Vasculitides

Nephritic syndrome is a broad category of glomerular diseases characterized by glomerular hematuria, variable loss of renal function, and hypertension. These features are in contrast to those of nephrotic syndrome, which includes glomerular diseases characterized by severe proteinuria, although there is sometimes overlap of > 1 glomerular disease in the same individual. The clinical presentations of nephritic syndrome are highly varied, from asymptomatic with urinary abnormalities to life-threatening critical illness. Diagnosis is suggested by hematuria, mild-to-moderate proteinuria, and certain serologies (e.g., ANCA); kidney biopsy is necessary in most cases. Management varies as widely as the clinical presentations, from watchful waiting in mild cases to immunosuppression and plasmapheresis in aggressive disease.

Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease of unknown etiology. It leads to a necrotizing granulomatous inflammation of small and medium-sized blood vessels of the nose, sinuses, throat, lungs, and kidneys. Early stages of GPA often present with localized manifestations such as infections of the upper respiratory tract, skin lesions, and/or constitutional symptoms. Later stages can present with renal failure and severe respiratory disease. Early diagnosis and treatment of granulomatosis with polyangiitis (which involves the administration of corticosteroids and immunosuppressive agents such as methotrexate) may lead to a full remission but without treatment, the condition has a high mortality rate.

Vasculitides are a group of conditions characterized by vasculitis, ischemia, and damage to the organs supplied by the affected vessels. The affected arteries are of different sizes and locations and vary by the type of vasculitis. Vasculitides can be a primary condition or secondary to another underlying disease. There is no clearly known pathophysiology. The diagnosis should be considered in any individual with palpable purpura, pulmonary infiltrates, ischemic events, and multisystem disease. Prompt recognition and therapy of the vasculitides are imperative, as they are often serious and sometimes fatal diseases. Management includes immunosuppressive, antiviral, and/or antiinflammatory agents.

Antinuclear cytoplasmic antibody (ANCA)-associated vasculitis (AAV) includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). All 3 diseases cause life-threatening small-vessel vasculitis with a wide range of systemic manifestations, which can involve the lungs, kidneys, skin, and heart. Diagnosis is suspected by clinical presentation and a positive cytoplasmic (c)- or perinuclear (p)-ANCA test. Biopsy of involved tissue confirms the diagnosis. Glucocorticoids and immunosuppressive therapy are the mainstays of treatment.

Giant cell arteritis (GCA), also known as temporal arteritis, is a type of large-vessel vasculitis that predominantly affects the aorta and its major branches, with a predilection for the branches of the carotid (including the temporal artery). Giant cell arteritis is defined by inflammatory leukocytes in the vessel walls leading to reactive damage, ischemia, and necrosis. Giant cell arteritis causes headaches, scalp tenderness, jaw pain, vision problems, and potentially blindness. The diagnosis is made with temporal artery biopsy. Prompt treatment with glucocorticoids can relieve symptoms and prevent vision loss.

Henoch-Schönlein purpura (HSP), also known as immunoglobulin A vasculitis, is an autoimmune small-vessel vasculitis that typically presents as a tetrad of abdominal pain, arthralgia, hematuria, and purpuric rash. The pathophysiology involves the deposition of IgA immune complexes in multiple vessels following a trigger (infection/environmental), and the symptoms depend on the tissues that are involved. The diagnosis is established clinically, but can be supported with laboratory studies and skin or kidney biopsy. Management is mostly supportive, but may involve steroids and immunosuppressants in more severe cases. Prognosis is usually excellent, but some patients may develop end-stage renal failure.

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome or infantile polyarteritis, is a medium-sized necrotizing febrile vasculitis that affects children < 5 years of age. Multiple systems are involved but the most serious is the predilection of the coronary arteries. Management involves intravenous immunoglobulin and high-dose aspirin. Follow-up requires serial echocardiograms to monitor for coronary artery aneurysm.