SYSTEMIC VASCULITIS COMPLICATING INFECTIO NS - RECOVERY WITHOUT CORTICOTHERAPY

In the most cases the causes of systemic vasculitis are unknown and tr eatment is symptomatic (corticosteroids often associated with immunosu pressive agents). We report three cases of systemic vasculitis associa ted with infections for which dramatic improvement was observed withou t corticotherapy (in two patients). Case report 1 : A previously overw eight 72-year-old woman was admitted because of a one-year history of fever, fourteen kilogram weight loss, vascular purpura, and polyneurop athy. Abnormal laboratory values included inflammatory syndrome [eryth rocyte sedimentation rate (ESR) : 80 mm/first hour, thrombocytosis : 5 00 000/mu l, hypereosinophilia (1 200/mu l) and positive perinuclear a nti-neutrophil cytoplasmic antibodies (p-ANCA) [anti-myeloperoxydase a ntibodies : 30 U (normal < 7)]. Neuromuscular biopsy showed necrotizin g vasculitis involving small and medium arteries. Further studies reve aled a florid diverticulosis of the colon and no other severe visceral involvement. Treatment was starred then with sigmoidectomy. Within si x weeks her general condition improved dramatically without corticothe rapy : regression of all systemic manifestations, the ESR normalized, and p-ANCA became negative, Ten months later she was still asymptomati c. Case report 2 : An 50-year-old-man developed a progressive fifteen- kilogram weight loss (within 2 months). severe polyneuropathy of all f our limbs, His ESR was 120 mm/first hour, and C-reactive protein 200 m g/l. Neuromuscular biopsy showed necrotizing vasculitis affecting smal l vessels in the nerve and no immune deposits. Stomatologic examinatio n revealed a multiple foci of dental infections. The extraction of all these foci of infections associated with antibiotics improved dramati cally all systemic manifestations (within eight weeks), once more with out corticotherapy. Light months later the patient remained asymptomat ic. Case report 3 : A 30-year-old-woman was admitted because of five-w eek history of fever, myalgias, polyarthritis, and cutaneous nodules i n her limbs. Abnormal laboratory values included inflammatory syndrome , proteinuria of 0,7 g/day, and a significant rise in Chlamydia tracho matis antibodies titres from 1/64 to 1/256 over a 5 week period. She h ad a previous history of genital condyloma. The prednisone initialed ( 0,5 mg/kg/day) twelve days prior to admission was gradually reduced (s topped within 2 months) and treatment with doxycycline (200 mg/day) wa s initiated. Within six weeks of antibacterial treatment we assisted t o a total regression of the initial clinical manifestations and labora tory values became normalized. Ten months later she remained asymptoma tic. Conclusion: In systemic vasculitis, investigations in a search of foci of infections are of dual interest : possible etiologic agent li ke our case reports (strong evidence for an infectious association) an d, from a therapeutic perspective, we must identify the microbes behin d vasculitis syndromes, since treatment with corticosteroids may have serious consequences if the patient has an active infectious disease ( J Mal Vasc 1997 ; 22 : pages 29-34).