Background
A patient is said to have GPA when three of the following six criteria are present: | |
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Upper Airway Involvement | Chronic purulent or bloody nasal discharge, or recurrent epistaxis/crusts/granulomata Nasal septal perforation or saddle-nose deformity Chronic or recurrent sinus inflammation |
Pulmonary Involvement | Chest X-ray or CT scan showing the presence of nodules, cavities, or fixed infiltrates |
Renal Involvement | Proteinuria > 0.3 g/24H, or greater than 30 umol/mg of urine albumin/creatinine ratio on a spot morning sample Hematuria or red blood cell casts: > 5 red blood cells per high-power field, or red blood cell casts in urinary sediment, or > 2+ on dipstick Necrotizing pauci-immune glomerulonephritis |
Granulomatous Inflammation | Granulomatous inflammation within wall of artery or in perivascular or extravascular area of artery or arteriole |
Laryngotracheobronchial stenosis | Subglottic, tracheal, or bronchial stenosis |
ANCA | ANCA positivity by immunofluorescence or by ELISA (MPO/p or PR3/c ANCA) |
Case presentations
Case 1
Laboratory Investigations: General | Laboratory Reference Ranges | Case 1 Laboratory Results | Case 2 Laboratory Results |
---|---|---|---|
Erythrocyte Sedimentation Rate (ESR) | 0–15 mm/hr | 59 mm/hr at presentation; 2 mm/hr 6 months post-treatment | 14 mm/hr at presentation; 2 mm/hr 6 months post-treatment |
C-reactive Protein (CRP) | < 0.5 mg/dL | 12.9 mg/dL at presentation; < 0.5 mg/dL 6 months post-treatment | 25 mg/dL at presentation; < 0.5 mg/dL 6 months post-treatment |
Hemoglobin | 13.0–16.0 g/dL | 7.3 GM/dL | 8.3 GM/dL |
Creatinine | 0.71–1.16 g/dL | 0.98 at presentation | 1.21 at presentation |
Urinalysis | RBC: 0–2/hpf Protein: Negative | RBC > 100/hpf Protein 100 mg/dL | RBC 6–10/hpf at admission; > 100/hpf day 9 hosopitalization |
Protein/Creatinine ratio | 0- < 0.2 | 2.07 | 3.72 |
Laboratory Investigations: Rheumatologic | |||
Anti-Nuclear Antibody (ANA) | < 1:80 | 1:80 | < 1:80 |
Double-Stranded DNA | 0–9 IU/mL | 0 IU/mL | 0 IU/mL |
Complements (C3, C4) | C3: 82–193 mg/dL C4: 15–57 mg/dL | C3: 154 mg/dL C4: 32 mg/dL | C3: 169 mg/dL C4:26 mg/dL |
Anti-Smith | 0.0–0.9 | < 0.2 | < 0.2 |
anti-RNP | 0.0–0.9 | < 0.2 | < 0.2 |
SSA | 0.0–0.9 | < 0.2 | < 0.2 |
SSB | 0.0–0.9 | < 0.2 | < 0.2 |
Cardiolipin IgG | < 20 GPL U/mL | 0 GPL U/mL | 0 GPL U/mL |
Cardiolipin IgM | < 20 MPL U/mL | 0 MPL U/mL | 0 MPL U/mL |
Beta-2-Glycoprotein IgG | < 20 SGU | Not detected | Not detected |
Beta-2-Glycoprotein IgM | < 20 SMU | Not detected | Not detected |
DRVVT | 33–43 seconds | 35 seconds | 38 seconds |
STACLOT | No lupus anti-coagulant detected | No lupus anti-coagulant detected | No lupus anti-coagulant detected |
Anti-glomerular basement membrane antibody IgG (EU) | 0–19 AU/mL | 0 AU/mL | 0 AU/mL |
ANCA profile (during hospitalization) | < 1:20 AU/mL, PR3 0 | C-ANCA pattern 1:640, PR3 812 AU/mL | c-ANCA pattern 1:5120, PR3 1242 AU/mL |
ANCA profile (6 months post-treatment) | < 1:20 AU/mL, PR3 0 | < 1:20 AU/mL, PR3 0 | < 1:20 AU/mL, PR3 0 |
Laboratory Investigations: Infectious | |||
Hepatitis A Antibodies, total Hepatitis A Antibody, IgM | Negative | Negative | Negative |
Hepatitis B Virus Core Antibodies (total) Hepatitis B Virus Core Antibody, IgM Hepatitis B Virus Surface Antibody Hepatitis B Virus Surface Antigen | Negative | Negative | Negative |
Hepatitis C Virus Genotype Hepatitis C Virus Antibody Hepatitis C Virus by Quantitative NAAT | Negative | Negative | Negative |
Bartonella henselae Antibody, IgG and IgM | Negative | Negative | Negative |
Bartonella quintana Antibody, IgG and IgM | Negative | Negative | Negative |
Herpes Simplex Virus (HSV) DFA with Reflex to HSV Culture | Negative | Negative | Negative |
Blood cultures | Negative | 1 of 4 bottles positive for Coagulase-Negative Staphylococcus > 24 hours after collection | Negative |
PCR Respiratory Viral Panela | Negative | Negative | Negative |
AFB Stain and culture: Bronchoalveolar lavage (BAL) | No organisms on gram stain; negative cultures | Negative | Negative |
Fungal stain and culture: BAL | No organisms on gram stain; negative cultures | Negative | Negative |
Bacterial stain and culture: BAL | No organisms on gram stain; negative cultures | Negative | Negative |
Universal PCR: BAL | Negative | Negative | Negative |
Aspergillus antigen Index: BAL | < 0.5 | < 0.5 | 0.55 |
Anti-Streptolysin O | 0–240 IU/mL | 125 IU/mL | 200 IU/mL |
DNAse B | 0–250 U/mL | < 250 U/mL | < 250 U/mL |
Tuberculosis | Negative | Negative | Negative |
Histoplasmosis antigen (urine) | < 0.5 ng/mL | < 0.5 ng/mL | < 0.5 ng/mL |
Histoplasmosis antigen (serum) | 0.19–60.0 ng/mL | Not detected | Not detected |
Human Immunodeficiency Virus (HIV) | Negative | Negative | Negative |
Case 2
Discussion
Author | Patient Age, Sex | Onset of Cardiac Involvement | Description of Cardiac Involvement | Other organ involvement | ANCA-titer at time cardiac involvement found (pattern and antigen) | Treatment | Outcome |
---|---|---|---|---|---|---|---|
N/A | 15yo, M | Diagnosis | thickened aortic valve leaflets with perforation within the right coronary leaflet as well as 1–2 small areas with vegetation on the aortic valve with mild aortic regurgitation, as well as thickening of the anterior leaflet of the mitral valve | Upper and lower respiratory tract, renal, cutaneous, CNS (thromboembolic stroke) | C-ANCA pattern 1:640, PR3 812 AU/mL | Pulse glucocorticoids (1GMx3 days), 5 days TPE, followed by methylprednisolone 2 mg/kg/day, Rituximab 1000 mg week 0 and week 2, followed by 1000 mg Rituximab every 6 months | Normalization of renal function, resolution of inflammatory markers and ANCA titers, recovery of symptoms; ultimately remission on treatment |
N/A | 16yo, M | Diagnosis | small mitral valve vegetation, likely perforation of the anterior leaflet near the medial annulus | Lower respiratory tract, cutaneous, renal | c-ANCA pattern 1:5120, PR3 1242 AU/mL | Pulse glucocorticoids (1GMx3 days), 5 days TPE, followed by methylprednisolone 2 mg/kg/day, Rituximab 375 mg/m2 once weekly for 4 doses, followed by 1000 mg Rituximab every 6 months | Improvement in renal function, resolution of inflammatory markers and ANCA titers, recovery of symptoms; ultimately remission on treatment |
Harris et al. [19] | 14yo, F | Diagnosis | Ovoid, homogenous pedunculated mass in apex of left ventricle with EF 40% | Upper and lower respiratory tract, cutaneous, arthritis, renal | C-ANCA (titer not available); PR3 148 EU/mL | Pulse glucocorticoids (30 mg/kg) followed by methylprednisolone 2 mg/kg/day, cyclophosphamide 1 mg/kg/day, 7 days TPE; mass resection | Unknown |
Kosovsky et al. [20] | 16yo, M | Diagnosis | Ventricular tachycardia, mass involving full thickness of right anterior ventricular wall extending into base of papillary muscles of the anterior leaflet of the tricuspid valve; biopsy revealed acute and organizing granulomatous vasculitis | Upper and Lower respiratory tract | ANCA studies negative | Cyclophosphamide (exact dosing not provided), Prednisone (exact dosing not provided) | Unknown |
Varnier et al. [21] | 16yo, M | Diagnosis | Vegetation adjacent to tricuspid valve | Cutaneous, upper and lower respiratory tract, renal, genital | C-ANCA (titer not available); PR3 194 EU/mL | Methylprednisolone pulse 1 g daily for 3 consecutive days followed by high dose oral prednisolone; 10 days TPE; Rituximab 1 g at week 0 and 2; Cyclophosphamide 500 mg/m2 every 3 weeks for 4 doses | Normalization of renal function, resolution of inflammatory markers, recovery of symptoms; ultimately remission on treatment with prednisolone 3 mg daily, Azathioprine 125 mg daily, Amlodipine 5 mg daily |
Leff et al. [22] | 17yo, M | Diagnosed 1 year after treatment | Mild LV enlargement, AI, AV perforation | Cutaneous, upper and lower respiratory tract, arthritis | C-ANCA 1:512; PR3 (exact unavailable) | Oral cyclophosphamide 150 mg/day, prednisone 40 mg/day | AV replacement due to progressive insufficiency; flare -- > re-initiation of cyclophosphamide, oral prednisone, Bactrim |
Moghadam et al. [23] | 10yo, M | Diagnosis | Diffuse ectasia and dilation with large aneurysm in the left anterior descending artery (14 mm) | Perforated otitis media with effusion, saddle nose deformity, mastoiditis, sinusitis, deep vein thrombosis | P-ANCA (titer not available); antigen not provided | Methylprednisolone pulse (30 mg/kg/day for 3 days/monthly), cyclophosphamide 750 mg/m2/monthly for 6 months. Oral prednisolone 1 mg/kg/day, mycophenolate mofetil 1200 mg/m2/day. Aspirin 5 mg/kg, warfarin 0.1 mg/kg. | Maintenance therapy with low-dose prednisolone, mycophenolate mofetil, antithrombotic therapy. No flare 1.5 years after diagnosis. |