Difference between revisions of "Vasculitides"
Jump to navigation
Jump to search
(→Kawasaki disease: more) |
(→Giant cell arteritis: format) |
||
| Line 250: | Line 250: | ||
==Giant cell arteritis== | ==Giant cell arteritis== | ||
*[[AKA]] ''temporal arteritis''. | |||
===General=== | ===General=== | ||
* | *Classically afflicts the ''temporal artery''. | ||
Clinical features: | |||
*Classic finding: jaw claudication, in a patient older than 50 years. | *Classic finding: jaw claudication, in a patient older than 50 years. | ||
*Other findings: headache, vision loss or diplopia, scalp tenderness, polymyalgia, weight loss, chills, fever. | *Other findings: headache, vision loss or diplopia, scalp tenderness, polymyalgia, weight loss, chills, fever. | ||
| Line 267: | Line 267: | ||
===Microscopic=== | ===Microscopic=== | ||
Features: | Features: | ||
* | *Artery with intramural inflammatory cells. | ||
**Classically [[granuloma|granulomatous inflammation]]. | |||
***Granulomas not required for the diagnosis! | |||
*Destruction of arterial wall, e.g. fibrinoid necrosis (pink anucleate arterial wall). | |||
Image(s): | Image(s): | ||
Revision as of 16:13, 14 January 2012
This article deals with the vasculitides (singular vasculitis). Vascular disease that is not vasculitides is covered in the article vascular disease.
The histology of normal vessels is dealt with in normal blood vessels.
Overview
Most common[1]
- Polyarteritis nodosa (PAN).
- Microscopic polyangiitis.
- Wegener's granulomatosis.
- Predominantly cutaneous vasculitis.
- Giant cell arteritis (GCA).
Grouping by size
Small vessel vasculitides
Definition
Small vessel vasculitis = vasculitis of vessels smaller than arteries; affects arterioles, venules, and capillaries.[2]
- What is an arteriole?
- There is no histologic definition according to Sternberg's Histology for Pathologists; however, a diameter of <100 micrometers is suggested as a definition.[3]
Types
- Predominantly cutaneous vasculitis.
- Henoch-Schoenlein purpura.
- Essential cryoglobulinemic vasculitis.
- ANCA-associated:
- Wegener's granulomatosis (c-ANCA > p-ANCA).
- Churg-Strauss syndrome (50% ANCA +ve).
- Microscopic polyangiitis (usually p-ANCA).
Notes:
- ANCA = anti-neutrophil cytoplasmic antibodies.
- The terminology has changed as more knowledge has been gained:
- MPO-ANCA = p-ANCA.
- PR3-ANCA = c-ANCA.
- The terminology has changed as more knowledge has been gained:
Medium vessel vasculitides[4]
- Polyarteritis nodosa (PAN).
- Kawasaki disease.
Large vessel vasculitides[4]
- Giant cell arteritis (AKA temporal arteritis).
- Takayasu's arteritis.
Pathologist's role in the diagnosis of vasculitis
General
- Pathologists often cannot, based on morphology alone, arrive at the definitive diagnosis.
- The presentation & distribution are more characteristic than the pathology.[5][6]
Microscopic
Features:[7]
- Inflammatory cells within the blood vessel wall.
- Vessel injury:
Notes:
- Involvement is usually patchy.
- If there is an inkling of vasculitis... it should prompt deeper cuts.
Features to consider
- Presence of granulomas.
- Type inflammatory cells, i.e. eosinophils, mononuclear cells.
- Size of vessels involved.
- Extent of involvement.
- Acuity (acute vs. subacute vs. chronic vs. acute on chronic).
- Chronic = thick fibrotic appearing vessels with a small lumen.
Vasculitis vs. neuropathy
| Vasculitis | Neuropathy | |
| Clinical | pain, diffuse/ patchy distribution |
focal/isolated |
| Pathological (inflammatory cells) |
epineurium | endoneurium |
Small vessel vasculitides
The follow section has information specific to the individual types of small vessel vasculitis.
Small vessel leukocytoclastic vasculitis
- AKA leukocytoclastic vasculitis, abbreviated LCV.
General
- Most common cutaneous vasculitis.[9]
Clinical:
- Palpable purpura, usu. lower extremity.
Microscopic
Features:[9]
- Small upper dermis vessels with:
- Neutrophils.
- Fragmentation of neutrophils (leukocytoclasia).
- Vessel damage: fibrin deposition (bright pink acellular stuff).
- Neutrophils.
Has a very broad DDx:[9]
- Infectious:
- Bacterial.
- Viral.
- Fungal.
- Vasculitic disorders:
- ANCA mediated vasculitides:
- Henoch–Schönlein purpura.[10]
- Urticarial vasculitis.
- Other:
- Connective tissue disease.
- Cryoglobulinemia - may be due to multiple myeloma, hepatitis C; have intravascular thrombi.
- Paraneoplastic.
- Drugs.
Image:
Stains
- PAS - look for fungus.
Microscopic polyangiitis
General
- Classically MPO-ANCA (p-ANCA) +ve.
Microscopic
Features - small-sized vessels with:
- Inflammatory cells (neutrophils, lymphocytes) within the tunica media.
- Fibroid necrosis: dead vessel wall - pink anucleate stuff, nuclear debris (black specks of nuclear material).
- No granulomas.
Images:
Wegener granulomatosis
- Abbreviated WG.
- AKA granulomatosis with polyangiitis.
General
- Autoimmune.
Clinical
- Epistasis.
- Renal failure - present as nephritic syndrome.
- Renal biopsy: crescentic glomerulonephritis (AKA rapidly progressive glomerulonephritis).
- Pulmonary hemorrhage.
Serology:
- c-ANCA +ve.[11]
Notes:
- Pulmonary hemorrhage syndromes:[12]
- Goodpasture syndrome.
- Idiopathic pulmonary hemosiderosis.
- Vasculitis-assoc. hemorrhage (hypersensitivity angiitis, Wegener granulomatosis).
- Systemic lupus erythematosus.
Microscopic
Features:
- Vasculitis:
- Inflammatory cells within the vessel wall.
- Vessel wall injury.
- Granulomas typically poorly formed.[13]
Images:
- www:
- WC:
Churg-Strauss syndrome
General
Defining features - memory device GAFE:
- Granulomata.
- Asthma.
- Fever.
- Eosinophilia.
Notes:
- Similar to Wegener's granulomatosis (classically c-ANCA +ve) and microscopic polyangiitis.[15]
Microscopic
Features:
- Small vessel vasculitis.
- Abundant eosinophils.
- Granulomas.
Images:
DDx:
- Eosinophilic vasculitis associated with a CTD.[16]
Medium vessel vasculitides
The follow section has information specific to the individual types of medium vessel vasculitis.
Kawasaki disease
General
- Medium vessel disease.
- Classically afflicts the coronary arteries of children - usu. less than 5 years old.
- May lead to coronary artery aneurysms.[17]
Clinical features - mnemonic Warm CREAM:[18]
- Warm = fever.
- Conjunctivitis, non-exudative.
- Rash, polymorphous.
- Erythema or edema of hands and feet.
- Adenopathy, usu. cervical and unilateral.
- Mucosal manifestations - strawberry tongue, cracked lips.
Treatment:
- High dose IV aspirin.
Microscopic
Features:
- Medium-sized vessels with intramural inflammatory cells.
- Vessel destruction, e.g. fibrinoid necrosis (very pink anucleate arterial wall).
Polyarteritis nodosa
- Abbreviated PAN.
General
- Involves small and medium sized vessels.
- Often - renal vessels, mesenteric vessels.[19]
- Strong association with hepatitis B (see medical liver diseases); ~1/3 of patients with PAN have HBV.
Serology:
- ANCA is usually negative.
Microscopic
Features - medium-sized vessels with:
- Inflammatory cells (neutrophils, lymphocytes) within the tunica media.
- Fibroid necrosis: dead vessel wall - pink anucleate stuff, nuclear debris (black specks of nuclear material).
- Usu. focal (wall) involvement; classically leads to berry microaneurysms - ergo the name polyarteritis nodosa.
Image:
Large vessel vasculitides
The follow section has information specific to the individual types of large vessel vasculitis.
Giant cell arteritis
- AKA temporal arteritis.
General
- Classically afflicts the temporal artery.
Clinical features:
- Classic finding: jaw claudication, in a patient older than 50 years.
- Other findings: headache, vision loss or diplopia, scalp tenderness, polymyalgia, weight loss, chills, fever.
Work-up:
- CRP, ESR, temporal artery biopsy.
Treatment:
- Treat right away with high dose steroids.
- Biopsy is confirmatory.
Microscopic
Features:
- Artery with intramural inflammatory cells.
- Classically granulomatous inflammation.
- Granulomas not required for the diagnosis!
- Classically granulomatous inflammation.
- Destruction of arterial wall, e.g. fibrinoid necrosis (pink anucleate arterial wall).
Image(s):
Takayasu arteritis
General
Features:[20]
- Disease of medium/large arteries.
- Classically involves the aortic arch (leading to decreased pulses in the upper limbs).
- Typically in patients <40 yrs old.
- Usually asian.
Microscopic
Features:[20]
- Adventitial mononuclear infiltrate with perivascular cuffing of the vasa vasorum.
- Mononuclear inflammation in media.
- Granulomas, giant cells.
- +/-Patchy necrosis of media.
Other
LAMP-2 vasculitis
- Associated with pauci-immune necrotizing and crescentic glomerulonephritis.[21]
- Grouped with the ANCA-associated vasculitides.[22]
See also
- Cardiovascular pathology.
- Vascular disease - covers atherosclerosis, medial cystic degeneration.
- Inflammatory skin disorders.
References
- ↑ TN05 RH3.
- ↑ Jennette JC, Falk RJ (November 1997). "Small-vessel vasculitis". N. Engl. J. Med. 337 (21): 1512–23. doi:10.1056/NEJM199711203372106. PMID 9366584. http://www.nejm.org/doi/full/10.1056/NEJM199711203372106.
- ↑ Sternberg, Stephen S. (1997). Histology for Pathologists (2nd ed.). Lippincott Williams & Wilkins. pp. 769. ISBN 978-0397517183.
- ↑ 4.0 4.1 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 512. ISBN 978-1416031215.
- ↑ URL: http://www.pathology.ubc.ca/path425/PrincipleofPathophysiology/CirculatoryDisorders/SystemicVasculitisDrBWalker.doc. Accessed on: 26 November 2010.
- ↑ URL: http://www.icapture.ubc.ca/who/who_bios_david_walker.shtml. Accessed on: 26 November 2010.
- ↑ URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908435/. Accessed on: 26 November 2010.
- ↑ URL: http://dictionary.weather.net/dictionary/amorphous. Accessed on: 26 November 2010.
- ↑ 9.0 9.1 9.2 Brinster, NK. (Nov 2008). "Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II).". Adv Anat Pathol 15 (6): 350-69. doi:10.1097/PAP.0b013e31818b1ac6. PMID 18948765.
- ↑ Kraft, DM.; Mckee, D.; Scott, C. (Aug 1998). "Henoch-Schönlein purpura: a review.". Am Fam Physician 58 (2): 405-8, 411. PMID 9713395.
- ↑ TN05 RH6.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 745. ISBN 0-7216-0187-1.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 747. ISBN 0-7216-0187-1.
- ↑ http://emedicine.medscape.com/article/333492-overview
- ↑ URL: http://emedicine.medscape.com/article/334024-overview. Accessed on: 22 January 2011.
- ↑ Chen, KR.; Su, WP.; Pittelkow, MR.; Conn, DL.; George, T.; Leiferman, KM. (Aug 1996). "Eosinophilic vasculitis in connective tissue disease.". J Am Acad Dermatol 35 (2 Pt 1): 173-82. PMID 8708015.
- ↑ Taubert, KA.; Shulman, ST. (Jun 1999). "Kawasaki disease.". Am Fam Physician 59 (11): 3093-102, 3107-8. PMID 10392592.
- ↑ URL: http://www.medicalmnemonics.com/cgi-bin/return_browse.cfm?&system=Other%2FMiscellaneous&discipline=Pathology&browse=1. Accessed on: 14 January 2012.
- ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 14. ISBN 978-1416002741.
- ↑ 20.0 20.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 538. ISBN 0-7216-0187-1.
- ↑ Bosch X, Mirapeix E (May 2009). "Vasculitis syndromes: LAMP-2 illuminates pathogenesis of ANCA glomerulonephritis". Nat Rev Nephrol 5 (5): 247–9. doi:10.1038/nrneph.2009.51. PMID 19384321. http://www.nature.com/ki/journal/v76/n1/abs/ki2009123a.html.
- ↑ Chen M, Kallenberg CG (2009). "New advances in the pathogenesis of ANCA-associated vasculitides". Clin. Exp. Rheumatol. 27 (1 Suppl 52): S108–14. PMID 19646356.