vasculitis a diagnostic dilemma for primary care · 2015-04-20 · mri in cns vasculitis •...
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Vasculitis – A Diagnostic
Dilemma for Primary Care
Scott R. Burg, D.O.
Orthopedic and Rheumatologic Institute
Cleveland Clinic
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Vasculitis
How to recognize it and
when to ask for help
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Challenging Diagnosis for All
• Non-specific symptoms
• Overlapping syndromes
• Lack of highly specific or
sensitive tests
• Absence of generally accepted
diagnostic criteron
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Classification criteria for different
vasculitic syndromes proposed for
research purposes is not useful in the
clinical setting
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2012 Revised International Chapel Hill
Consensus Conference on Nomenclature
of Vasculitides
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Diagnosis of Specific Forms
of Vasculitis
Depends on recognition of
particular patterns of
- Clinical
- Radiographic
- Laboratory
- Histopathology
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Vasculitis – Definition
• A general term for a group of
uncommon diseases that feature
inflammation of blood vessels
• Each of these diseases defined by
characteristic distributions of blood
vessel involvement, patterns of organ
involvement and lab test abnormalities
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Primary and Secondary
Vasculitides
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Classification of Vasculitis
Some types of vasculitis previously
had different, eponym-based names:
Old Name New Name
Wegener’s Granulomatosis Granulomatosis with Polyangiitis
Churg-Strauss Syndrome Eosinophilic Granulomatosis
with Polyangiitis
Henoch-Schönlien Purpura IgA Vasculitis
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Primary
• Large Vessel Involvement
- Giant cell arteritis
- Takayasu’s arteritis
- Behcet’s syndrome
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Primary
• Medium and Small Vessel Involvement
- Polyarteritis nodosa
- Cutaneous polyarteritis
- Granulmatosis with polyangitis
- Eosinophilic granulomatosis with polyangitis
- Microscopic polyangitis
- Thromboangitis obliterans
- Cryoglobulinemia
- Kawaski’s disease
- Behcet’s syndrome
- Primary angitis of the CNS
- Cogan’s syndrome
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Primary
• Predominately Small Vessel Involvement
- Cutaneous leukocytoclastic vasculitis
- Urticarial vasculitis
- Behcet’s syndrome
- IgA vasculitis
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Evaluation of Patients Where
Vasculitis is Considered• Individually tailored
• Based on extent of organ involvement
• Tempo of the disease
• Tissue biopsy remains the gold
standard for diagnosis
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Initial Approach to Diagnosis
of Vasculitis• History and physical exam
• Accurately catalogue areas of disease
involvement
• No single typical presentation
• Must recognize patterns of signs and
symptoms
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Patterns of Symptoms / Signs
Size of Vessels
Skin
Syste
m
Small Medium Large
Skin Palpapable Erythema nodosum Cyanosis
purpura Livedo reticularis Discoloration of
extremities
Gastrointestinal Mucositis Abdominal pain Bowel infarction
GI bleeding Bowel perforation
Renal Hematuria without Hematuria with Hypertension
RBC casts RBC casts
Proteinuria Flank pain No hematuria
Neuro Polyneuropathy Mental status ∆’s Strokes
Strokes
Muscles Myalgias Myositis Claudication
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Clinical Manifestations
• Chronic fevers
• Palpable purpura
• Symptoms of tissue ischemia in unusual populations
• Neuropathy
• Rapidly progressive multisystem inflammatory disease
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History
• Illicit drug use
• High risk sexual activity
• Prior thrombosis
• Miscarriages
• Travel history
• Prior malignancies
• Operations and dental procedures
• Medications and OTC supplements
or herbal preparations
• Chemical exposure
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GCA
• Headaches
• Scalp tenderness
• Jaw claudication
• Vision loss
• Muscle pain/stiffness
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Pulmonary-Renal Syndrome
• Cough and hemoptysis
• Hematuria
• Chronic sinusitis
• Asthma
• Eosinophilia
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Physical Exam
Provide clues to presence of vasculitis
or its mimics
Complete vascular exam includes:
1. Palpation of arterial pulses
2. Auscultation for bruits
3. BP measurement of all extremities
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Bruits
• Takayasu’s arteritis
• GCA
• Behcets syndrome
• Cogans syndrome
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Loss of Pulse
• Takayasu’s arteritis
• GCA
• Thromboangitis obliterans
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Polyarteritis Nodosa
• New onset hypertension
• Abdominal pain
• Mononeuritis multiplex
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Laboratory Evaluation
• CBC with diff, CMP, UA, ESR, CRP,
CPK, aldolase
• No specific lab test to diagnose
vasculitis
• Neither ANCA or complement levels
should be used as screening tests
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Testing That is Suggestive
of Vasculitis
• Normochromic, normocytic anemia
• Thrombocytosis (acute phase response)
• Eosinophilia
• Hematuria
• Proteinuria
• Elevated transaminases = hepatitis B and HCV
• Elevated ESR but normal does not exclude vasculitis – 24% normal ESR in GCA
• ESR elevation most also exclude malignancies and infections
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ANCA – What’s the Deal ?
No specific lab tests for
diagnosis of vasculitis
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Proposed Indications for
ANCA Testing
• Cutaneous vasculitis with systemic features
• Pulmonary hemorrhage
• Glomerulonephritis (especially rapidly progressive)
• Multiple lung nodules
• Chronic destructive upper airway disease
• Longstanding sinusitis or otitis
• Subglottic or tracheal stenosis
• Peripheral neuorpathy
• Retro-orbital mass
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ANCA
• c ANCA (cytoplasmic staining) –
generalized GPA
• p ANCA (perinuclear staining) –
microscopic polyangitis or MPA
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Positive ANCA
• Does not establish a diagnosis
• Seen in diverse spectrum of disease
- Inflammatory bowel disease
- SLE
- Drug induced vasculitic reactions
- Infections
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Demonstrating the presence of a
circulating ANCA is NOT equivalent
to diagnosing vasculitis
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What to do if ANCA
Immunofluresence Test is Positive?
• Elisa testing for PR3 and MPO
• Elisa testing vs immunofluorescence higher
predictive value (83% versus 45%)
• c ANCA + PR3 highly suggestive of GPA
• p ANCA + MPO highly suggestive of MPA
• But 10-20% of patients with GPA have +p
ANCA and +MPO
• Some with MPA or EGPA are c ANCA positive
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Cocaine and Levamisole
Associated Vasculitis
• High titer p ANCA
• Low titer MPO antibodies
• PR3 antibodies
• Human neutrophil elastase, lactoferrin,
cathepsin G
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Radice and Sinico, 2005
• 10-50% of patients with biopsy proven vasculitis will have negative serologies
• 10% of patients with positive c ANCA and PR3 ABS with other diagnosis, i.e. malignancy, infection or other connective tissue disease
• Increased use of ANCA in patients with low clinical suspicion of vasculitis or recent changes in detection methods
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ANCA Testing
• Should not replace tissue confirmation
of GPA or MPA
• Unless clinical findings are classic and
other causes exhaustively excluded
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Complement Levels (C3 and C4)
• Decreased in lupus nephritis,
cryoglobulinemia or endocarditis
• Normal in GPA or MPA
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Antiglomerular Basement
Membrane (GBM)
• Alveolar hemorrhage
• Normocomplementemic GN
• Pulmonary-renal syndrome
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ANA and Rheumatoid Factor
• Not useful screening tests for vasculitis
• RF elevated in Sjogren’s
cryoglobulinemia and subacute
bacterial endocarditis
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Secondary Vasculitis
• Vasculitis when documented may not be primary
• Especially the case in cutaneous small vessel vasculitis and purpura
• Leukemia, myelodysplasia, I.E., viral hepatitis, rickettsial and neisserialinfections, carcinomas and systemic autoimmune disease
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Secondary and Mimics
• Infections
- Subacute bacterial endocarditis
- Syphilis
- Hepatitis B
- Hepatitis C
- Cytomegalovirus
- Epstein-Barr virus
- Human immunodeficiency virus
- Meningococcemia
- Tuberculosis
- Brucella
- Salmonella
- Rocky Mountain spotted fever
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Helpful Tests Useful in Excluding
Some Secondary Causes of
Vasculitis or Mimics
• 3 sets of blood cultures
• TEE despite negative cultures
• Serologic tests for organisms, i.e.
syphilis tests in evaluation of aortitis
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Bacterial Endocarditis
• Purpura
• Mesenteric arterial microaneurysms
• G.N.
• Retinal vasculitis
• Stroke
• Arthritis
• Cryglobulins
• R.F. and PR3 + ANCA
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Secondary and Mimics
• Medications
- B-lactams
- Sulfonamides
- Quinolones
- Macrolides
- Thiazides
- Loop diuretics
- Beta blockers
- Phenytoin
- Propylthiouracil
- Selective serotonin
reuptake inhibitors
- NSAIDS
- Antitumor necrosis factor
- alpha inhibitors
- Colony stimulating
factors (GM-CSF, G-GSF)
- Carbimazole
- Clopidogrel
- Montelukast
- Minocycline
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Cutaneous Vasculitis
• 172 adults ( Cutaneous Vasculitis -120 ) Hypersensitivity Vasculitis - 70, HSP-39, Mixed Cryoglobulinemia-11
• 23 systemic necrotizing vasculitis ( P nodosa-17,GPA-4, EGPA-2)
• 4 malignancy
• 5 systemic bacterial infection
• 20 autoimmune disease
• 80% of mixed cryoglobulinemia associated with Hep C
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Secondary and Mimics
• Drugs
- Cocaine +
levamisole
- Amphetamines
- Heroin
• Other- Malignancy
- Thrombotic
thrombocytopenic purpura
- Cardiac myxoma
- Cholesterol emboli syndrome
- Atherosclerosis
- Calciphylaxis
- Amyloidosis
- Moyamoya disease
- Ehlers-Danlos syndrome
- Fibromuscular dysplasia
- Antiphospholipid antibody
syndrome
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Secondary Testing
• Focus on providing supportive
evidence for vasculitis
• Exclude mimics
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Cancer
• Purpura
• Fever
• Mononeuritis multiplex
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Peripheral
Neuropathy / Myopathy• EMG / NC
• Infection, toxin, malignancy, metabolic,
inflammatory processes
• Nerve / muscle biopsy
• Direct imaging
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Imaging Studies in Arteritis
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Angiography
• Important in evaluation of aorta for arteritis, aneurysmal or occlusive diseases
• Angitis of CNS
• Coronary arteritis in Kawasaki disease
• Limited spatial resolution therefore small vessel vasculitis will typically not be seen
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Microaneurysms
• Highly suggestive of vasculitis if seen in more than one organ
• Medium sized muscular arteries (PAN)
• Prolonged time to develop and with negative results early in disease course
• Traditional angiography only visualizes vessel lumen and misses thickening of vessel wall seen in early stenosis or aneurysms
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• PAN, MPA, EGPA and Behcets
• Atrial myxoma, endocarditis, peritoneal
carcinomatosis
• Severe arterial hypertension with
amphetamine abuse
Microaneurysms
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MRI
• More common than traditional
angiography for aorta and primary
branches
• Visualizes vessel lumen and demonstrates
edema and thickness of vessel walls
• Can overestimate vascular occlusions
• No consistent correlation of wall edema
with symptoms, acute phase reactants or
new anatomic changes
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CT or MRI Studies
• Determine areas of suspected organ involvement
• MRI for air fluid levels, mucosal inflammation, cavitary lesions, retro-ortibal involvement
• CT scans for air fluid levels, mucosal thickening, sclerosing osteitis, bone thickening, destruction
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MRI in CNS Vasculitis
• Abnormal in 90% of histologically
proven angitis
• Ischemia, infarcts, mass lesions and
meningeal enhancement
• Normal MRI does not exclude CNS
vasculitis
• Lumbar puncture, cerebral angiogram,
brain biopsy
• Normal MRI and normal CSF = CNS
vasculitis is rare
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Pulmonary Disease
• CXR normal study does not exclude disease
• HRCT very sensitive means of detecting pulmonary abnormalities
• HRCT can differentiate between ground glass changes and fibrosis
• HRCT cannot differentiate alveolar hemorrhage from vasculitis, infection or medication
• Biopsy of lung
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Ultrasound
• Better for medium sized peripheral
arteries
• Halo sign – hypoechoic dark wall
swelling
• Sensitivity 69%, specificity 82%
compared to temporal artery biopsy
• Much less effective in detecting
recurrent disease
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PET Scanning
• Useful in diagnosis and follow up of
large vessel vasculitis
• PET signal strong for branches
extending from aorta
• Evaluation of atypical presentation of
vasculitis, FUO, increased ESR or CRP
• PET/CT upper respiratory tract and lung
lesions in G.P.A. and vascular lesions
in Behcet’s
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What Should I Biopsy?
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Biopsy Location
• Suspicion of clinical involvement
• Accessibility of tissue
• Several organ systems involved biopsy
site determined by morbidity and
amount of disease specific data
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Skin Biopsy
• Small vessel vasculitis of involved skin
easily demonstrated but not specific
• IgA vasculitis with IgA deposits
Henoch-Schonlein purpura
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Sample Size
• Vasculitis may not equally effect all portions of organ/vessel
• Skip areas of vasculitic involvement not unique to GCA
• Lung, nasal and sinus biopsies in GPA
• Muscle and nerve in small/medium sized vessels
• Blind biopsy of non-involved tissue low yield (19%-nerve, 29%-muscle)
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Demonstration of Vasculitis
on Biopsy
• Not a final diagnosis
• Is a sign of underlying condition to be
evaluated in the context of clinical,
serologic and imaging to establish final
diagnosis
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GCA
• Vague signs and symptoms, fevers, myalgia and anemia
without headache or jaw claudication
• 65-year-old patients or older diagnosed in 16% of all
patients with FUO
• Biopsy considered in all with FUO with malignancy and
infections excluded
• Unilateral versus bilateral TA biopsy
• Specimen .5 cm in length positive in 19%
• Specimen >2 cm in length positive in 89%
• 10% with clinical diagnosis of GCA have normal biopsies
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Lung Biopsy
• Transbronchial – low diagnostic return
in vasculitis
• Helpful for infection, malignancy and
hemorrhage
• VATS low morbidity and mortality
compared to open lung with high
sensitivity and specificity
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Nasal and Sinus Biopsy
• For GPA and EGPA low diagnostic
yield
• Vasculitis or granulomas rarely seen
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Renal Biopsy
• Arteritis or granulomas rarely seen
• Generalized GPA biopsy site of choice
is lung
• Proteinuria, increased CR, casts in
setting of multisystem disease
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General Steps to Diagnosing a Vasculitis
• Identify a collection of clinical findings (symptoms,
signs) which either suggest a vasculitis in general, or
optimally, a specific vasculitis
• Check routine labs (including coags, UA), and
consider checking imaging studies (e.g. CTA, MRA)
and/or ANCAs
- Narrow down differential diagnosis to 1-2 specific vasculitides
- Search for an associated systemic illness (e.g. malignancy,
infection, connective tissue disease, etc…)
- Rule out mimics
• Confirm diagnosis with biopsy (usually preferred) and/or
angiography
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VASCULITIS TREATMENT APPROACH
• REMISSION INDUCTION
- Medium to high dose corticosteroids
- Immunosuppressive agents disease
specific
- Failure of disease recognition associated
with significant morbidity and mortality
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REMISSION MAINTENANCE
• Corticosteroid dose steadily tapered to
reduce toxicity
• Immunosuppressive/Corticosteroid
treatment continued for a period of time-
disease specific and protocol based
• Goals
- Control of disease activity
- Prevent recurrence
- Minimize drug toxicity
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MONITORING
• Active treatment phase-disease activity
and drug toxicity
• Disease recurrence in drug free remission
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DISEASE SPECIFIC
THERAPY
• Based on specific diagnosis
• Severity of disease
• Vessel size does not determine which
medication or treatment regime
effectiveness or type of monitoring
required
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TREATMENT
• Randomized Trials
• Observational Studies
• Large Cohort Studies
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PROGNOSIS
• Good outcomes for many
• Highly dependent on diagnosis
• Acute remission induction and
subsequent maintenance phase of
treatment
• Adverse drug effects and infections
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