Clinico-histopathological Spectrum of Cutaneous Vasculitis

Clinico-histopathological Spectrum of cutaneal VasculitisArticle Type OriginalTitle Clinico-histopathological Spectrum of cuticular Vasculitis A Retrospective Study of 62 casesRunning Title A Clinico-pathological account of Cutaneous vasculitisAuthors Nadia Shirazi*, Rashmi Jindal, Neha Tyagi*, Samarjit Roy, Meena Harsh,* Sohaib AhmadAffiliation Department of *Pathology, Dermatology and Internal Medicine, Himalayan Institute of Medical Sciences. SRH University. Jolly Grant. Dehradun. Uttarakhand. IndiaCorresponding Author Dr. Nadia ShiraziABSTRACTContext Cutaneous Vasculitis is the inflammation of watercraft walls which leads to hemorrhagic or ischemic events. The histopathological classification of dermal vasculitis depends on the vas surface and the dominant immune cell mediating the inflammation.Object We studied the etiological factors and clinico-pathological spectrum of patients with epidermal vasculitis at a tertiary referral centre of magnetic unification India.Desi gn genuflect biopsies of all patients with clinically suspected dermic vasculitis accedeing over 5 years , mingled with 2009-2014 were reviewed. Cutaneous vasculitis was classified on the basis of etiology (primary or secondary), on the basis of surface of vessel wall as well as on the dominant inflammatory cell infiltrating the vessels.Results Over 5 years, 62 / 103 patients evaluated for vasculitic syndromes had histologically proven vasculitis. clinically, vasculitis was primary (77.4%) or secondary (22.5%) to drugs, infections, underlying connective tissue diseases and malignancy. Neutrophilic (n=30), lymphocytic (n=18), eosinophilic (n=10), and granulomatous (n=4) vasculitis were the major histopathological groups. Small vessel involvement was seen in 97% cases.Conclusion Skin biopsy remains the gold standard for diagnosing cutaneous vasculitis. Small vessel vasculitis is the most common type of cutaneous vasculitis with the dominant cell type being neutrophilic. Eosinoph ilic infiltrate was exclusively associated with primary vasculitis.Keywords Cutaneous vasculitis, Small vessel vasculitis, Skin biopsyINTRODUCTIONCutaneous vasculitis (CV) is an inflammatory process of the vessels leading to the destruction of their wall with subsequent hemorrhagic features with or without ischemic necrosis.1 The relative incidence of cutaneous vasculitis ranges from 15.4 to 29.7 cases per million per year.2,3 The condition usually affects adults with a slight female predominance, however, all long times may be afflicted. CV is classified histo-morphologically on the basis of size of vessel affected (small or medium vessel vasculitis) and on the basis of the dominant cell mediating inflammation- neutrophilic/leukocytoclastic, lymphocytic, eosinophilic and granulomatous. On the basis of etiology, they are classified as primary/idiopathic or secondary to an underlying cause standardized drug induced, connective tissue disorders, infections, malignancy, etc.Vasculit is in a medium or large vessel is defined as presence of inflammatory cells within their walls, whereas in small vessels diapedesis of unhomogeneous leukocytes often take place and this criteria alone is non significant. It must be associated with signs of vessel damage, such as fibrin within the walls, thrombi or endothelial necrosis. Veins are involved more commonly than arterioles. clinically, CV can present with a variety of signs and symptoms like urticaria, palpable purpura, ulcers, maculopapular rash, nodules, hemorrhagic vesicles, etc. It can be limited to skin or manifest in other organs like kidney, lungs and heart. Due to this myriad of presentations, CV can pantomime a variety of other dermatological and systemic diseases. Skin biopsy remains the gold standard for diagnosis of cutaneous vasculitis complemented by clinical data and relevant haematological and immunological investigations. In this article, we will be presenting the histopathological spectrum of cutaneou s vasculitis at a angiotensin converting enzyme centre of north India.MATERIALS AND METHODSAll patients with clinical suspicion of cutaneous vasculitis attending the dermatology OPD between August 2009 and July 2014 at a single tertiary referral centre of north India were included. An informed consent was taken wherever possible in writing. Approval was obtained from the institutes research committee for compiling the data from the hospital records. A punch biopsy, 4mm in depth was taken from the edge of the lesion. Though efforts were made to collect most of the biopsies within 48 hours of appearance of the suspected vasculitic lesion, a a few(prenominal) patients presented as late as 1 -2 weeks. These biopsies were routinely processed and stained with Haematoxylin and Eosin (HE). Serial sections were taken in which no vasculitis was identified on initial section. Elastic tissue staining to assess the damage to the elastic lamina in muscular vessels was also performed. Simultaneo usly, a hemogram, ESR, kidney and liver functions, rheumatoid factor and immunological tests like ANA and ANCA were also carried out for assessment. Direct immunoflourescence (DIF) could not be undertaken in any case due to poor patient affordability and overlook of infrastructure. Patients with thrombocytopenia (RESULTSOver 5 years a total of 480 skin biopsies were studied out of which 103 cases were performed in those with clinically suspected vasculitis. However, 62 out of these 103 cases were histologically confirmed to have vasculitis the be had unremarkable and non-specific histologic features. Those with positive histological features had a mean age of 44.5 years range 6-83 years with the male to female ratio of 1.11. The maximum number of patients (n=15) were seen in the age group 31-40 years followed by those in the second decade. Clinically vasculitis was primary (n=48, 77.4%) or secondary (n=14 22.5%). (Table I)History of drug intake and presence of new-made upper resp iratory tract infection was seen in 7 and 3 patients respectively. The commonest offending drugs were antibiotics of -lactam group and analgesics followed by anti-histaminics. Connective tissue disorders (n=3) and malignancy (n=1) were also arrange to be the cause of secondary vasculitis. Clinically palpable purpura was the most common finding followed by maculopapular rash.( framing I). Three-quarters of granulomatous vasculitis presented clinically with symptoms of allergic granulomatosis 25% (n=4/17) of leukocytoclastic vasculitis presented clinically with features of microscopic polyangiitis. Among the haematological parameters, a raised ESR was the most consistent finding. (Tables II III).Most of these were small vessel (venules and arterioles) vasculitis (n=60, 97%). Only 2 cases showed medium vessel vasculitis particularly associated with panniculitis. Depending upon the dominant cell mediating inflammation, the dominant cell type was neutrophilic (n=30), lymphocytic (n=18) , eosinophilic (n=10), and granulomatous (n=4). Histopathological military rating in neutrophilic vasculitis showed transmural percolation of vessel wall with neutrophils (Figure II). Fibrinoid necrosis, neutrophilic debris with or without extravasated red cells were features of leucocytoclastic vasculitis. Lymphocytic vasculitis is shown in Figure III. Epithelioid granulomas were seen surrounding and destroying the vessel wall in granulomatous vasculitis with transmural vessel wall infiltration by lymphocytes and polymorphs (Figure IV). Medium vessel vasculitis showed infiltration by neutrophils in vessel wall which was associated with septal panniculitis. (Figure V).Six of the 10 cases with urticarial vasculitis had an eosinophilic infiltrate the remaining showed lymphocytes predominantly. Clinically most cases (n=8 47%) of idiopathic vasculitis were of neutrophilic type. medicine reaction was the commonest cause of secondary vasculitis (n=7) and most of these (n=4, 57%) showed l ymphocytic infiltrate (Table IV).DISCUSSIONCutaneous vasculitis presents as a mosaic of clinical and histological findings due to varied pathogenic mechanisms.3 Even in the presence of suggestive dermatological lesions, biopsy showed histological features in around 60% cases. We observed primary vasculitic syndromes leading to cutaneous histologic changes in 77% of all cases. Joint pain and swelling was the main presenting feature, palpable purpura and maculopapular rash were the predominant clinical cutaneous markers and raised ESR was a consistent feature. Mostly small vessels were affected and neutrophils predominated in infiltrates. However, there was a unanimous overlap in the calibre of the vessel, the cellular infiltrate and the clinical diagnosis.Our observations corroborate with the case series of Carlson et al in terms of the dominance of primary vasculitis and lack of organ involvement.3 Raised ESR was also observed by Ekenstam et al and Gupta et al.4, 5 Arthralgia was the commonest systemic manifestation also observed by Gupta et al. 5 uneasy and renal involvement was seen in 15 (24.1%) and 18 (29%) patients respectively in our series. Earlier studies showed visceral involvement is seen in 6, 7, 8 Fatal disease occurs in a minority (3, 8Different therapeutic approaches are the main reason for sub-classifying vasculitis. Avoidance or treatment of the causative factor may redress or limit the activity of secondary vasculitis whereas immunosuppressive therapy is the treatment of choice for primary vasculitis. Given this broad range of presentations of cutaneous vasculitis and the numerous disorders that can mimic vasculitis, it is not surprising that it is difficult to correctly and confidently classify these patients. 9 Currently the most widely adopted vasculitis classification system is that of Chapel agglomerate Consensus Conference (CHCC) which is based on pathologic criteria . 10 The other widely used system is that of the American College of genus Rheumatology (ACR) which is based on clinical findings. 11-18 As yet, no ideal system of classification exists for vasculitis. 3, 19, 20The most accepted classification is one which distinguishes between primary and secondary vasculitis, recognizes the dominant blood vessel size involved as well as incorporates patho-physiological markers such as top immune-fluorescence (DIF) and ANCA.21,22 Therefore the classification of cutaneous vasculitis into specific syndromes is best first approached morphologically by determining vessel size and principal inflammatory response. 3This is the first case series classifying cutaneous vasculitis based on the vessel calibre and histo-morphologic features from the north Indian state of Uttarakhand. Though, the referral centre caters to a million people, this data cannot be extrapolated to the general population as the people are treated in the interference fringe by practitioners, the data of which is non-existent. A major limitation of our study was the non-availability of direct immunofluorescence which is considered very important for delineating the immunoglubulin type. Nevertheless, since this facility is not available in most of the Indian subcontinent and there is a lack of expertise in the field of dermatopathology, our data merits attention.CONCLUSIONVasculitis occurs as a primary disorder or secondary to various medical conditions, the treatment differing accordingly. The severity may range from a self-limited condition to a life threatening disorder with multiple organ failure. Skin biopsy is an important tool in arriving at a definitive diagnosis duly complemented by clinical features, pertinent laboratory data, serological evaluation, ANCA with or without direct immunofluorescence.REFERENCES1. Carlson JA, Cavaliere LE, Grant-Kels JM. Cutaneous Vasculitis diagnosis and management. Clin Dermatol 2006 24 414-29.2. Chen KR, Carlson JA. Clinical approach to cutaneous vasculitis. Am. J Clin Dermatol 2008 9 7 1-92.3. Carlson JA, Ng BT, Chen KR. Cutaneous vasculitis update diagnostic criteria, classification, epidemiology, etiology, pathogenesis, evaluation and prognosis. Am J Dermatopathol 2005 27 (6) 504-28.4. Ekenstam E, Callen JP. Cutaneous leukocytoclastic vasculitis-clinical and laboratory features of 82 patients seen in private practice. Arch Dermatol 1984120 484-95. Gupta S, Handa S, Kanwar AJ, Radotra BD, Minz RW. Cutaneous Vasculitides Clinico-pathological correlation. Indian J Dermatol Venereol Leprol 200975356-626. Fiorentino DF. Cutaneous Vasculitis. J Am Acad Dermatol 2003 48(3) 311-407. Carlson JA, Chen KR. Cutaneous vasculitis update small vessel neutrophilic vasculitis syndromes. Am J Dermatopathol 2006 28(6) 486-5068. Tai YJ, Chang AH, Williams RA et al. Retrospective analysis of adult patients with cutaneous leukocytoclastic vasculitis. Australas J Dermatol 2006 47(2) 92-69. Carlson JA, Chen KR. Cutaneous pseudovasculitis. Am J Dermatopathol 2007 29(1) 44-55.10. Jennett e JC, Falk RJ, Andrassy K et al. Nomenclature of systemic vasculitides proposal of an international consensus conference. Arthritis Rheum 1990 33 (8) 1135-6.11. Fries JF, Hunder GG, Bloch DA et al. The American college of Rheumatology 1990 criteria for the classification of vasculitis Summary. Arthritis Rheum 1990, 33(8)1135-6.12. Leavitt Ry, Fauci AS, Bloch DA et al. The American college of Rheumatology 1990 criteria for the classification of wegeners granulomatosis.199033(8)1101-713. Masi AT, Hunder GG, Lie JT, et al. The American College of Rheumatology 1990 criteria for the classification of Churg-Strauss Syndrome (allergic granulomatosis and angitis). Arthritis Rheum 1990 33(8) 1094-10014. Hunder GG, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990 33(8) 1122-815. Mills JA, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of Henoch-Schonlei n purpura. Arthritis Rheum 1990 33(8) 1114-21.16. Calabrese LH, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of hypersensitivity vasculitis. Arthritis Rheum 1990 33(8) 1108-13.17. Lightfoot Jr RW, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of polyarteritis nodosa. Arthritis Rheum 1990 33(8) 1088-93.18. Arend WP, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990 33(8) 1129-34.19. Callen JP. Cutaneous vasculitis what have we learned in the past 20 years? Arch Dermatol 1998134(3)355-720. Jennette JC, Falk RJ. Do vasculitis categorization systems really matter? Curr Rheumatol repp 2000 2(5) 430-821. Sunderkotter C, Sindritaru A. Clinical classification of vasculitis. Eur J Dermatol 2006 16(2)114-24.22. Watts RA, Scott DG. Classification and epidemiology of the vasculitides. Baillie res Clin Rheumatol 1997 11 (2) 191-217Table I. Causes of vasculitis in our study (n=62)CausesNumber (%)HistomorphologyPrimary48 (77.4)Neutrophilic (n=22)Lymphocytic (n=13)Eosinophilic (n=10)Granulomatous (n=3) substitute(prenominal)14 (22.5)Drugs7 (50)Neutrophilic (n=3)Lymphocytic (n=3)Eosinophilic (n=1)Infections3 (21.4)Neutrophilic (n=2)Granulomatous (n=1)Connective tissue disorders3 (21.4)Lymphocytic (n=3)Malignancy1 (7.1)Neutrophilic (n=1)Table II Clinical features of cases with histologically proven vasculitisClinical featureNumber (%)Arthralgia/ arthritis45 (72.5)Palpable purpura34 (54.8)Maculopapular rash18 (29.0)Fever15 (24.1) nettle rash12 (19.3)Nodule4 (6.4)Papule4 (6.4)Ulcer2 (3.2)Haematuria1 (1.6)Table III Laboratory parameters of patients of patients with histologically proven vasculitisParameterPositive nixNot doneAnemia123020Raised ESR5012Leukocytosis with neutrophilia113120Eosinophilia43820Thrombocytopenia84212Kidney function tests458ANA122228Anti-ds DNA62828ANCA1646 CRP122624Anti HCV557ASO titre81539Table IV necktie of histomorphological diagnosis with clinical impressionHISTOPATHOLOGICAL DIAGNOSISCLINICAL DIAGNOSISPrimary Small Vessel Vasculitis (n=48)Neutrophilic / Leukocytoclastic (n=22)Vasculitis(n=8)Pustular dermatosis (n=5)Microscopic polyangiitis (n=4)Rheumatoid vasculitis (n=2)Hypersensitivity vasculitis (n=1)Erythema Elevatun Diutinum (n=1)Henoch-Schonlein Purpura (n=1)Lymphocytic (n=13)Chronic Urticaria (n=4)Perniosis (n=3)Pityriasis Lichenoides (n=2)Atrophie Blanche (n=2)Erythema Annulare Centrifugum (n=1)Polymorphous Light Eruptions (n=1)Eosinophilic (n=10)Urticarial vasculitis (n=6)Prurigo nodularis (n=2)Hypersensitivity vasculitis (n=1)Granuloma faciale (n=1)Granulomatous (n=3)Allergic granulomatosis (n=2)Churg-Strauss Syndrome (n=1)Secondary Small Vessel Vasculitis (n= 12)Neutrophilic (n=6)Drug reaction (n=3)Behcets disease (n=1)Sweets syndrome (n=1)Acute neutrophilic dermatosis (n=1)Lymphocytic (n=5)Drug reaction (n=4)Discoid l upus erythematosis (n=1)Granulomatous (n=1)Wegeners granulomatosis (n=1)Medium vessel vasculitis (n=2)Neutrophilic (n=2)Polyarteritis Nodosa (n=2)LEGENDSFigure I Palpable purpuraFigure II H E (20x10X) Neutrophilic vasculitisFigure III HE (10x10X) Lymphocytic vasculitisFigure IV HE (20x 10X) Granulomatous vasculitisFigure V HE (20x10X) Medium vessel vasculitis with panniculitis