Vasculitis
Vasculitis
What is vasculitis?
The term vasculitis, also known as arteritis or angiitis, refers to a group of about two dozen rare diseases that share one common characteristic- inflammation of blood vessels. When blood vessel walls become inflamed, they can become thickened or weakened and compromise blood flow and oxygen to tissues and organs, causing damage.
Any size blood vessel can become inflamed, from the largest artery in the body, the aorta, to the tiny arteries or veins in the skin or kidneys. As such, different types of vasculitis impact virtually every part of the body; some result in relatively mild symptoms, while others are severe and even life threatening. Vasculitis can affect both men and women of all ages. Some forms are seen only in children, while others effect predominantly older adults.
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Vasculitis Program
U-M Health's Vasculitis Program includes a team of experts experienced in diagnosing and treating even the most uncommon forms of vasculitis.
What are the types of vasculitis?
Doctors categorize the different types of vasculitis based on the size of blood vessels they impact – large, medium, and small.
Giant cell arteritis (GCA): One of the more common forms of large vessel vasculitis occurring in adults older than age 50. It can present with headaches and/or jaw pain, sometimes with flu-like symptoms, fatigue and fever. GCA can impact blood flow to the eye, resulting in visual disturbance or loss. GCA can co-occur with polymyalgia rheumatica (PMR) which causes stiffness and pain in the shoulders and hips. Aortitis, or inflammation of the aorta and its large branches, is common in GCA.
Takayasu’s arteritis (TAK): An inflammation of the walls of the aorta and its main branches, TAK occurs predominantly in younger women. Reduced blood flow to arms, legs and major organs may cause symptoms of arm or leg pain, elevated blood pressure, discoloration in hands or feet, fatigue, headache, vision problems, chest pain, heart attack or stroke. TAK symptoms may develop slowly over time, making it difficult to diagnose.
Aortitis: Inflammation of the aorta which can have no identifiable underlying cause (“isolated aortitis”) or can occur secondary to another autoimmune disease (such as Cogan’s syndrome, Behcet’s syndrome or spondyloarthropathy). Aortitis can cause fever, weight loss, or pain in the chest, limbs, or abdomen, or can be asymptomatic. If untreated, it can lead to thinning and an outpouching of the aortic wall called an aneurysm.
Kawasaki disease (KD): Inflammation to the blood vessels that supply the heart occurring in childhood, usually under the age of 5. KD can cause fever, rash, red eyes, cracked lips and tongue, and swollen lymph nodes. Symptoms of KD might resolve on their own, but if not diagnosed and treated, KD can damage the heart. Pediatric rheumatologists diagnose and treat KD.
Polyarteritis nodosa (PAN): Inflammation to the blood vessels in the skin, nervous system, kidneys, gastrointestinal tract, heart, and other organs, more commonly in middle aged men. Because it can involve multiple systems in the body, it can present with a wide range of symptoms including fatigue, numbness, high blood pressure, abdominal pain, leg pain and skin sores.
Granulomatosis with polyangiitis (GPA): Formally known as Wegener’s Granulomatosis, is an inflammation to the blood small vessels of the lungs, kidneys, upper airway, skin, nerves and sinuses. Symptoms can also be caused by small areas of inflammation called granulomas in the sinuses, lungs, ear canals and orbits of the eyes. Depending on which system is involved it can present with chronic nasal congestion, shortness of breath, cough and nosebleeds, joint pain, eye pain and redness, trouble hearing, skin rashes, fatigue, fever, weight loss, weakness and numbness.
Microscopic polyangiitis (MPA): Inflammation of small blood vessels in most commonly in the kidneys, lungs and nerves but also can involve the skin and joints. The most common symptoms are blood in the urine and high blood pressure from kidney inflammation, and shortness of breath and coughing up blood from lung inflammation. Weight loss, fever, skin lesions and nerve damage can also occur.
Eosinophilic granulomatosis with polyangiitis (EGPA), formally known as Churg-Strauss syndrome: Nearly all EGPA patients have asthma and/or sinus polyps, but additional symptoms depend on which body parts are involved and can include the lungs, sinuses, nerves, heart, skin, and kidneys.Patients with EGPA have elevated levels of eosinophils, a kind of white blood cell, which drive the inflammation.
GPA, MPA and EGPA arise from inflammation caused by antineutrophil cytoplasmic antibodies (ANCA). ANCAs are antibodies that damage blood vessels by attacking white blood cells called neutrophils.
Primary angiitis of the central nervous system (PACNS): This form of vasculitis is limited to the blood vessels in the brain and usually occurs in adults after age 50, and is twice as likely to occur in men. The most common symptoms are headache, brain dysfunction (encephalopathy) and/or recurrent strokes.
IgA vasculitis (Henoch-Schonlein Purpura - HSP): Usually diagnosed in children as a self-limited illness, however can also impact adults in a more serious form of the disease, The most common symptom of HSP is purpura, a red or dark purple rash usually seen on the legs and buttocks. HSP may also cause joint swelling, abdominal pain, and kidney inflammation. While children usually make a full recovery, some cases of HSP (particularly in adults) can result in kidney disease, making early detection and treatment important.
Systemic lupus erythematosus (SLE or lupus) or Sjögren’s syndrome (small Vessel Vasculitis related to rheumatoid arthritis): Inflammation of small arteries can occur in conjunction with one of these three autoimmune conditions.
- Cryoglobulinemic vasculitis: Can be associated with the hepatitis C virus (HCV), Sjogren’s, lupus, blood cancer, or idiopathic (no cause identified). Symptoms include purplish patches of skin (purpura), nerve damage, weakness, joint pain, and kidney problems.
- Anti-GBM disease / Goodpasture’s syndrome): Can cause inflammation of the the kidneys and/or lungs.The inflammation causes the organs to bleed, which can eventually lead to organ failure, making early diagnosis and treatment very important. Symptoms of advanced disease include bloody cough, bloody urine, chest pain and leg swelling.
- Drug-induced vasculitis: Vasculitis has been associated with use of a variety of medications, including (and not limited to) various antibiotics, hydralazine, minocycline, levamisole (a contaminant found in cocaine), and anti-thyroid drugs, to name a few. Symptoms frequently include rash but can include serious organ damage including the kidneys.
Behcet’s disease/ Behcet’s syndrome: This chronic form of vasculitis, which is seen most commonly in people of Middle Eastern or East Asian descent, can cause sores in the mouth, skin and genitals, joint and muscle pain, headache, eye inflammation, and blood clots.
Relapsing polychondritis (RP): Results from inflammation of cartilage, typically causing pain and swelling to the ear, nose, upper airway and joints. Symptoms usually begin between ages 20 and 60, but children may be diagnosed with RP as well.
What are the symptoms of vasculitis?
There are many types of vasculitis, each capable of restricting the flow of blood to virtually any tissue, organ or structure of the body. This leads to an extensive list of potential symptoms, depending on where the inflammation is occurring or the blood flow is being compromised.
Symptoms may be mild or severe and may occur only once or return regularly. In some instances, there are no symptoms until the disease is very advanced.
- Heart: Fatigue, dizziness, lightheadedness, impaired breathing, chest pain
- Lungs: Chest pain, impaired breathing, asthma, coughing up blood
- Central Nervous System: Headache, impaired vision, nerve damage, strokes
- Arms/Legs/Hands/Feet: Pain, stiffness, discoloration, numbness, weakness
- Kidneys: Elevated blood pressure, weight loss, nausea, bloody urine
- Digestive tract: Abdominal pain, bloody stools, weight loss
- Skin: Sores or lesions, rash, discoloration (including purpura)
- Eyes: Eye pain, blurred vision, vision loss, red eyes
- Ears: Hearing trouble, hearing loss, ear pressure
- Nose: Sinus problems, congestion, nosebleeds
How is vasculitis diagnosed?
Vasculitis is challenging to diagnose because it comes in so many forms, with such a wide variety of symptoms, and because in its early stages, some patients may be virtually symptom free. Early diagnosis and treatment is the best way to avoid severe disease and permanent damage to organs and tissues.
One or more of the following are used to diagnose vasculitis:
- Physical examination and health history: Based on symptoms, doctors may suspect vasculitis and pursue additional tests to confirm the diagnosis.
- Blood / laboratory tests: Blood that tests positive for the antibody ANCA may be an indication of one of three ANCA-associated forms of vasculitis, also can be helpful to rule out other diseases that can mimic vasculitis.
- Biopsy: Removal of a sample of tissue from the affected area for analysis.
- Imaging: Can include ultrasound to look at blood flow and/or angiography (CT or MR) a form of imaging used to examine blood vessels.
How is vasculitis treated?
The key to lessening the symptoms of the many types of vasculitis is to reduce inflammation. Anti-inflammatory medications, notably glucocorticoids such as prednisone or methylprednisolone, are the most common first-line treatments. Glucocorticoids are effective, but patients who take them over a long time period may experience side effects and toxicities.
Medications that suppress the body’s immune system, such as rituximab or cyclophosphamide, may also be used to reduce dosages of glucocorticoids and reduce the long-term risks associated with them. There are various types of medications that suppress the immune system and selection of the appropriate agent depends on the type of vasculitis, the severity of the disease, and the organ systems involved.
In general, the approach is to use a strong drug (for 3 to 6 months) to put the vasculitis in remission (where there is no sign of active disease) and then a more mild drug (over 12 to 36 months or longer) to maintain that remission and protect from flare ups of disease.
Immunosuppressants used to treat vasculitis include:
- Cyclophosphamide
- Rituximab
- Methotrexate
- Azathioprine
- Mycophenolate mofetil
- Leflunomide
- Tocilizumab
- TNF inhibitors (infliximab, adalimumab, certilizomab or golimumab)
In some severe cases, a patient’s plasma, which contains harmful antibodies, may be exchanged for healthy plasma through a procedure similar to dialysis.
When advanced forms of vasculitis cause significant damage to blood vessels, vascular bypass surgery may be performed to redirect the flow of blood around the damaged vessel. Surgery may also be required to repair or replace (via transplant) damaged or failed organs resulting from vasculitis.
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