Systemic vasculitis

Giant-cell arteritis and Takayasu's arteritis have much in common,[8] but usually affect patients of different ages,[9] with Takayasu's arteritis affecting younger people, and giant-cell arteritis having a later age of onset.

Aortitis can also be considered a large-vessel disease.[10]

Takayasu arteritis: primarily affects the aorta and its main branches. At least three out of six criteria yields sensitivity and specificity of 90.5 and 97.8%:

• Onset < 40 years affects young and middle -aged women (ages 15–45)
• Claudication of extremities
• Decreased pulsation of one or both brachial arteries
• At least 10 mmHg systolic difference in both arms
• Bruit over one or both carotid arteries or abdominal aorta
• Arteriographic narrowing of aorta, its primary branches, or large arteries in upper or lower extremities
• Ocular manifestation
  • Visual loss or field defects
  • Retinal hemorrhages
• Neurological abnormalities
• Treatment: steroids

Giant cell (temporal) arteritis. Chronic vasculitis of both large and medium vessels, primarily affecting cranial branches of the arteries arising from the aortic arch. At least three out of five criteria yields sensitivity and specificity of 95 and 91%:

• Age at onset ≥ 50 years
• New onset headache with localized tenderness
• Temporal artery tenderness or decreased pulsation
• Elevated ESR ≥ 50 mm/hour Westergren
• Temporal artery biopsy showing vasculitis with mononuclear cell infiltrate or granulomatous inflammation, usually with multinucleated giant cells

These conditions are sometimes considered together with the small-vessel vasculitides.[11]

Polyarteritis nodosa (PAN): systemic necrotizing vasculitis and aneurysm formation affecting both medium and small arteries. If only small vessels are affected, it is called microscopic polyangiitis (MPA), although it is more associated with granulomatosis with polyangiitis (GPA) than to classic PAN. At least 3 out of 10 criteria yields sensitivity and specificity of 82 and 87%:

• Unexplained weight loss > 4 kg
• Livedo reticularis
• Testicular pain
• Myalgias, weakness
• Abdominal pain, diarrhea, and GI bleeding
• Mononeuropathy or polyneuropathy
• New onset diastolic blood pressure > 90 mmHg
• Elevated serum blood urea nitrogen (> 40 mg/dL) or serum creatinine (> 1.5 mg/dL)
• Hepatitis B infection
• Arteriographic abnormalities
• Arterial biopsy showing polymorphonuclear cells

Kawasaki disease: usually in children (age<4), it affects large, medium, and small vessels, prominently the coronary arteries. Associated with a mucocutaneous lymph node syndrome. Diagnosis requires fever lasting five days or more with at least four out of five criteria:

• Bilateral conjunctival injection
• Injected or fissured lips, injected pharynx, or strawberry tongue
• Erythema of palms/soles, edema of hands/feet, periungual desquamation
• Polymorphous rash
• Cervical lymphadenopathy (at least one node > 1.5 cm)

Isolated cerebral vasculitis: affects medium and small arteries over a diffuse CNS area, without symptomatic extracranial vessel involvement. Patients have CNS symptoms as well as cerebral vasculitis by angiography and leptomeningeal biopsy.

There are several vasculitides that affect small vessels.[12]

Granulomatosis with polyangiitis (GPA): systemic vasculitis of medium and small arteries, including venules and arterioles. Produces granulomatous inflammation of the respiratory tracts and necrotizing, pauci-immune glomerulonephritis. Most common cause of saddle nose deformity in USA (nose flattened due to destruction of nasal septum by granulomatous inflammation). Almost all patients with granulomatosis with polyangiitis have c-antineutrophil cytoplasmic antibody, but not vice versa. Current treatment of choice is cyclophosphamide. At least two out of four criteria yields sensitivity and specificity of 88 and 92%.

• Nasal or oral inflammation (oral ulcers or purulent/bloody nasal discharge, may be painful)
• Abnormal chest X-ray with showing nodules, infiltrates, or cavities
• Microscopic hematuria or red blood cell casts
• Vessel biopsy shows granulomatous inflammation
• Peak incidence: ages 40–60, males > females

Eosinophilic granulomatosis with polyangiitis (formerly known as Churg–Strauss syndrome): affects medium and small vessels with vascular and extravascular granulomatosis. Classically involves arteries of lungs and skin, but may be generalized. At least four criteria yields sensitivity and specificity of 85 and 99.7%.

• Asthma (history of wheezing or presently wheezing)
• Eosinophilia > 10% on complete blood count
• Mononeuropathy or polyneuropathy
• Migratory or transient pulmonary opacities on chest x-ray
• Paranasal sinus abnormalities
• Vessel biopsy showing eosinophils in extravascular areas

Microscopic polyarteritis/polyangiitis. Affects capillaries, venules, or arterioles. Thought to be part of a group that includes granulomatosis with polyangiitis since both are associated with antineutrophil cytoplasmic antibody and similar extrapulmonary manifestations. Patients do not usually have symptomatic or histologic respiratory involvement.

Hypersensitivity vasculitis (allergic vasculitis): usually due to a hypersensitivity reaction to a known drug. Drugs most commonly implicated are penicillin, sulphonamides and thiazide diuretics.[13] Methamphetamine and other sympathomimetics can cause a cerebral vasculitis alongside polyarteritis nodosa like systemic features. With other drugs,there is presence of skin vasculitis with palpable petechiae or purpura. Biopsy of these lesions reveal inflammation of the small vessels, termed leukocytoclastic vasculitis, which is most prominent in postcapillary venules. At least three out of five criteria yields sensitivity and specificity of 71 and 84%:

• Age > 16
• Use of possible triggering drug in relation to symptoms
• Palpable purpura
• Maculopapular rash
• Skin biopsy showing neutrophils around vessel

IgA vasculitis (formerly known as Henoch–Schonlein purpura; HSP): Systemic vasculitis due to tissue deposition of IgA-containing immune complexes. Biopsy of lesions shows inflammation of small vessels. It is considered a form of hypersensitivity vasculitis but is distinguished by prominent deposits of IgA. This is the most common vasculitis in children. Presence of three or more criteria yielded sensitivity of 87% while less than two criteria yielded hypersensitivity vasculitis in 74%:

• Palpable purpura (usually of buttocks and legs)
• Bowel angina
• GI bleed
• Hematuria
• Onset < 20 years
• No new medications

Essential cryoglobulinemic vasculitis: most often due to hepatitis C infection, immune complexes of cryoglobulins – proteins that consists of immunoglobulins and complement and precipitate in the cold while dissolving upon rewarming – are deposited in walls of capillaries, venules, or arterioles. Therefore, complement will be low with histology showing vessel inflammation with immune deposits.

Vasculitis secondary to connective tissue disorders: usually secondary to systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), relapsing polychondritis, Behçet's disease, and other connective tissue disorders.

Vasculitis secondary to viral infection: usually due to hepatitis B and C, human immunodeficiency virus, cytomegalovirus, Epstein–Barr virus, and parvovirus B19.