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Kamide Y, Taniguchi M. Eosinophilic granulomatosis with polyangiitis: current status and future perspectives. Respir Investig 2025; 63:639-650. [PMID: 40383090 DOI: 10.1016/j.resinv.2025.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2025] [Revised: 04/18/2025] [Accepted: 04/24/2025] [Indexed: 05/20/2025]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis with hypereosinophilia that is preceded by asthma and chronic rhinosinusitis with nasal polyps. Since multiple organs may be involved in this disease, early treatment is required. In this regard, glucocorticoid (GC) therapy is often initiated before a definitive diagnosis is made. A biopsy of an injured organ is useful for a diagnosis but is not performed in all cases due to its invasiveness and, at times, diagnostic accuracy. Therefore, a comprehensive diagnosis is often made based on symptoms and clinical course of disease. However, it is sometimes difficult to distinguish EGPA from other hypereosinophilic diseases or vasculitides. In recent years, in addition to GC and immunosuppressive agents, anti-interleukin (IL)-5/IL-5 receptor alpha (IL-5Rα) antibodies targeting eosinophils have become increasingly important in the treatment of EGPA. However, accumulating data suggest that such anti-IL-5/IL-5Rα antibody therapy may have effects beyond those observed in eosinophils. This paper outlines the clinical features, diagnosis, pathogenesis, and current treatment of EGPA, a hypereosinophilic disease.
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Affiliation(s)
- Yosuke Kamide
- Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, 18-1 Sakuradai, Minamiku, Sagamihara, Kanagawa, Japan.
| | - Masami Taniguchi
- Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, 18-1 Sakuradai, Minamiku, Sagamihara, Kanagawa, Japan
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Karageorgiou I, Bhatia U, Alakhras H, Celik B, Halalau A. Cardiac Magnetic Resonance Imaging Findings in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitides: A Systematic Review. ACR Open Rheumatol 2025; 7:e70026. [PMID: 40241489 PMCID: PMC12003957 DOI: 10.1002/acr2.70026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Revised: 02/19/2025] [Accepted: 02/24/2025] [Indexed: 04/18/2025] Open
Abstract
OBJECTIVE Our objective was to review the available literature on cardiac magnetic resonance imaging (cMRI) findings in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), evaluate its diagnostic utility, and assess its potential as a screening tool. METHODS We systematically searched PubMed, Embase, Scopus, and Web of Science from inception to March 29, 2023, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. English-language studies involving adult patients diagnosed with AAV-eosinophilic granulomatosis with polyangiitis (EGPA), granulomatosis with polyangiitis (GPA), or microscopic polyangiitis (MPA)-using recognized classification criteria were included. Studies had to report specific cMRI parameters in at least three patients. Three independent reviewers conducted study selection, data extraction, and quality assessment. RESULTS Of 2,251 studies, 30 met the inclusion criteria, encompassing 1,149 patients with AAV (87% with EGPA, 13% with GPA, and 0.3% with MPA). The mean patient age was 52 ± 5 years, with 50.4% being female. The mean left ventricular ejection fraction (LVEF) was 55.6% ± 11.3%, and 29% of patients had an LVEF less than 50%. Myocardial fibrosis, indicated by late gadolinium enhancement (LGE), was present in 49% of patients, with predominantly subendocardial or endocardial (23%), intramyocardial (14%), and subepicardial (10%) patterns. Patients in remission (26%), when compared to those not in remission (74%), exhibited higher proportions of LGE (55% vs 47%) and glucocorticoid use (77% vs 68%), despite similar rates of abnormal electrocardiograms (44% vs 42%). CONCLUSION This systematic review reveals a high prevalence of myocardial fibrosis detected by cMRI in patients with AAV, even during remission. Significant subclinical cardiac involvement may be missed by conventional diagnostic methods, underscoring the utility of cMRI during routine evaluation.
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Affiliation(s)
| | - Unnati Bhatia
- Corewell Health William Beaumont University HospitalRoyal OakMichigan
| | - Hazem Alakhras
- Corewell Health William Beaumont University HospitalRoyal OakMichigan
| | - Berk Celik
- Corewell Health William Beaumont University HospitalRoyal OakMichigan
| | - Alexandra Halalau
- Corewell Health William Beaumont University Hospital, Royal Oak, and Oakland University William Beaumont School of MedicineRochesterMichigan
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Liu X, Zhou Y, Li J, Guo T, Lv Z, Zhang D, Feng X, Zhang J, Fang L, Tian X, Zeng X, Chen W. Cardiac involvement in eosinophilic granulomatosis with polyangiitis: acute eosinophilic myocarditis and chronic inflammatory cardiomyopathy. Rheumatology (Oxford) 2025; 64:722-731. [PMID: 38335934 DOI: 10.1093/rheumatology/keae085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/06/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Currently, cardiac involvement is used to describe all eosinophilic granulomatosis with polyangiitis (EGPA) cardiac problems. However, heterogeneity exists among them. We aimed to depict the disease spectrum of EGPA cardiac involvement and identify the high-risk population. METHODS We included EGPA patients hospitalized in our centre from 2012 to 2023 and in public databases. Based on the cardiac enzymes, cardiac MRI and endomyocardial biopsy results, the patients were divided into three groups: eosinophilic myocarditis (EGPA-EM), chronic inflammatory cardiomyopathy (EGPA-ICM) and EGPA-Control. Their clinical, laboratory, imaging results and prognoses were collected and compared. RESULTS A total of 193 EGPA patients were included, 118 with cardiac involvement (74 EGPA-EM, 44 EGPA-ICM) and 75 control. Among EGPA-Control, EGPA-ICM and EGPA-EM, eosinophil increased (6.12/8.71/10.42 × 109/l, P < 0.01), ANCA positivity decreased (41.33/31.82/14.86%, P < 0.01) and lung involvement was reduced (73.33/72.73/43.24%, P = 0.02). In EGPA-EM, cardiac troponin was further elevated (0.27 vs 6.00 ng/ml, P < 0.01), ejection fractions decreased (57.79 vs 33.20%, P < 0.01) while more ST-T abnormality was observed (41.89 vs 20.45%, P = 0.02). The prognosis of EGPA-EM was significantly worse, with a 14.86% death rate and 2-year event-free survival rate below 50%. Furthermore, we proposed a LATE-EAST diagnostic score (7 items, 9 points) to discriminate EGPA-EM from EGPA-ICM using 4 points as threshold [area under the receiver operating characteristic curve 0.85 (95% CI 0.78-0.92), sensitivity 0.78, specificity 0.86]. CONCLUSIONS We first proposed different subtypes of cardiac involvement in EGPA. Identification and treatment of EGPA-EM needs improvement. LATE-EAST score could recognize the high-risk EGPA-EM effectively. Multi-disciplinary treatment is warranted, immunosuppressive therapy should be given in a timely manner and anti-IL-5 antibodies should be be tested in trials.
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Affiliation(s)
- Xiaohang Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jing Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Tianchen Guo
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhuoyao Lv
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Dingding Zhang
- Department of Epidemiology and Biostatistics, Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiaojin Feng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jingdai Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Asada AM, Kahwash R, Trovato V. Eosinophilic Myocarditis: A Concise Review. Curr Cardiol Rep 2025; 27:38. [PMID: 39847306 PMCID: PMC11758188 DOI: 10.1007/s11886-024-02184-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2024] [Indexed: 01/24/2025]
Abstract
PURPOSE OF REVIEW Eosinophilic myocarditis (EM) is a rare and heterogeneous form of inflammatory heart disease that can present with a wide range of severity. Current literature is limited to case reports or small case series that outline the evaluation process, disease course, and the nonstandardized treatments trialed. This review aims to concisely summarize the current literature on EM including an update on maintenance therapy for refractory or recurrent disease. RECENT FINDINGS In the last several years, several observational studies have reported the clinical benefit of mepolizumab and benralizumab in refractory EM. EM is a complex and heterogenous cause of inflammatory heart disease with a wide range of etiologies and presentations. Treatment of this disease has not been standardized as there are no large scale trials quantifying benefit of any specific therapy regimen. Targeted biologics show promise in observational studies; therefore, prospective studies are needed to quantify this benefit in EM.
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Affiliation(s)
- Ashlee M Asada
- Division of Internal Medicine, The Ohio State University, Columbus, OH, USA.
| | - Rami Kahwash
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Vincenzo Trovato
- Division of Heart and Vascular, Metrohealth Medical Center, 2500 Metrohealth Dr, Cleveland, OH, 44109, USA.
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Hua L, Xie M. Heterogeneity and individualized therapy for eosinophilic granulomatosis with polyangiitis. Ther Adv Respir Dis 2025; 19:17534666251318615. [PMID: 39980304 PMCID: PMC11843704 DOI: 10.1177/17534666251318615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 01/08/2025] [Indexed: 02/22/2025] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), as a heterogeneous component of antineutrophil cytoplasmic antibody-associated vasculitis, may be induced by a series of environmental and genetic factors, involved with a variety of immune cells and immune components, and presented with various clinical manifestations, with multiple organs and systems (respiratory, skin, heart, kidney, nerve, etc.) involved. The choice of glucocorticoid (GC) dosage and immunosuppressant in traditional treatment strategies varies greatly from individual to individual and is not universally applicable in all the EGPA phenotype spectrum, especially in relapsing or refractory diseases. With the understanding of the heterogeneity of EGPA, a variety of therapeutic approaches are emerging and improving the traditional treatment model. In this review, we summarized the heterogeneity of EGPA etiology and pathogenesis. Clinical and pathological manifestations of the same organ involved also show significant differences and there are even gender differences. Biological treatments that mainly target type 2 inflammatory pathways are widely used in clinical practice for remission induction and maintenance of EGPA. Targeted biological therapy has shown excellent performance in reducing GC dosage and controlling symptoms and recurrence. However, a large number of high-quality randomized controlled studies are still under research for relapsing or refractory EGPA with special organ involvement. We believe that EGPA has a highly heterogeneous phenotype spectrum, and the treatment patterns targeting key molecules in the pathogenesis are of great value for individual treatment of EGPA.
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Affiliation(s)
- Lijuan Hua
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Min Xie
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, Hubei, China
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Hua A, Sularz A, Wheen P, Alam V, Rajani R, Chiribiri A, D'Cruz D, Fernando M, Dhariwal J, Nanzer AM, Jackson DJ, Ismail TF. Detection of Cardiac Involvement in Eosinophilic Granulomatosis With Polyangiitis (EGPA) With Multiparametric Cardiovascular Magnetic Resonance (CMR). JACC Cardiovasc Imaging 2024; 17:1261-1264. [PMID: 39001733 DOI: 10.1016/j.jcmg.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/22/2024] [Accepted: 05/15/2024] [Indexed: 07/15/2024]
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Segreti A, Mastroberardino S, Frau L, Appetecchia A, D'Antonio L, Ricciardi D, Ussia GP, Grigioni F. Severe heart failure and intracardiac thrombosis: going beyond the appearance for diagnosis and treatments. Monaldi Arch Chest Dis 2024. [PMID: 38700128 DOI: 10.4081/monaldi.2024.2882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/27/2024] [Indexed: 05/05/2024] Open
Abstract
We describe the case of a 45-year-old female affected by asthma and nasal polyposis who presented to the emergency department because of worsening dyspnea and paresthesia of the left lower limb. Comprehensive instrumental examinations revealed the presence of severe left ventricle dysfunction, intra-cardiac thrombus, deep vein thrombosis, pulmonary embolism, lung infiltrates, polyserositis, and neurological involvements. Finally, the patient was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA), formerly Churg-Strauss syndrome, a rare vasculitis of small-medium blood vessels with several organ involvements. Treatment with anticoagulants, corticosteroids, and cyclophosphamide led to a significant clinical improvement. However, a subcutaneous cardiac defibrillator was implanted because of the persistence of severe left ventricular dysfunction and the high cardiovascular risk phenotype. Indeed, several cardiac manifestations may occur in EGPA, particularly in patients with anti-neutrophil cytoplasmic antibody-negative disease. Therefore, clinicians should have high clinical suspicion because cardiac involvement in EGPA results in a poor prognosis if not diagnosed and adequately treated.
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Affiliation(s)
- Andrea Segreti
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico".
| | - Sara Mastroberardino
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Lorenzo Frau
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Alessandro Appetecchia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Luca D'Antonio
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Danilo Ricciardi
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome.
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 227] [Impact Index Per Article: 227.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Collini V, Burelli M, Favaretto V, Pegolo E, Fumarola F, Lepre V, Pellin L, Taurian M, Quartuccio L, Imazio M, Sinagra G. Eosinophilic myocarditis: comprehensive update on pathophysiology, diagnosis, prognosis and management. Minerva Cardiol Angiol 2023; 71:535-552. [PMID: 37161920 DOI: 10.23736/s2724-5683.23.06287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Hypereosinophilic syndromes are a group of disorders secondary to the accumulation of eosinophils leading to the injury of one or more organs. Among them, eosinophilic myocarditis (EM) is a rare form of inflammatory cardiomyopathy characterized by eosinophilic infiltration into myocardial tissue and subsequent release of substances with cell membrane damage and cell destruction. The degree of infiltration is thought to depend on the underlying condition, as well as the degree and duration of eosinophil exposure and ranges from mild localized disease to diffuse multifocal infiltrates associated with myocardial necrosis, thrombotic complications and endomyocardial fibrosis. The main causes of EM are hypersensitivity reactions, eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome variants, infections and cancer. Clinical presentation can be variable, ranging from asymptomatic forms to life-threatening conditions, to chronic heart failure due to progression to chronic restrictive cardiomyopathy. Marked eosinophilia in peripheral blood, elevated serum eosinophilic cationic protein concentration and multimodality imaging may suggest the etiology of EM, but in most cases an endomyocardial biopsy must be performed to establish a definitive diagnosis. Systemic treatment varies greatly depending on the underlying cause, however the evidence of an eosinophilic infiltrate allows initiation of immunosuppressive therapy, which is the mainstay of treatment in idiopathic and in most forms of EM. Patients with helminthic infection benefit from anti-parasitic therapy, those with myeloid clone often need a tyrosine kinase inhibitor, while anticoagulant therapy should be undertaken in case of possible thrombotic complications.
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Affiliation(s)
- Valentino Collini
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy -
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy -
| | - Massimo Burelli
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Virginia Favaretto
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Enrico Pegolo
- Institute of Anatomic Pathology, Department of Medical and Biological Sciences, University Hospital of Santa Maria della Misericordia, Udine, Italy
| | - Francesca Fumarola
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Veronica Lepre
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Lisa Pellin
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Marco Taurian
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Quartuccio
- Unit of Rheumatology, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Massimo Imazio
- Unit of Cardiology, Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
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He JL, Liu XY, Zhang Y, Niu L, Li XL, Xie XY, Kang YT, Yang LQ, Cai ZY, Long H, Ye GF, Zou JX. Eosinophilic granulomatosis with polyangiitis, asthma as the first symptom, and subsequent Loeffler endocarditis: A case report. World J Clin Cases 2023; 11:6523-6530. [PMID: 37900222 PMCID: PMC10601009 DOI: 10.12998/wjcc.v11.i27.6523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/18/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare form of anti-neutrophil cytoplasmic antibody-associated vasculitis characterized by asthma, vasculitis, and eosinophilia. CASE SUMMARY We report an atypical case of EGPA in a 20-year-old female patient. Unlike previously reported cases of EGPA, this patient's initial symptom was asthma associated with a respiratory infection. This was followed by Loeffler endocarditis and cardiac insufficiency. She received treatment with methylprednisolone sodium succinate, low molecular weight heparin, recombinant human brain natriuretic peptide, furosemide, cefoperazone sodium/sulbactam sodium, and acyclovir. Despite prophylactic anticoagulation, she developed a large right ventricular thrombus. EGPA diagnosis was confirmed based on ancillary test results and specialty consultations. Subsequent treatment included mycophenolate mofetil. Her overall condition improved significantly after treatment, as evidenced by decreased peripheral blood eosinophils and cardiac markers. She was discharged after 17 d. Her most recent follow-up showed normal peripheral blood eosinophil levels, restored cardiac function, and a reduced cardiac mural thrombus size. CONCLUSION This case illustrates the swift progression of EGPA and underscores the significance of early detection and immediate intervention to ensure a favorable prognosis.
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Affiliation(s)
- Jia-Ling He
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Xing-Yu Liu
- Department of Orthopedic Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Yi Zhang
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Li Niu
- Department of Internal Cardiovascular Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Xin-Lin Li
- Department of Medical Cosmetology, Beijing Puxiang Traditional Chinese Medicine Hospital, Beijing 100080, China
| | - Xing-Yu Xie
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Yang-Ting Kang
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Lan-Qing Yang
- College of Pediatrics, Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Zheng-Yang Cai
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
| | - Hui Long
- Department of Internal Cardiovascular Medicine, People’s Hospital of Baiyun District, Guiyang 550014, Guizhou Province, China
| | - Guang-Fei Ye
- Department of Orthopedic Surgery, Hospital of Guizhou Panjiang Coal Power Group Limited Liability Company, Liupanshui 553537, Guizhou Province, China
| | - Jun-Xin Zou
- Department of Imaging, Affiliated Hospital of Guizhou Medical University, Guiyang 550001, Guizhou Province, China
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11
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Watanabe R, Hashimoto M. Eosinophilic Granulomatosis with Polyangiitis: Latest Findings and Updated Treatment Recommendations. J Clin Med 2023; 12:5996. [PMID: 37762936 PMCID: PMC10532073 DOI: 10.3390/jcm12185996] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) causes necrotizing vasculitis and eosinophil-rich granulomatous inflammation in small- to medium-sized vessels, resulting in multiple organ damage. EGPA is classified as an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, with myeloperoxidase-ANCA detected in approximately one-third of the patients. Conventional treatment of EGPA relies on systemic glucocorticoids (GCs) in combination with cyclophosphamide when poor prognostic factors are present; however, the dilemma between disease control and drug-related adverse effects has long been a challenge. Recent studies have revealed that the genetic background, pathophysiology, and clinical manifestations differ between ANCA-positive and ANCA-negative patients; however, mepolizumab, an interleukin (IL)-5 inhibitor, is effective in both groups, suggesting that the IL-5-eosinophil axis is deeply involved in the pathogenesis of both ANCA-positive and ANCA-negative EGPA. This review summarizes the latest knowledge on the pathophysiology of EGPA and focuses on the roles of eosinophils and ANCA. We then introduce the current treatment recommendations and accumulated evidence for mepolizumab on EGPA. Based on current unmet clinical needs, we discuss potential future therapeutic strategies for EGPA.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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12
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Fijolek J, Radzikowska E. Eosinophilic granulomatosis with polyangiitis - Advances in pathogenesis, diagnosis, and treatment. Front Med (Lausanne) 2023; 10:1145257. [PMID: 37215720 PMCID: PMC10193253 DOI: 10.3389/fmed.2023.1145257] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease characterized by eosinophil-rich granulomatous inflammation and necrotizing vasculitis, pre-dominantly affecting small-to-medium-sized vessels. It is categorized as a primary antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) but also shares features of hypereosinophilic syndrome (HES); therefore, both vessel inflammation and eosinophilic infiltration are suggested to cause organ damage. This dual nature of the disease causes variable clinical presentation. As a result, careful differentiation from mimicking conditions is needed, especially from HES, given the overlapping clinical, radiologic, and histologic features, and biomarker profile. EGPA also remains a diagnostic challenge, in part because of asthma, which may pre-dominate for years, and often requires chronic corticosteroids (CS), which can mask other disease features. The pathogenesis is still not fully understood, however, the interaction between eosinophils and lymphocytes B and T seems to play an important role. Furthermore, the role of ANCA is not clear, and only up to 40% of patients are ANCA-positive. Moreover, two ANCA-dependent clinically and genetically distinct subgroups have been identified. However, a gold standard test for establishing a diagnosis is not available. In practice, the disease is mainly diagnosed based on the clinical symptoms and results of non-invasive tests. The unmet needs include uniform diagnostic criteria and biomarkers to help distinguish EGPA from HESs. Despite its rarity, notable progress has been made in understanding the disease and in its management. A better understanding of the pathophysiology has provided new insights into the pathogenesis and therapeutic targets, which are reflected in novel biological agents. However, there remains an ongoing reliance on corticosteroid therapy. Therefore, there is a significant need for more effective and better-tolerated steroid-sparing treatment schemes.
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13
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Ali AM, Yakupoglu HY, Fuchs TA, Larsen TH, Aukrust P, Gunnarsson R, Saeed S. Cardiac involvement in systemic and local vasculitides: The value of non-invasive multimodality imaging. Curr Probl Cardiol 2023; 48:101718. [PMID: 37003450 DOI: 10.1016/j.cpcardiol.2023.101718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
Despite significant advances in managing systemic vasculitides, cardiovascular morbidity and mortality are still of primary concern. Advances in non-invasive imaging have broadened our understanding of the clinical heterogeneity of cardiac involvement in vasculitides. Common cardiovascular complications in primary or secondary vasculitides are; coronary artery aneurysms, acute coronary syndromes, myocarditis, pericarditis, endocarditis, and valvular dysfunction. Echocardiography, cardiac magnetic resonance (CMR), positron emission tomography (PET), and CT angiography are essential in identifying cardiac involvement and guiding treatment. Here, we present our experiences of cardiac involvement in systemic vasculitides, covering most aspects of common cardiac complications based on a multi-modality approach to challenging (real-world) cases. As many cardiac manifestations are clinically silent, heart function should be systemically assessed by a multi-modality imaging-based approach, including ECG, serial echocardiograms with strain imaging and 3D, and CMR to detect early signs of cardiac manifestations. This enables timely intervention and optimal medical treatment, which is essential for a better prognosis. There is a need for better and closer collaboration in clinical practice and research fields between Cardiologists and Rheumatologists.
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Affiliation(s)
- Abukar Mohamed Ali
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - H Yakup Yakupoglu
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Tobias A Fuchs
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Terje H Larsen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.; Department of Biomedicine, University of Bergen, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital - Rikshospitalet, Oslo; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo.; Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital - Rikshospitalet, Oslo
| | | | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway..
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14
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Zhao B, Zheng H, Yang T, Zheng R. Eosinophilic granulomatosis with polyangiitis in allergic asthma: Efforts to make early diagnosis possible. Allergy Asthma Proc 2023; 44:59-63. [PMID: 36719697 DOI: 10.2500/aap.2023.44.220072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare autoimmune disease that can affect multiple organ systems in the body. A majority of patients with EGPA present with asthma-like symptoms and may be misdiagnosed with refractory asthma. It is necessary to distinguish EGPA from asthma and provide a theoretical basis for effective future prevention and treatment. Objective: This study aimed to compare the clinical features of EGPA and the clinical features of allergic asthma in an effort to make an early diagnosis possible. Methods: We reviewed the basic information, test results, pre-onset conditions, and prognosis of 44 adult patients with EGPA who were admitted to our hospital between January 2013 and June 2021, and conducted a 1:1 matched case-control study to compare patients with EGPA and patients with allergic asthma. Results: The 44 patients with EGPA were older than those with allergic asthma, but more than half of the patients with EGPA had been diagnosed with bronchial asthma, with a history of 10 months to 40 years, and had previously used inhalers or systemic steroids. The proportion of male-to-female cases was ∼1:1, with seven antineutrophil cytoplasmic antibodies (ANCA) positive cases (15.9%), 20 limited EGPA cases (45.45%), and 24 systemic EGPA cases (54.55%). Although the peripheral blood eosinophil count and percentage were lower in the male patients than in the female patients, male patients with higher five-factor scores might indicate worse prognosis. The fractional exhaled nitric oxide (FeNO) level, eosinophil percentage and count, and total immunoglobulin E (IgE) level were higher in the EGPA group than in the allergic asthma group. Unlike in allergic asthma, the FeNO level is not correlated with the blood eosinophil count or percentage in EGPA. Seven patients received cardiac emission computed tomography (ECT) tests, with abnormalities suggested in six patients. Results of an electrocardiogram, color-Doppler echocardiography, myocardial enzyme level, and troponin level suggested no obvious abnormality. Conclusion: The proportion of patients with EGPA who tested positive for ANCA is not high, and patients with high eosinophil counts should be alert to the possibility of having EGPA. For patients with infiltration of eosinophils into the airway, a diagnosis should not be based on peripheral blood eosinophil counts. It is recommended that the FeNO level and pulmonary function should also be monitored for patients who present with symptoms in other body systems. The sensitivity of cardiac ECT tests is higher than routine tests, so timely screening by cardiac ECT is recommended for all patients with EGPA.
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Affiliation(s)
- Bo Zhao
- From the Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China and
| | - Haiming Zheng
- From the Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China and
| | - Tengfei Yang
- Department of Health Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Rui Zheng
- From the Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China and
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15
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Bond M, Fagni F, Moretti M, Bello F, Egan A, Vaglio A, Emmi G, Dejaco C. At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement. Curr Rheumatol Rep 2022; 24:337-351. [PMID: 36194339 DOI: 10.1007/s11926-022-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of existing literature on pathogenetic and clinical aspects of cardiac and vascular involvement in eosinophilic granulomatosis with polyangiitis (EGPA). RECENT FINDINGS In EGPA, cardiac and vascular involvement are more common than previously thought. However, no international recommendations on the topic are available yet. Herein, we summarize the existing evidence on the topic and propose a diagnostic approach for cardiac involvement in EGPA. The prevalence of cardiovascular involvement in patients with EGPA varies greatly among published studies, ranging between 3.1-18.7% for occlusive arterial disease, 5.8-30% for venous thrombosis and 17-92% for heart involvement. Cardiac involvement in EGPA is associated with high mortality even though manifestations are heterogeneous. In principle, every anatomical structure of the heart can be involved, and EGPA-related heart disease may be completely asymptomatic at first. A careful diagnostic work-up for early detection and prompt treatment initiation is therefore required. While cardiac manifestations are more common in anti-neutrophil cytoplasmic antibodies (ANCA)-negative patients, arterial and venous thrombotic events are not linked to ANCA status but correlate closely with disease activity and accumulate at disease onset. Thrombotic events (mainly venous) are considerably more frequent in EGPA than in the general population contributing substantially to morbidity and highlighting the importance of developing specific prevention strategies for patients who are diagnosed with EGPA.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michele Moretti
- Department of Cardiology - Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Allyson Egan
- Vasculitis & Lupus Unit, Department of Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy. .,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
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16
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Condurache DG, Raisi-Estabragh Z, Baslas R, Hamdulay S. A case report of myocarditis secondary to eosinophilic granulomatosis with polyangiitis. EUROPEAN HEART JOURNAL - CASE REPORTS 2022; 6:ytac307. [PMID: 36052400 PMCID: PMC9426485 DOI: 10.1093/ehjcr/ytac307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/23/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis. Cardiac involvement is the major cause of morbidity and mortality in these patients. Early recognition and treatment initiation for such manifestations are key to improved patient outcomes. Case summary We report the case of a 60-year-old man with a history of therapy-resistant asthma and rhinitis. He presented with acute chest pain, sinus tachycardia, and marked peripheral eosinophilia. Transthoracic echocardiogram (TTE) showed segmental anterior left ventricular (LV) wall motion abnormalities with impaired systolic function (LV ejection fraction 45%) and a small pericardial effusion. Invasive coronary angiography revealed unobstructed coronary arteries. Cardiac magnetic resonance imaging confirmed the TTE findings and demonstrated oedema and active inflammation of the anterior and anteroseptal LV segments [Short inversion time recovery (STIR)-T2] and an unusual pattern of non-ischaemic late gadolinium enhancement extending across multiple coronary territories. Autoantibody testing detected a positive P-ANCA and myeloperoxidase (MPO) antibodies. Overall, the investigation findings supported a diagnosis of ANCA-positive EGPA with acute myocardial involvement. He was initially treated with high-dose corticosteroids, cyclophosphamide, and rituximab. The patient had a good symptomatic and biochemical (normalized troponin T and MPO titre) recovery. In addition, subsequent TTE showed improvement of LV systolic function and resolution of regional wall motion abnormalities. Discussion In this case, prompt diagnosis facilitated early initiation of immunosuppressive therapy and disease remission. CMR provides non-invasive assessment of myocardial tissue characterization and, used in conjunction with other tools, can be instrumental in detecting myocardial involvement in EGPA.
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Affiliation(s)
| | - Zahra Raisi-Estabragh
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square , London, EC1M 6BQ , UK
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust , West Smithfield, EC1A 7BE, London , UK
| | - Rohit Baslas
- London North West University Healthcare NHS Trust , Watford Road, Harrow, HA1 3UJ , UK
| | - Shahir Hamdulay
- London North West University Healthcare NHS Trust , Watford Road, Harrow, HA1 3UJ , UK
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Sierra-Galan LM, Bhatia M, Alberto-Delgado AL, Madrazo-Shiordia J, Salcido C, Santoyo B, Martinez E, Soto ME. Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review. Front Cardiovasc Med 2022; 9:870200. [PMID: 35911548 PMCID: PMC9326004 DOI: 10.3389/fcvm.2022.870200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.
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Affiliation(s)
- Lilia M. Sierra-Galan
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Mona Bhatia
- Department of Imaging, Fortis Escorts Heart Institute, New Delhi, India
| | | | - Javier Madrazo-Shiordia
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Carlos Salcido
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Bernardo Santoyo
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Eduardo Martinez
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Maria Elena Soto
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
- Immunology Department of the National Institute of Cardiology, “Ignacio Chavez”, Mexico City, Mexico
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