Chapter 61- Vasculitis

Question 0

What are the diseases that hypersensitivity vasculitis is associated with?

Answer 0

Rheumatoid arthritis
SLE
Bacterial endocarditis
Chronic infection with HCV(b/c causes essential mixed cryoglobulinemia)

Question 1

What are the different vasculitis?

Answer 1

Polyarteritis nodosa
Wegener granulomatosis
Takayasu arteritis
Temporal arteritis
Churg-strauss disease
Hypersensitivity vasculitis (henich-Schönlen purpura)
Microscopic polyangitiis

Question 2

Chronic hepatitis B and C are associated with teo types of vasculitis, what are they?

Answer 2

Microscopic polyangitiis and polyarteritis nodosa

Question 3

What are the hx and PE findings for wegener granulomatosis?

Answer 3

HX-> hemoptysis, cough, dyspnea, recurrent sinusitis

PE-> HTN, palpable purpura, septal ulceration, saddle-nose

Question 4

What are the findings for polyarteritis nodosa in Hx and PE?

Answer 4

Hx-> nothing specific, general symptoms of fever, weight loss, malaise and arthralgia
PE-> HTN, palpable purpura

Question 5

What are the Hx and PE findings of churg-strauss disease?

Answer 5

Hx-> general sx of fever, malaise, wieght loss and arthralgias. Also recurrent asthma attacks.
PE-> CHF, purpura most common in churg-strauss disease compared to the other vasculitis

Question 6

What are the findings in Hx and PE for hypersensitivity vasculitis?

Answer 6

Hx-> fever, malaise, weight loss, arthralgias, for henich-schölein purpura : abdominal pain before rash,
Pe-> often skin involvement is the only system involved, rashes are very common, HTN,

Question 7

What are the Hx and PE findings for temporal arteritis?

Answer 7

Hx-> new onset headache, scalp tenderness, jaw claudication

PE-> tender and thickened temporal arteries

Question 8

What are the hx and pe findings for takayasu arteritis?

Answer 8

Hx-> syncope, stroke

PE-> diminished peripheral pulses (pulseless)

Question 9

What are the hx and pe findings in microscopic polyangitiis?

Answer 9

Hx-> general findings of vasculitis

Pe->

Question 10

Pe findings in vasculitis (general ones)?

Answer 10

Mononeuritis multiplex, cranial nerve palsies, palpable purpura, skin rashes,

Question 11

Bx findings in vasculitis

Answer 11

Granuloma-> churg-strauss (with eosinophils), WG and temporal arteritis
Mononuclear cell or PMN + necrotizing-> polyarteritis nodosa, microscopic polyangitiis
Leukocytoclastic vasculitis-> hypersensitivity vasculitis (in henoch-schölein purpura you have IgA)

Takayasu -> usually dont bx

Question 12

Ddx of palpable purpura for vasculitis?

Answer 12

Disseminated meningococcal, gonococcal or rocky mountain spotted fever

Question 13

What other etiology is important to consider when pt presenting with fever, skin lesions and weight loss?

Answer 13

Subacute bacterial endocarditis

Question 14

Eosinophilia and pulmonary inflitrates are characteristic for churg-strauss disease yet, you need to make sure it is not….(3)

Answer 14

Allergic bronchopulmonary aspergilliosis, loeffler syndrome, chronic eosinophilic pneumonia.

Question 15

Pulmonary + renal disease are strongly aa with WG but make sure it is not…

Answer 15

Goodpasterur syndrome

Question 16

Explain the diagnostic evaluation for vasculitis.

Answer 16

1. Blood test: increased ESR (>100mm per hour), normocytic & normochromic anemia, thrombocytosis, leukocytosis (* bacterial), high eosinophil (think churg-strauss although also possible in hypersensitivity vasculitis)
2. CXR-> WG will have nodules and cavitation, churg-strauss also has findings of pulmonary infiltrates.
3. Blood culture when suspecting bacterial infection.
4. Serology testing:
   - C-AMCA: WG
   - P-ANCA: WG, microscopic polyangitiis and churg-strauss disease.
   - rheumatoid factor: rheumatoid vasculitis, mixed cryoglobulinemia
   - hepatitis c antibody: mixed cryoglobulinemia
   - hepatitis b antibody: polyarteritis nodosa
5. Biopsy
6. Angiogram
   - Polyarteritis nodosa: mesenteric vessels will show beaded appearance of aneurysm with segmental stenosis
   - takayasu arteritis: irregular wall of aorta and subclavian arteries
7. MRI to dx and follow takayasu arteritis

Question 17

List the different treatments for every type of vasculitis.

Answer 17

Polyarteritis nodosa: prednisone (6 mo) + cyclophosphamide (1yr)
Wegener granulomatosis:prednisone + cyclophosphamide. Plasma exchange in severe cases.
Microscopic polyangitiis: prednisone + cyclophosphamide
Takayasu arteritis: steroids, methotrexate and sx grafting
Temporal arteritis: prednisone
Churg-strauss disease: prednisone
Hypersensitivity arteritis, esp. Henoch-schölein purpura: can resolve but it doesn’t, prednisone.

Cyclophosphamide can be replaced by methotrexate and azathioprine after 3-6 mo of administration in order to avoids complications (hemorrhagic cystitis, bladder cancer, myelodysplasia and infertility)of this one.