Small-sized vessel vasculitis with arthralgia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Abbreviations: ABG= Arterial blood gas, ANA= Antinuclear antibody, ANP= Atrial natriuretic peptide, ASO= Antistreptolysin O antibody, BNP= Brain natriuretic peptide, CBC= Complete blood count, COPD= Chronic obstructive pulmonary disease, CRP= C-reactive protein, CT= Computed tomography, CXR= Chest X-ray, DVT= Deep vein thrombosis, ESR= Erythrocyte sedimentation rate, HRCT= High Resolution CT, IgE= Immunoglobulin E, LDH= Lactate dehydrogenase, PCWP= Pulmonary capillary wedge pressure, PCR= Polymerase chain reaction, PFT= Pulmonary function test.

Diseases			Clinical manifestations								Para-clinical findings									Gold standard	Additional findings
			Symptoms					Physical examination
											Lab Findings				Imaging				Histopathology
			Headache	Fever	Weight loss	Arthralgia	Claudication	Bruit	HTN	Focal neurological disorder	Biomarker	CBC	ESR	Other	CT scan	Angiography	Ultrasound/ Echocardiography	Other
Small-Vessel Vasculitis	ANCA-associated vasculitis	Microscopic polyangiitis	+	-	-	+/-	-	-	-	+	Anti-PR3 antibody (C-ANCA) (40%), Anti-MPO antibody (P-ANCA) (60%)	Leukocytosis, Normocytic anemia	↑	Proteinuria, Erythrocyte casts	Suspected pancreatitis	Mesenteric angiography for differentiating from polyarteritis nodosa	-	Bilateral nodular, and patchy opacities in CXR	Glomerulonephritis with focal necrosis, crescent formation, and lack or paucity of immunoglobulin deposits	Histological confirmation	Rash, Hemoptysis
		Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)	+/-	-	-	+	-	-	-	+	Anti-MPO antibody (P-ANCA) (40%), Eotaxin-3	Eosinophilia, Anemia	↑	↑Cr or BUN, Proteinuria, Erythrocyte casts, ↑IgE levels	Significant enlargement of peripheral pulmonary arteries	Myocardial ischemia and infarction in coronary angiography	Congestive heart failure (CHF) in echocardiography	Extensive air-space opacities in CXR	Small necrotizing granulomas with eosinophilic core surrounded by macrophages and epithelioid giant cells	Histological confirmation	Allergic rhinitis, Asthma, Urticarial rash
		Hydralazine-associated ANCA-associated vasculitis	-	-	-	+	-	-	-	+/-	Anti-MPO antibody (P-ANCA), Anti-histone antibodies	Anemia	-	↑Cr or BUN, Hypoalbuminemia	Bilateral pulmonary infiltrates	Aneurysms or occlusions of the visceral arteries	-	-	Pauci-immune necrotizing and crescentic glomerulonephritis	Histological confirmation	Sinusitis, Hemoptysis
	Immune complex small-vessel vasculitis	Cryoglobulinemic vasculitis	+/-	+/-	-	+	+/-	-	-	-	C4 component	Leukocytosis, Anemia	↑	ANA, hypocomplementemia	R/O underlying malignancy	Stenosis or occlusions of the visceral arteries	Bacterial endocarditis in echocardiography	Interstitial involvement or pleural effusions in CXR	HCV-associated proteins in vasculitic skin, Intraluminal cryoglobulin deposits	Histological confirmation	Acrocyanosis, Retinal hemorrhage, Purpura
		Hepatitis C virus-associated cryoglobulinemic vasculitis	+/-	+/-	+	+	-	-	+	+/-	HCV RNA, Cryoglobulins	Leukocytosis, Anemia	↑	↓Serum C4, Positive RF	Increased hepatic echogenicity	-	Hepatomegaly, Splenomegaly	Increased hepatic echogenicity in MRI	Vasculitic skin, Antigen infilteration in lesions	HCV RNA, Histological confirmation	Palpable purpura, Microscopic hematuria
		IgA vasculitis (Henoch-Schönlein purpura)	-	-	+	+	-	-	-	-	IgA	Normochromic anemia, Leukocytosis	↑	Stool OB, ↓C3, ↓C4	-	-	Increased bowel wall thickness, hematomas, peritoneal fluid, and intussusception	Dilated loops of bowel consistent in abdominal X-ray	Leukocytoclastic vasculitis in postcapillary venules with IgA deposition	History and physical examination	Hematuria, Palpable purpura
		Hypocomplementemic urticarial vasculitis (anti-C1q vasculitis)	-	-	+/-	+	-	-	-	-	C1q	Mild anemia	↑	ANA, ↓C1q, ↓C3, ↓C4	-	-	Hepatomegaly, Splenomegaly	-	Deposits of immunoglobulins, complement, or fibrin around blood vessels	Urticaria, Histological confirmation	Urticaria, Hematuria
	Cardiovascular disease	Leukocytoclastic Vasculitis	+	-	-	+	-	-	-	+	IgM, IgA, IgG	Leukocytosis, Anemia	↑	Hypocomplementemia	-	Vascular stenosis and obstruction in visceral angiography	-	-	Perivascular inflammatory infiltrate of neutrophils with leukocytoclasia (releasing nuclear debris)	Histological confirmation	Palpable purpura, Petechiae
	Pulmonary disease	Langerhans Cell Histiocytosis	+/-	-	-	+	-	-	-	-	CD1a, CD207,BRAF-V600E	Anemia	↑	Hypercalcemia	Pulmonary cysts and nodules, Bone lytic lesions	-	Hepatomegaly, Splenomegaly	Cerebellum and pons hyperintensity in MRI	Birbeck granules by electron microscopy	Histological confirmation	Brown to purplish papules, Eczematous rash
	Renal disease	Acute Poststreptococcal Glomerulonephritis	-	-	-	+	-	-	+	+/-	Antistreptolysin-O (ASO) titers	Leukocytosis	↑	Hypocomplementemia	-	-	Normal to slightly enlarged kidneys	Central venous congestion in a hilar pattern in CXR	Hypercellularity of endothelial and mesangial cells, Infiltration of the glomerular tuft with polymorphonuclear cells	Histological confirmation	Hematuria
	Hematologic disease	Hemolytic-Uremic Syndrome	+	+	-	+	-	-	+	+	C5b-9, ADAMTS13	Anemia, Thrombocytopenia, Reticulocytosis	↑	↑Lactate dehydrogenase (LDH), Hypercalcemia	Thalami, brainstem, or cerebellum abnormality	Cerebral microangiopathy or hypertension	Hypoechoic kidney	Abnormal hyperintensity in the brain cisterns in MRI	Microthromboses include fibrin thrombi that may occlude the glomerular tuft	Clinical findings coupled with laboratory abnormalities	Hematuria, Proteinuria
		Chronic Lymphocytic Leukemia (CLL)	+	+	+	+	+/-	-	-	+/-	CD5, CD19, CD20, IgVH	Absolute lymphocytosis, Smudge cells	↑	Flow cytometry	Staging	-	-	-	Large atypical cells, cleaved cells, and prolymphocytes	Chromosomal and genetic testing	Easy bruising
		Multiple Myeloma	+	-	+	+	+	+	+/-	+/-	Ig light chain	Anemia, Thrombocytopenia, Leukopenia	↑	Bone marrow aspiration and biopsy, ↑Cr	Osseous involvement and lytic lesions	Peripheral zone of increased vascularity in lesions	-	Punched-out lesion in skull X-ray	Clonal proliferation of plasma cells	Protein electrophoresis plus conventional X-rays	Constipation
		Non-Hodgkin Lymphoma	+	+	+	+	+/-	+/-	+/-	+/-	MYC, BCL2, BCL6, and TP53	Lymphocytosis, Anemia, Thrombocytopenia	↑	↑Lactate dehydrogenase (LDH), Hypercalcemia	Enlarged lymph nodes, Hepatosplenomegaly, Filling defects in the liver and spleen	-	Hepatosplenomegaly	Mediastinal lymphadenopathy	Small cleaved or noncleaved, intermediate, or large cell with a follicular or diffuse pattern	Surgically excised tissue biopsy	Easy bruising, Testicular mass, Skin lesion
		Serum Sickness	+	+	-	+/-	+/-	-	-	+/-	IL-1, IL-6, TNF	Leukopenia	↑	Polyclonal gammopathy, ↑Cr, Cryoglobulinemia	-	-	-	-	Arteritic lesions are focal, necrotizing, and inflammatory involving all layers of the artery	Clinical findings coupled with laboratory abnormalities	Hematuria, Skin rash
		Disseminated Intravascular Coagulation	+/-	+	-	+/-	-	-	+	+	Fibrin degradation product (FDP)	Thrombocytopenia, Schistocytes	↑	↑D-dimer, aPTT and PT	Intracranial hemorrhage	-	-	-	Ischemia and necrosis due to fibrin deposition in small and medium-sized vessels	Clinical findings coupled with laboratory abnormalities	Acral cyanosis, Hemorrhagic skin infarctions
		Idiopathic Thrombocytopenic Purpura	+	+/-	-	+	-	-	-	+	FC gamma receptors (FCGR) IIb	Anemia, Thrombocytopenia	-	HIV, ANA	R/O other causes	-	R/O splenomegaly	-	Increased number of normal morphologic megakaryocytes	Clinical findings coupled with thrombocytopenia	Easy bruising, Purpura
	Systemic disease	Sarcoidosis	+	+	+	+	-	-	-	+/-	IL-2 and IFN-γ	Mild anemia	↑	↑ACE, ↑1, 25-dihydroxyvitamin D	Active alveolitis or fibrosis	-	Hepatosplenomegaly	Bilateral hilar adenopathy	Noncaseating granulomas (NCGs)	Histological confirmation	Heart block, Ocular lesion
		Legionella Infection	+	+	+	+	-	-	-	+/-	Inflammatory cytokines	Leukocytosis with left shift, Thrombocytosis	↑	↑D-dimer, FDP, Hyponatremia	Pleural effusion	-	-	Nonspecific and indistinguishable CXR	Intra-alveolar inflammation, Microabscesses in the parenchyma	Sputum culture	Cough, Diarrhea
		Systemic lupus erythematosus	+	+	+	+	-	-	+	+	Anti dsDNA, ANA	Leukopenia, Lymphopenia, Anemia, Thrombocytopenia	↑	↑Cr or BUN, ↑ALT or AST, Proteinuria	Interstitial lung disease, Pneumonitis, Pulmonary emboli, Alveolar hemorrhage	Aneurysms	Pericardial effusion, pulmonary hypertension, or verrucous Libman-Sacks endocarditis in echocardiography	Central nervous system (CNS) lupus white-matter changes in MRI	Staging lupus nephritis	Anti-dsDNA antibody test	Skin rashes or photosensitivity
		Rheumatoid arthritis	-	-	+	+	+	+	-	-	RF, Anti-CCP antibody	Anemia	↑	↑Cr or BUN, ↑ALT or AST, ANA	Microfractures	Aneurysms	Effusions in joints	Basilar invagination with cranial migration of an eroded odontoid peg in MRI	Influx of inflammatory cells into the synovial membrane, with angiogenesis, proliferation of chronic inflammatory cells	Clinical findings coupled anti-CCP antibody	Rheumatoid nodules
		Relapsing polychondritis	-	+/-	+/-	+	+	-	-	-	-	Leukocytosis, Anemia	-	Cryoglobulins, ANA, C-ANCA	Calcification of cartilaginous structures	Aortic root dilatation	Aortic root dilatation and degree of aortic regurgitation in echocardiography	Tracheal stenosis in CXR	Chondrolysis, Chondritis, Perichondritis	Clinical findings coupled with imaging	Ear pain and redness, Polyarthritis