamma herpesviruses. It is a ubiquitous virus in poultry populations of the world and is highly cell-associated and contagious, yet only a proportion of infected fowl develop tumours. Evidence is presented to suggest that at least one of the reasons for a wide variation in the incidence of the disease is a temporal interplay between virulent viruses and viruses of low or no virulence. The viral genes associated with the oncogenicity of Marek''s disease virus (MDV) are discussed and it is concluded that it is likely that several genes are involved. Finally, a brief history of vaccination to control Marek''s disease is given and mode of action discussed. It is concluded that the mechanism of protection is mainly through an antiviral cell mediated immune response, resulting in a lowered challenge virus burden. Marek''s disease viruses over the past 40 years have been evolving greater oncogenicity, some of which are not adequately controlled by the vaccines that are currently available. It is suggested that for MDV to produce tumours, there is a need for the cytolytic infection phase and that infection must be with an MDV which possesses a functional gC, ICP4 for maintaining latency which allows the expression of at least the 1.8 kb family, pp38, meq, and possibly pp14 genes, for maintaining the tumour state and possibly initiating this state. Intervention in this process reduces the chance of tumour formation and incidence in a population which can occur through natural or man-mediated infection with non-pathogenic MDVs.     

Prophylactic effect of cimetidine in duodenal ulcer disease.

Fifty-seven symptom-free patients with duodenal ulcer entered a double-blind trial to assess the prophylactic effect of cimetidine. Patients were randomly allocated to receive cimetidine 400 mg twice daily (29 patients) or placebo (28 patients). The trial was designed to imitate daily clinical practice, so duodenal ulcer disease was diagnosed by means of x-ray examination. Three patients from each group withdrew from the trial. All remaining patients continued to receive treatment for 12 months or until symptoms recurred. Three out of 26 patients suffered relapses during cimetidine treatment, compared with 20 out of 25 receiving placebo. No side effects were attributable to cimetidine. Long-term cimetidine treatment had no curative effect as relapses occurred soon after treatment was stopped. The estimated chance (cumulative remission rate +/- 2 SE) of remaining symptom-free 13 weeks after one year''s cimetidine treatment had been completed was 47 +/- 21%. Maintenance treatment with cimetidine is a suitable alternative to elective in surgery in patients with duodenal ulcer subjects frequent relapses. Further study is needed to establish the optimal duration and safety of prolonged cimetidine treatment.     

Ocular and systemic manifestations of connective tissue disease: Part II,the seronegative spondyloarthropathies and vasculitides

The connective tissue diseases are musculoskeletal disorders which have multisystemic involvement, frequently have associated ocular manifestations, and although the specific etiologies are unknown, they all demonstrate abnormalities of the immune system. In the second of this two part series, the systemic and ocular findings of a number of the seronegative spondyloarthropathies and vasculitides will be discussed. These include ankylosing spondylitis, Reiter's syndrome, polyarteritis nodosa, Wegener's granulomatosis, and giant cell arteritis.     

Refractory Pituitary Granulomatosis with Polyangiitis (Wegener's) Treated with Rituximab

ObjectiveGranulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis, is an autoimmune disease characterized by inflammation of blood vessels most often seen in the upper respiratory tract, lungs, kidneys, and skin. Central nervous system (CNS) involvement of GPA is rare, particularly in the pituitary, and can be difficult to treat.MethodsCase report.ResultsWe present a 30-year-old woman with pituitary and ocular GPA, whose unusually recalcitrant disease led to the development of pan-hypopituitarism and neartotal vision loss. After failing multiple systemic immunosuppressants, she was ultimately treated with the novel immunomodulatory agent rituximab together with pulse corticosteroids, which achieved a gratifying response.ConclusionPituitary and optic chiasm involvement is a rare complication of GPA. We believe this case illustrates the complexity of management of pituitary GPA and provides insight into the potential utility of the biologic agent rituximab in this disease. (Endocr Pract. 2013;19:e1-e7)     

French recommendations for the management of systemic necrotizing vasculitides (polyarteritis nodosa and ANCA-associated vasculitides)

Systemic necrotizing vasculitis comprises a group of diseases resembling polyarteritis nodosa and anti-neutrophil cytoplasmic antibody-associated vasculitis (ANCA): granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. The definitive diagnosis is made in cooperation with a reference center for autoimmune diseases and rare systemic diseases or a competency center. The management goals are: to obtain remission and, in the long term, healing; to reduce the risk of relapses; to limit and reduce the sequelae linked to the disease; to limit the side effects and the sequelae linked to the treatments; to improve or at least maintain the best possible quality of life; and to maintain socio-professional integration and/or allow a rapid return to school and/or professional activity. Information and therapeutic education of the patients and those around them are an integral part of the care. All health professionals and patients should be informed of the existence of patient associations. The treatment of vasculitis is based on variable combinations of glucocorticoids and immunosuppressants, chosen and adapted according to the disease concerned, the severity and/or extent of the disease, and the underlying factors (age, kidney function, etc.). Follow-up clinical and paraclinical examinations must be carried out regularly to clarify the progression of the disease, detect and manage treatment failures and possible relapses early on, and limit sequelae and complications (early then late) related to the disease or treatment. A distinction is made between the induction therapy, lasting approximately 3–6 months and aimed at putting the disease into remission, and the maintenance treatment, lasting 12–48 months, or even longer. The role of the increase or testing positive again for ANCA as a predictor of a relapse, which has long been controversial, now seems to have greater consensus: Anti-myeloperoxidase ANCAs are less often associated with a relapse of vasculitis than anti-PR3 ANCA.

     

Staphylococcus aureus bacteraemia: 400 episodes in St Thomas's Hospital.

Four hundred episodes of Staphylococcus aureus bacteraemia occurred in St Thomas''s Hospital from 1969 to 1983, accounting for 17.5% of all episodes of bacteraemia. The mortality was 24%, half attributable to underlying disease, and was highest in patients over 50. Almost 60% of the bacteraemias were acquired in hospital, and the source of the organism was generally obvious, with vascular access sites the most common (37%). Bone and joint infections accounted for 11.5% of episodes and endocarditis for 7%. Most staphylococci were resistant to penicillin only; three isolates were resistant to methicillin and five to fusidic acid. Microbiologists seldom influenced directly the choice of initial antibiotic treatment (though this usually conformed to the hospital''s antibiotic prescribing policy) but had considerable influence over definitive treatment, usually cloxacillin or flucloxacillin alone or in combination with fusidic acid. S aureus bacteraemia is easy to identify and treat, though underlying disease may influence the outcome. Efforts should be made to prevent the largely iatrogenic disease.     

Immune complexes in Beh?et's syndrome and recurrent oral ulceration.

Seventeen patients with Behçet''s syndrome, 11 with recurrent oral ulceration, and eight controls were studied in an investigation of the part possibly played by immune complexes in the transition from focal oral ulceration to the multifocal syndrome. Changes in the distribution of C3 within the first peak of Sephadex G200 fractionated plasma were found in nine of the 17 patients with Behçet''s syndrome (55%), three of the 11 patients with recurrent oral ulcers, and none of eight controls. These findings provide indirect evidence that immune complexes are found in the plasma of these patients. Immune complexes were more common in patients with the neuro-ocular type of Behçet''s syndrome than in those with the mucocutaneous type, and in those with herpetiform ulcers than in those with major or minor aphthous ulcers. Immune complexes were also associated with active disease. These findings support the hypothesis that the formation of immune complexes is an important step in the pathogenesis of Behçet''s syndrome.     

Pneumococcal bacteraemia: 325 episodes diagnosed at St Thomas's Hospital.

Three hundred and twenty five episodes of pneumococcal bacteraemia occurred at St Thomas''s Hospital during 1970-84, accounting for 13.3% of all episodes of bacteraemia. Twice as many cases occurred in male as in female patients, and common predisposing factors included chronic chest disease, alcoholism, haematological malignancies, cirrhosis, and sickle cell anaemia. Mortality was 28.6% overall but only 11.8% among patients who received antibiotic treatment for at least 24 hours. Most patients (261) had pneumonia, 26 had meningitis, and eight were children with occult bacteraemia. The commonest serotype of pneumococcus in adults was type 3 (39 episodes), and these strains were associated with a high mortality. Other factors determining a fatal outcome included underlying disease (such as cirrhosis, malignancy, and chronic chest disease) and extrapulmonary infection. Almost half the survivors were treated for 10 days or less and became afebrile within 48 hours.     

Trypanosoma cruzi: The immunological consequences of infection

Trypanosoma cruzi, the causative agent of Chagas' disease, infects an estimated 12 million people in Latin America and may induce cardiopathy and megaformation of the oesophagus and colon. During the early, acute stage of the infection, parasite-induced inflammatory infiltrates may cause transitory disease which terminates with the emergence of an immune response sufficient to reduce the parasite to insignificant levels. Even so, severe disease may develop many years after the original infection. It has been suggested that this might result from an autoimmune process triggered by the parasite and mediated either (1) by the adsorption of parasite antigens to host cells, thus rendering these cells susceptible to the host's own antiparasite immune response, or (2) via cross-reactive antigens shared by the host and parasite. In common with many parasitic diseases, there is an urgent need for studies on the T-cell response to T cruzi infection, as this might not only hold the key to the immunopathology but also serve as a means of clearing this lifelong infection which survives by sequestering into an intracellular site.