Behçet’s disease (BD) is a chronic, multi systemic, recurrent vasculitis disease of unknown aetiology. The clinical manifestations are composed of relapsing episodes of recurrent oral ulcers, uveitis, skin lesions and genital ulcers along with musculoskeletal and neurological involvement. Pro-inflammatory cytokines are a key feature of the disease but the triggers for their induction are not well understood and/or controversial. Many cytokines (including IFNγ, IL-12, IL-23, IL-10 and IL-6) activate the JAK-STAT signalling pathway which is negatively regulated by Suppressor of Cytokine Signalling (SOCS) proteins. Therefore, it was hypothesised that SOCS proteins may be dysregulated in BD. The expression of SOCS 1-3 mRNA and protein was studied in peripheral blood mononuclear cells (PBMCs), Neutrophils and buccal mucosal cells (BMC) of BD patients and compared with healthy controls (HC) and recurrent aphthous stomatitis (RAS) patients. SOCS 1 and 3 were significantly upregulated in PBMCs of BD patients compared with HC (p=0.0149; p=0.0007) and there were subtle differences between expression in relapsed and symptom free BD (quiet BD). SOCS1 and SOCS 3 also significantly upregulated in BMC from oral ulcers of BD compared with HC (both at p=0.0001). Cytokines were examined in serum, saliva and culture supernatants from stimulated PBMCs. IL-6 were significantly upregulated in the saliva of relapsed BD patients compared with HC (p=0.0104) and the capacity for IL-10 secretion from BD was compromised. Phosphorylation of STATs, transcription factors RORγt, T-bet and 48 protein kinases were investigated using a novel PhosphFlow method and by microarray analysis. STATs were upregulated in BD and seven novel kinase proteins showed differential phosphorylation in BD. Conclusion: SOCS 1-3 expression has changed in BD patients with differences in PBMC and Neutrophil expression between the SOCS proteins. Phosphorylation of STATs and several kinases show up-regulation in BD and seven kinases with altered phosphorylation states in BD were identified as novel targets for future investigation.

No description available.

Infective endocarditis due to Bartonella bacilliformis is rare. A 64-year-old woman, without previous heart disease, presented with 6 weeks of fever, myalgias, and arthralgias. A systolic murmur was heard on the tricuspid area upon examination, and an echocardiogram showed endocardial lesions in the right atrium. Bartonella bacilliformis was isolated in blood cultures, defining the diagnosis of infective endocarditis using Duke’s criteria. Subsequently, the patient developed clinical and laboratory features compatible with antineutrophil cytoplasmic antibody-associated vasculitis. This case presents an uncommon complication of B. bacilliformis infection associated with the development of systemic vasculitis.

No description available.

Introduction: The two subtypes of Antineutrophil Cytoplasmic autoantibody associated systemic vasculitis (AASV) cANCA and pANCA associated vasculitis are the commonest causes of rapidly progressive glomerulonephritis. In spite of recent advances in the pathogenesis and development of new therapeutic agents, long term outcomes are still poor with five year mortality of 25%. There are epidemiological, histological, clinical and outcome related differences between these two conditions. This strongly suggests that there must be differences between genetic factors and pathogenesis of these two conditions. There was also a perception amongst the clinicians that AASV is more common in the Greater Manchester area. Hence in this study I calculated the incidence of pauciimmune glomerulonephritis in Greater Manchester and analysed the genetic differences between cANCA and pANCA associated vasculitis. Methods: Five year incidence of pauciimmune glomerulonephritis was calculated in Greater Manchester between 1/1/1999 to 31/12/2003. I recruited 147 patients with ANCA associated vasculitis. Clinical data was collected. I studied single nucleotide polymorphisms (SNPs) of tumour necrosis factor alpha(TNFα), interleukin 8 (IL-8), transforming growth factor beta (TGFβ), platelet endothelial cell adhesion molecule 1 (PECAM-1), Chemokine (CC motif) ligand-5 C chemokine (CCL-5), interleukin 10 (IL-10) and interleukin 18 (IL-18) genes and compared the frequencies of genotypes and alleles in patients with cANCA and pANCA associated small vessel vasculitis and healthy volunteers. I also studied circulating cytokine profiles of IL-10 and IL-18. Results of IL-18 SNPs were validated in AASV cohort from South-East USA. Further I studied the gene expression patterns of active and remission state of AASV and metabolomics profile of cANCA and pANCA positive patients during active and remission state of vasculitis. Clinical outcomes (relapses and renal survival) were correlated with the genotypes. Results: I found a significantly higher incidence (9.8/million population) of pauciimmune glomerulonephritis in Greater Manchester compared to the previously published data from UK and USA (2.73 to 4.6/million). Renal function at the time of diagnosis predicted the long term renal survival. I also found a novel genetic association of increased frequency of high producer IL-18 SNPs 113T, 127C and 137G in pANCA positive patients compared to normal volunteers (p=0.04) and cANCA positive patients (trend- p=0.08). This was associated with increased levels of circulating IL-18 levels in these patients. This association was further confirmed in an independent cohort of AASV from USA. I also found a lower frequency of low producer GG genotype of IL-10 -1082 SNP (p=0.05) and this was associated with lower levels of circulating IL-10 in these patients compared to pANCA positive patients. I found significant difference in the metabolomics profiles of cANCA andpANCA positive patients. In paired plasma samples, levels of some metabolites were high during remission state compared to active vasculitis. Conclusions: These findings strongly support the hypothesis that there is an increased incidence of pauciimmune glomerulonephritis in Greater Manchester. There are genetic differences in cANCA and pANCA positive patients which may explain the different observed outcomes. Genome wide association study would strengthen these findings and should guide the vasculitis community to reclassify, assess and perhaps treat these two conditions separately.

Urticarial vasculitis is a relatively rare diagnosis in a patient presenting with urticaria. The process is classically described as a generalized eruption, painful more so than pruritic, lasting longer than 24 hours. Two forms of urticarial vasculitis have been described: ahypocomplementemic form more commonly associated with systemic disease, and a normocomplementemic form that is generally limited to the skin. We report on a uniquely distributed vasculitic eruption restricted mainly to the anterior belt line area in a patient presenting with urticaria and intense pruritus. Urticarial vasculitis as a unique entity is reviewed along with its clinical and histopathologic presentation and the pharmacologic agents used for treatment.

Background: IgA vasculitis/Henoch-Schoenlein purpura (IgAV/HSP) is a systemic small vessel vasculitis of unknown pathogenesis predominantly affecting children. While skin, GI tract, joints, and kidneys are frequently affected and considered, central nervous system (CNS) involvement of this disease is underestimated. Methods: We provide a case report and systematically review the literature on IgAV, collecting data on the spectrum of neurological manifestations. Results: We report on a 7-year-old girl with IgAV who presented with diplopia and afebrile focal seizures, which preceded the onset of purpura. Cranial magnetic resonance imaging was consistent with posterior reversible encephalopathy syndrome (PRES), showing typical focal bilateral parietal swelling and cortical and subcortical high signal intensities on T2-fluid attenuated inversion recovery (FLAIR) images predominantly without diffusion restriction. Cerebrospinal fluid analysis and blood tests excluded systemic inflammation or vasculitis. Interestingly, hypertension was not a hallmark of the developing disease in the initial phase of PRES manifestation. Renal disease and other secondary causes for PRES were also excluded. Supportive- and steroid treatment resulted in restitution ad integrum. Reviewing the literature, we identified 28 other cases of IgAV with CNS involvement. Severe CNS involvement includes seizures, cerebral edema, or hemorrhage, as well as PRES. Thirteen patients fulfilled all diagnostic criteria of PRES. The mean age was 11.2 years (median 8.0, range 5-42 years), with no reported bias toward gender or ethnic background. Treatment regimens varied from watchful waiting to oral and intravenously steroids up to plasmapheresis. Three cases showed permanent CNS impairment. Conclusion: Collectively, our data demonstrate that (I) severe CNS involvement such as PRES is an underappreciated feature of IgAV, (II) CNS symptoms may precede other features of IgAV, (III) PRES can occur in IgAV, and differentiation from CNS vasculitis is challenging, (IV) pathogenesis of PRES in the context of IgAV remains elusive, which hampers treatment decisions. We, therefore, conclude that clinical awareness and the collection of structured data are necessary to elucidate the pathophysiological connection of IgAV and PRES.

Kawasaki disease (KD) is a multisystem vasculitis that results in localized coronary artery elastin breakdown and aneurysm formation. It is the leading cause of acquired heart disease of children in North America. Despite conventional treatment, a significant proportion of patients continue to develop coronary sequelae. The mechanisms of arterial aneurysm formation in KD are not known. Using a murine model of KD, Lactobacillus casei cell wall extract-induced coronary arteritis, the processes leading to coronary aneurysm formation were examined. Vessel damage occurred as a result of the increased enzymatic activity of the elastase, matrix metalloproteinase (MMP)-9. MMP-9 protein and activity levels were elevated in the heart post-disease induction. Expression and activity were specific for and localized to inflamed coronary arteries. The pro-inflammatory cytokine, tumour necrosis factor (TNF)-α, was required for increasing local MMP-9 expression. Importantly, MMP-9-deficient animals had a significantly reduced incidence of elastin breakdown. Furthermore, in a cohort of KD patients, serum MMP-9 did not correlate with coronary outcome, highlighting the importance of local expression of this elastase. Intravenous immunoglobulin (IVIG) and aspirin/salicylate are therapeutic agents in current use for the treatment of KD, though their exact mechanisms of action in KD are not known. The biologic effects of IVIG and salicylate on critical stages of disease development were examined. IVIG and salicylate had differential effects on TNF-α expression, with therapeutic concentrations of IVIG inhibiting, and salicylate inducing, TNF-α expression leading to an indirect modulation of MMP-9 expression. Interestingly, TNF-α expression and MMP-9 activity were both directly inhibited by the metal-chelating drug doxycycline. Treatment of affected mice with doxycycline significantly improved coronary outcome. Inhibiting both the inflammatory response as well as the downstream effects of inflammation were of therapeutic value in this model of KD. These results taken together demonstrate the importance of MMP-9 in the pathogenesis of coronary artery aneurysms in KD. Targeting MMP activity holds the promise of transforming KD from the leading cause of acquired heart disease to a self-limited febrile illness.

INTRODUÇÃO: O significado clínico das vasculites, lesões isquêmicas, efeito Quilty e da presença de eosinófilos em biópsias endomiocardicas de receptores de transplante cardíaco com rejeições leves não foi ainda estabelecido. OBJETIVOS: Verificar se estes achados histológicos encontrados nas biópsias endomiocardicas (eosinófilos, vasculites, efeito Quilty e lesões isquêmicas) são capazes de predizer rejeição aguda do enxerto acompanhada ou não de grave comprometimento hemodinâmico e morte por rejeição aguda. MÉTODOS: Foram reavaliadas 939 biópsias endomiocardicas consecutivas classificadas como OR ou 1R pela de 2005 da Nomenclatura da Sociedade Internacional de Transplante de Coração e Pulmão e dividimos estas em dois grupos (1) Biópsias preditoras: aquelas que precederam rejeição aguda, rejeição aguda associada à grave comprometimento hemodinâmico ou morte e (2) Biópsias não preditoras aquelas que não precederam eventos clínicos. Comparamos a ocorrência dos seguintes achados histológicos: vasculites, lesões isquêmicas, efeito Quilty e eosinófilos por análise uni e multivariada entre os grupos. RESULTADOS: Após análise estatística verificou-se que a presença de vasculite intensa e de eosinófilos como maiores preditores tanto para rejeição aguda futura, apresentando respectivamente as seguintes razões de chance: 10,60 (IC95%: 3,62 31,06. p<0,001) e 6,26 (IC95%:3,16 12,43. p< 0,001) , quanto para rejeição aguda associada á grave comprometimento hemodinâmico, que para este desfecho clínico apresentaram respectivamente as seguintes razões de chance 7,52 (IC95%: 1,45-38,93. p=0,016) e 6,61 (IC95%: 2,38 18,31. p< 0,001), e também para morte em decorrência a rejeição aguda com as respectivas razões de chance: 11,20 (IC95%: 3,53 36,17. p < 0, 001) e 14,50 (IC95%: 2,19 36,17. p = 0,006). CONCLUSÕES: Vasculites intensas e eosinófilos em biópsias do miocárdio são os principais fatores preditores de rejeição aguda, rejeição aguda associada à grave comprometimento hemodinâmico e morte pós - transplante cardíaco / INTRODUCTION: The clinical meaning of vasculitis, ischemic lesions, Quilty effect and the presence of eosinophils in endomyocardial biopsies of transplant recipients with mild rejections have not been established yet. OBJECTIVES: Verify if these histological findings (eosinophils, vasculitis, Quilty effect and ischemic lesions), whose clinical meaning remains unknown so far, are able to predict acute rejection of the transplanted organ, accompanied or not by severe hemodynamic compromise and death due to acute rejection. METHODS: We reevaluated 939 consecutive endomyocardial biopsies classified as 0R or 1R, according to the nomenclature that the International Society for Heart and Lung Transplantation established in 2005. We divided these biopsies in 2 groups, as they follow: (1) Predictor biopsies, which are preceded by acute rejection, acute rejection associated to severe hemodynamic compromise or death and (2) Non-predictor biopsies that did not precede any clinical events. We compared the occurrence of the histological findings studied (eosinophils, vasculitis, Quilty effect and ischemic lesions) through univariate and multivariate analysis among the groups. RESULTS: After an appropriate statistical analysis, the result obtained was the presence of intense vasculitis and eosinophils as the greatest predictors of future acute rejection, presenting the respective odds ratio: 10,60 (IC95%: 3,62 31,06. p<0,001) and 6,26 (IC95%:3,16 12,43. p< 0,001), as well as acute rejection associated to severe hemodynamic compromise, which presented the respective odds ratio for this clinical outcome: 7,52 (IC95%: 1,45-38,93. p=0,016) and 6,61 (IC95%: 2,38 18,31. p< 0,001) and death due to acute rejection, presenting the respective odds ratio: 11,20 (IC95%: 3,53 36,17. p < 0, 001) and 14,50 (IC95%: 2,19 36,17. p = 0,006). CONCLUSIONS: Intense vasculitis and eosinophils in myocardial biopsies post-cardiac transplantation are the chief factors that can predict acute rejection, acute rejection associated to severe hemodynamic compromise or death

ANCA-associated vasculitis is a group of devastating autoimmune diseases that predominantly target and destroy small blood vessels. The interaction of neutrophils and monocytes with the endothelial cell lining of blood vessels is imperative to understanding the pathophysiology of the disease. The nature and temporal dynamics of these interactions are mostly unknown and could provide a currently unmet clinical need for more reliable biomarkers of disease activity. This study describes the development of a 4-dimensional in vitro live cell imaging model allowing the interactions of leukocytes with endothelial cells to be analysed in the context of health and disease. Monocytes and neutrophils were isolated from peripheral venous blood of AAV patients and healthy donors. Cells were fluorescently labelled and imaged on a monolayer of human umbilical vein endothelial cells (HUVEC) using a spinning disc confocal microscope. Leukocyte migration, partial and full transmigration, route of transmigration, degranulation and the presence of leukocyte-derived particles inside endothelial cells were measured and the influence of ANCA or BVAS status considered. Following a series of preliminary experiments, it was determined that neutrophil degranulation and partial transmigration indicated early promise as potential biomarkers of disease activity. Several circulating serum analytes correlated with in vitro leukocyte functions, complementing these findings but also highlighting the prevalent immune dysfunction in the pathophysiology and development of the disease. Fatigue is a common symptom within the AAV community and the complex relationship between autoimmune fatigue and leukocyte functions was examined. The data in this thesis describes the development of a novel in vitro live cell imaging platform which can be used to investigate leukocyte functions as potential markers of disease activity as well as understanding their role in the pathophysiology of AAV.