Churg-Strauss syndrome overview: Difference between revisions
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==Overview== | ==Overview== | ||
[[Eosinophilic granulomatosis with polyangiitis]] previously called [[Eosinophilic granulomatosis with polyangiitis|Churg-Strauss syndrome]] is a small and medium-sized necrotizing [[vasculitis]], with extravascular [[granuloma]] formation. The disease was first described by Churg and Strauss in 1951. The [[etiology]] is not known. However, various environmental factors, [[Allergen|allergens]], [[genetics]], and [[:Category:Drugs|drugs]] may play a role in triggering [[disease]] process by activating [[Eosinophil granulocyte|eosinophils]], [[B cell|B]] and [[T cell|T lymphocytes]] and [[Macrophage|macrophages]]. The disease is characterized by the presence of [[asthma]], peripheral [[eosinophilia]], [[rhinosinusitis]], [[peripheral neuropathy]] and multiple [[Organ (anatomy)|organ]] involvements including [[skin]], [[Gastrointestinal tract|GI tract]], and [[kidney]]. | |||
==Historical Perspective== | ==Historical Perspective== | ||
Two pathologists Churg and Strauss first described the disease in 1951. They named it as allergic granulomatosis with angiitis. Over the years, they called the disease by the name of Churg-Strauss syndrome. In 2010, American College of Rheumatology changed this name to [[eosinophilic granulomatosis with polyangiitis]] based on histopathology. | |||
==Classification== | ==Classification== | ||
Revised International Chapel Hill Consensus Conference 2012 on nomenclature of vasculitides, defines [[eosinophilic granulomatosis with polyangiitis]] (formerly known as Churg - Strauss syndrome) as an [[eosinophilic]], [[Inflammation|granulomatous inflammatory disease]] affecting most commonly the [[Respiratory tract|conducting pulmonary airways]], and leading to a [[necrosis]] of the small and/or medium sized vessels. [[Eosinophilic granulomatosis with polyangiitis]] is often synonymous with adult-onset [[asthma]]. According to revised CHCC 2012, [[eosinophilic granulomatosis with polyangiitis]] is considered as a variant of the [[Anti-neutrophil cytoplasmic antibody|ANCA]] - associated vasculitis. | Revised International Chapel Hill Consensus Conference 2012 on nomenclature of vasculitides, defines [[eosinophilic granulomatosis with polyangiitis]] (formerly known as Churg - Strauss syndrome) as an [[eosinophilic]], [[Inflammation|granulomatous inflammatory disease]] affecting most commonly the [[Respiratory tract|conducting pulmonary airways]], and leading to a [[necrosis]] of the small and/or medium-sized vessels. [[Eosinophilic granulomatosis with polyangiitis]] is often synonymous with adult-onset [[asthma]]. According to revised CHCC 2012, [[eosinophilic granulomatosis with polyangiitis]] is considered as a variant of the [[Anti-neutrophil cytoplasmic antibody|ANCA]] - associated vasculitis. | ||
==Pathophysiology== | ==Pathophysiology== | ||
Eosinophilic granulomatosis with polyangiitis is a medium and small vessel vasculitis, leading to necrosis. The pathogenesis of | [[Eosinophilic granulomatosis with polyangiitis]] is a medium and small vessel vasculitis, leading to [[necrosis]]. The pathogenesis of [[eosinophilic granulomatosis with polyangiitis]] is not fully understood. [[Eosinophilic granulomatosis with polyangiitis]] occurs as a result of a complex interaction involving genetic and environmental factors that lead to an inflammatory response involving [[eosinophils]], [[lymphocytes]]. [[Autoimmunity]] has an evident role in the presence of ANCA, [[hypergammaglobulinemia]], elevated levels of immunoglobulin E, and [[RF|rheumatic factor]] in the pathogenesis. HLA-DRB4 is correlated with increased risk of development of vascular manifestations of the Churg-Strauss syndrome. On microscopic pathology, eosinophilic infiltration, necrotizing granulomatous [[vasculitis]] and [[necrosis]] of small and medium-sized arteries can be seen. | ||
==Causes== | ==Causes== | ||
The etiology of [[eosinophilic granulomatosis with polyangiitis]] is not known. Various [[Allergen|allergens]], [[Infection|infections]], [[Vaccination|vaccinations]] and [[:Category:Drugs|drugs]] may be responsible for developing disease through an [[Allergy|allergic]] or [[Autoimmunity|autoimmune response]]. Genetics may play a role includes, [[HLA]] -DRB4 and [[Interleukin 10|IL-10]] gene [[polymorphisms]] are associated with the development of [[eosinophilic granulomatosis with polyangiitis]]. | The etiology of [[eosinophilic granulomatosis with polyangiitis]] is not known. Various [[Allergen|allergens]], [[Infection|infections]], [[Vaccination|vaccinations]] and [[:Category:Drugs|drugs]] may be responsible for developing disease through an [[Allergy|allergic]] or [[Autoimmunity|autoimmune response]]. [[Genetics]] may play a role includes, [[HLA]] -DRB4 and [[Interleukin 10|IL-10]] gene [[polymorphisms]] are associated with the development of [[eosinophilic granulomatosis with polyangiitis]]. | ||
==Differentiating Churg-Strauss syndrome from Other Diseases== | ==Differentiating Churg-Strauss syndrome from Other Diseases== | ||
[[Eosinophilic granulomatosis with polyangiitis]] must be differentiated from other diseases that can cause [[eosinophilia]], [[purpura]], [[Hemorrhage|alveolar hemorrhage]], necrotizing extra-capillary [[glomerulonephritis]], such as [[granulomatosis with polyangiitis]] and [[microscopic polyangiitis]]. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The [[incidence]] of [[Eosinophilic granulomatosis with polyangiitis]] range from 2.5 to 16.6 per 100,000 individuals. [[Prevalence]] ranges from 2 to 16 per 100,000 individuals. Mean age at [[diagnosis]] of [[eosinophilic granulomatosis with polyangiitis]] | The [[incidence]] of [[Eosinophilic granulomatosis with polyangiitis]] range from 2.5 to 16.6 per 100,000 individuals. [[Prevalence]] ranges from 2 to 16 per 100,000 individuals. Mean age at [[diagnosis]] of [[eosinophilic granulomatosis with polyangiitis]] around 45-50 years. In general, [[eosinophilic granulomatosis with polyangiitis]] affects men and women equally. | ||
==Risk Factors== | ==Risk Factors== | ||
There are no established risk factors for [[eosinophilic granulomatosis with polyangiitis]]. However, certain environmental agents including various [[Allergen|allergens]], [[Infection|infections]], [[Desensitization (medicine)|desensitization]], [[vaccination]]<nowiki/>and [[genetics]] may act as triggering agents. Those triggers may be responsible for the [[Inflammation|inflammatory response]] with [[Eosinophil granulocyte|eosinophils]] and [[Lymphocyte|lymphocytes]]. | There are no established risk factors for [[eosinophilic granulomatosis with polyangiitis]]. However, certain environmental agents including various [[Allergen|allergens]], [[Infection|infections]], [[Desensitization (medicine)|desensitization]], [[vaccination]] <nowiki/>and [[genetics]] may act as triggering agents. Those triggers may be responsible for the [[Inflammation|inflammatory response]] with [[Eosinophil granulocyte|eosinophils]] and [[Lymphocyte|lymphocytes]]. | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
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===History and Symptoms=== | ===History and Symptoms=== | ||
Obtaining a complete history is an important aspect in making a diagnosis of [[eosinophilic granulomatosis with polyangiitis]]. As it can help differentiate between the [[Anti-neutrophil cytoplasmic antibody|ANCA]] associated [[vasculitis]] and other possible causes that may mimic the [[disease]]. [[Symptom|Symptoms]] of [[eosinophilic granulomatosis with polyangiitis]] typically develops through three phases, include prodromal phase, eosinophilic phase, and vasculitis phase. Clinical presentation depends on organ system involvement. Most common symptoms include [[asthma]], [[Rhinosinusitis|sinusitis]], [[Muscle weakness|weakness]], [[arthralgia]], [[purpura]], [[Cardiac arrhythmia|arrythmias]], [[hematuria]] | Obtaining a complete history is an important aspect in making a diagnosis of [[eosinophilic granulomatosis with polyangiitis]]. As it can help differentiate between the [[Anti-neutrophil cytoplasmic antibody|ANCA]] associated [[vasculitis]] and other possible causes that may mimic the [[disease]]. [[Symptom|Symptoms]] of [[eosinophilic granulomatosis with polyangiitis]] typically develops through three phases, include prodromal phase, eosinophilic phase, and vasculitis phase. Clinical presentation depends on organ system involvement. Most common symptoms include [[asthma]], [[Rhinosinusitis|sinusitis]], [[Muscle weakness|weakness]], [[arthralgia]], [[purpura]], [[Cardiac arrhythmia|arrythmias]], [[hematuria]] and [[peripheral neuropathy]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
A comprehensive physical examination including [[Lung|pulmonary]], ENT, [[Nervous system|neurologic]], [[skin]], [[Abdomen|abdominal]] and [[Kidney|renal]] systems must be performed to help identify and properly diagnose [[eosinophilic granulomatosis with polyangiitis]] form other diseases. On examination, patients may show clinical manifestations of [[asthma]] ([[dyspnea]], [[tachypnea]]), [[Petechia|petechiae]], palpable [[purpura]], skin nodules, [[rhinitis]], [[Nasal polyp|nasal polyposis]], [[chest pain]], [[abdominal pain]], and neurologic manifestations. On auscultation, [[Wheeze|wheezing]], [[rhonchi]], [[Pericardial friction rub|friction rub]], abnormal heart sounds may be found. | A comprehensive physical examination including [[Lung|pulmonary]], ENT, [[Nervous system|neurologic]], [[skin]], [[Abdomen|abdominal]] and [[Kidney|renal]] systems must be performed to help identify and properly diagnose [[eosinophilic granulomatosis with polyangiitis]] form other diseases. On examination, patients may show clinical manifestations of [[asthma]] ([[dyspnea]], [[tachypnea]]), [[Petechia|petechiae]], palpable [[purpura]], skin nodules, [[rhinitis]], [[Nasal polyp|nasal polyposis]], [[chest pain]], [[abdominal pain]], and [[Neurology|neurologic]] manifestations. On auscultation, [[Wheeze|wheezing]], [[rhonchi]], [[Pericardial friction rub|friction rub]], abnormal [[heart sounds]] may be found. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
The laboratory findings in [[eosinophilic granulomatosis with polyangiitis]] include [[complete blood count]] with differntial to evaluate abnormal [[eosinophilia]], serologic and immunologic tests to identify [[Anti-neutrophil cytoplasmic antibody|antineutrophil cytoplasmic antibodies]], acute phase reactants, and urinalysis to evaluate [[proteinuria]] and [[microscopic hematuria]]. Gold standard for [[diagnosis]] is [[biopsy]] of [[lung]]. | The laboratory findings in [[eosinophilic granulomatosis with polyangiitis]] include [[complete blood count]] with differntial to evaluate abnormal [[eosinophilia]], serologic and immunologic tests to identify [[Anti-neutrophil cytoplasmic antibody|antineutrophil cytoplasmic antibodies]], [[Acute phase reactant|acute phase reactants]], and [[urinalysis]] to evaluate [[proteinuria]] and [[microscopic hematuria]]. Gold standard for [[diagnosis]] is [[biopsy]] of [[lung]]. | ||
===Chest X Ray=== | ===Chest X Ray=== | ||
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===CT Scan=== | ===CT Scan=== | ||
On [[Computed tomography|high-resolution computerized tomography]] ([[High Resolution CT|HRCT]]) scan, [[eosinophilic granulomatosis with polyangiitis]] will show airspace consolidation, ground-glass opacities, centrilobular nodules, bronchial wall thickening and/or dilatation, [[Pleural effusion|pleural effusions]], and hilar or mediastinal [[Lymphadenopathy|lymph node enlargement]]. | On [[Computed tomography|high-resolution computerized tomography]] ([[High Resolution CT|HRCT]]) scan, [[eosinophilic granulomatosis with polyangiitis]] will show airspace [[Consolidation (medicine)|consolidation]], ground-glass opacities, centrilobular nodules, bronchial wall thickening and/or dilatation, [[Pleural effusion|pleural effusions]], and hilar or mediastinal [[Lymphadenopathy|lymph node enlargement]]. | ||
===Ultrasound=== | ===Ultrasound=== | ||
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===Medical Therapy=== | ===Medical Therapy=== | ||
The mainstay of management for [[eosinophilic granulomatosis with polyangiitis]] is [[glucocorticoids]] and [[cyclophosphamide]]. [[Immunosuppressive agents]] (eg, [[azathioprine]] and [[methotrexate]]) can be used for maintenance therapy. [[Rituximab]], [[interferon-alpha]], anti IgE antibodies and [[Plasmapheresis|plasma exchange]] can be used as second-line therapy in the management of [[Eosinophilic granulomatosis with polyangiitis|eosinophilic granulomatosis with polyangiitis.]] | |||
===Surgery=== | ===Surgery=== | ||
Surgical intervention is not usually recommended for the management of [[eosinophilic granulomatosis with polyangiitis]]. However, [[myringotomy]], [[polypectomy]], and endoscopic sinus surgery may be performed in some patients to treat upper airway disease. | |||
===Prevention=== | ===Prevention=== | ||
There are no established measures for the primary and secondary prevention of [[eosinophilic granulomatosis with polyangiitis]]. | |||
==References== | ==References== | ||
Latest revision as of 17:38, 12 April 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]
Overview
Eosinophilic granulomatosis with polyangiitis previously called Churg-Strauss syndrome is a small and medium-sized necrotizing vasculitis, with extravascular granuloma formation. The disease was first described by Churg and Strauss in 1951. The etiology is not known. However, various environmental factors, allergens, genetics, and drugs may play a role in triggering disease process by activating eosinophils, B and T lymphocytes and macrophages. The disease is characterized by the presence of asthma, peripheral eosinophilia, rhinosinusitis, peripheral neuropathy and multiple organ involvements including skin, GI tract, and kidney.
Historical Perspective
Two pathologists Churg and Strauss first described the disease in 1951. They named it as allergic granulomatosis with angiitis. Over the years, they called the disease by the name of Churg-Strauss syndrome. In 2010, American College of Rheumatology changed this name to eosinophilic granulomatosis with polyangiitis based on histopathology.
Classification
Revised International Chapel Hill Consensus Conference 2012 on nomenclature of vasculitides, defines eosinophilic granulomatosis with polyangiitis (formerly known as Churg - Strauss syndrome) as an eosinophilic, granulomatous inflammatory disease affecting most commonly the conducting pulmonary airways, and leading to a necrosis of the small and/or medium-sized vessels. Eosinophilic granulomatosis with polyangiitis is often synonymous with adult-onset asthma. According to revised CHCC 2012, eosinophilic granulomatosis with polyangiitis is considered as a variant of the ANCA - associated vasculitis.
Pathophysiology
Eosinophilic granulomatosis with polyangiitis is a medium and small vessel vasculitis, leading to necrosis. The pathogenesis of eosinophilic granulomatosis with polyangiitis is not fully understood. Eosinophilic granulomatosis with polyangiitis occurs as a result of a complex interaction involving genetic and environmental factors that lead to an inflammatory response involving eosinophils, lymphocytes. Autoimmunity has an evident role in the presence of ANCA, hypergammaglobulinemia, elevated levels of immunoglobulin E, and rheumatic factor in the pathogenesis. HLA-DRB4 is correlated with increased risk of development of vascular manifestations of the Churg-Strauss syndrome. On microscopic pathology, eosinophilic infiltration, necrotizing granulomatous vasculitis and necrosis of small and medium-sized arteries can be seen.
Causes
The etiology of eosinophilic granulomatosis with polyangiitis is not known. Various allergens, infections, vaccinations and drugs may be responsible for developing disease through an allergic or autoimmune response. Genetics may play a role includes, HLA -DRB4 and IL-10 gene polymorphisms are associated with the development of eosinophilic granulomatosis with polyangiitis.
Differentiating Churg-Strauss syndrome from Other Diseases
Eosinophilic granulomatosis with polyangiitis must be differentiated from other diseases that can cause eosinophilia, purpura, alveolar hemorrhage, necrotizing extra-capillary glomerulonephritis, such as granulomatosis with polyangiitis and microscopic polyangiitis.
Epidemiology and Demographics
The incidence of Eosinophilic granulomatosis with polyangiitis range from 2.5 to 16.6 per 100,000 individuals. Prevalence ranges from 2 to 16 per 100,000 individuals. Mean age at diagnosis of eosinophilic granulomatosis with polyangiitis around 45-50 years. In general, eosinophilic granulomatosis with polyangiitis affects men and women equally.
Risk Factors
There are no established risk factors for eosinophilic granulomatosis with polyangiitis. However, certain environmental agents including various allergens, infections, desensitization, vaccination and genetics may act as triggering agents. Those triggers may be responsible for the inflammatory response with eosinophils and lymphocytes.
Natural History, Complications and Prognosis
Eosinophilic granulomatosis with polyangiitis develops through three phases, include prodromal phase, eosinophilic phase, vasculitic phase. Most complications result from the vasculitic phase. Most common complications include cardiomyopathy, myocardial infarction, perimyocarditis, rapidly progressive renal failure, GI bleeding, neuropathy and status asthmaticus. Prognosis of eosinophilic granulomatosis with polyangiitis is poor if left untreated. Prognosis is most likely dependent on stage at which the disease was diagnosed and organ involvement. The five-factor score assessment (FFS) is a good predictor of survival rate. It can be used to choose the appropriate treatment.
Diagnosis
History and Symptoms
Obtaining a complete history is an important aspect in making a diagnosis of eosinophilic granulomatosis with polyangiitis. As it can help differentiate between the ANCA associated vasculitis and other possible causes that may mimic the disease. Symptoms of eosinophilic granulomatosis with polyangiitis typically develops through three phases, include prodromal phase, eosinophilic phase, and vasculitis phase. Clinical presentation depends on organ system involvement. Most common symptoms include asthma, sinusitis, weakness, arthralgia, purpura, arrythmias, hematuria and peripheral neuropathy.
Physical Examination
A comprehensive physical examination including pulmonary, ENT, neurologic, skin, abdominal and renal systems must be performed to help identify and properly diagnose eosinophilic granulomatosis with polyangiitis form other diseases. On examination, patients may show clinical manifestations of asthma (dyspnea, tachypnea), petechiae, palpable purpura, skin nodules, rhinitis, nasal polyposis, chest pain, abdominal pain, and neurologic manifestations. On auscultation, wheezing, rhonchi, friction rub, abnormal heart sounds may be found.
Laboratory Findings
The laboratory findings in eosinophilic granulomatosis with polyangiitis include complete blood count with differntial to evaluate abnormal eosinophilia, serologic and immunologic tests to identify antineutrophil cytoplasmic antibodies, acute phase reactants, and urinalysis to evaluate proteinuria and microscopic hematuria. Gold standard for diagnosis is biopsy of lung.
Chest X Ray
On chest x-ray, eosinophilic granulomatosis with polyangiitis is characterized by bilateral multifocal nonsegmental consolidation, bronchial wall thickening, reticulonodular opacities, bilateral hilar adenopathy, and pleural effusion.
CT Scan
On high-resolution computerized tomography (HRCT) scan, eosinophilic granulomatosis with polyangiitis will show airspace consolidation, ground-glass opacities, centrilobular nodules, bronchial wall thickening and/or dilatation, pleural effusions, and hilar or mediastinal lymph node enlargement.
Ultrasound
There are no significant ultrasound findings associated with eosinophilic granulomatosis with polyangiitis.
Other Imaging Findings
Electrocardiogram and echocardiogram, GI endoscopy, electromyelography can be used to diagnose eosinophilic granulomatosis with polyangiitis.
Treatment
Medical Therapy
The mainstay of management for eosinophilic granulomatosis with polyangiitis is glucocorticoids and cyclophosphamide. Immunosuppressive agents (eg, azathioprine and methotrexate) can be used for maintenance therapy. Rituximab, interferon-alpha, anti IgE antibodies and plasma exchange can be used as second-line therapy in the management of eosinophilic granulomatosis with polyangiitis.
Surgery
Surgical intervention is not usually recommended for the management of eosinophilic granulomatosis with polyangiitis. However, myringotomy, polypectomy, and endoscopic sinus surgery may be performed in some patients to treat upper airway disease.
Prevention
There are no established measures for the primary and secondary prevention of eosinophilic granulomatosis with polyangiitis.