Arteritis
Arteritis is an inflammation of the walls of the arteries, which occurs primarily due to autoimmune disorders or secondarily as a complication of infectious and allergic processes of various localization. The disease manifests itself in several syndromes: intoxication, skin, joint, as well as signs of damage to internal organs. To diagnose arteritis, a comprehensive examination is carried out, which includes angiography, tissue biopsy, laboratory tests (biochemical blood analysis, urine analysis, immunogram). Treatment involves immunosuppressive, anti-inflammatory, antiplatelet therapy, as well as extracorporeal hemocorrection.
General information
The term “arteritis” refers to a group of vasculitis occurring with a predominant lesion of arterial vessels. Pathologies in which the arterial wall becomes inflamed are most often in the competence of cardiologists and rheumatologists, but doctors of any specialization may encounter secondary arteritis. The urgency of the problem in modern medicine is due to its ubiquity, the complexity of diagnosis, and the high risk of life-threatening complications.
Causes of arteritis
At the present stage, the disease is considered polyethological, arising from a combination of endogenous disorders and exogenous provoking factors. The key link in most cases of arterial lesions are idiopathic autoimmune disorders, damage to the vascular wall in systemic diseases of connective tissue. Predisposing factors for the development of vasculitis include the following:
Burdened heredity. The connection of pathology with race, as well as frequent family cases of the disease, allow us to establish the influence of genetic factors on the formation of arteritis. The increased risk of the disease is due to the carrier of certain genes of the main histocompatibility complex (HLA).
Infectious diseases. In this case, the lesion of the arteries develops as a complication of the infectious process of any localization. Most often, bacterial (streptococcal pharyngitis, syphilis, tuberculosis), viral processes (influenza, herpes infections, viral hepatitis, typhus) are a prerequisite for arteritis.
Iatrogenic factors. Vaccination, the introduction of serums for the purpose of immunization or treatment of infectious diseases, the use of certain medications often acts as a trigger for the manifestation of arteritis. At the same time, the negative consequences are an individual reaction of the body to the drug, and they are not associated with a medical error.
Other reasons. The triggering factor of the autoimmune process is occasionally exogenous influences: increased insolation, hypothermia, a sharp change in climate and / or time zones. In women, disorders of the immune system are often provoked by cyclical hormonal changes, pregnancy, menopause.
Pathogenesis
Antibodies that react with components of the vascular endothelium play a key role in the mechanism of arteritis development. These include antineutrophil cytoplasmic antibodies (ANCA), endothelial cell antibodies. Also, antibodies to proteinase-3 and myeloperoxidase are often found in the blood serum of patients with arterial inflammation. In addition, tumor necrosis factor is overexpressed, cytokine synthesis increases.
The pathogenesis includes an infectious and allergic component, which manifests itself in the form of eosinophilic infiltration of the vascular wall, the formation of granulomatous inflammation. Against the background of infections, cross-antibodies are often formed that can destroy not only pathogens, but also healthy cells of the vascular endothelium. Disorders in the blood coagulation system are of no small importance in the development of pathology.
The above-described changes cause an inflammatory process in different parts of the arterial wall, which ends with structural and functional vascular disorders. In the tissues that were supplied with blood by the affected arteries, typical processes of ischemia, metabolic disorders, and loss of functionality occur. The pathological process leads to organ disorders specific to the localization of arteritis.
Classification
Taking into account the pathogenesis, arteritis is divided into primary, which occurs when the vascular wall is damaged in the absence of other diseases, and secondary, having an infectious and allergic nature. According to the localization of the lesion, endarteritis, mesarteritis, periarteritis and panarteritis are distinguished. In practical cardiology , the following classification is also used:
Vasculitis of large vessels. The pathological process affects the aorta and the large branches extending from it, in the future it can spread to smaller vessels. This category includes Takayasu arteritis, giant cell arteritis (Horton’s disease).
Vasculitis of medium-sized vessels. Inflammatory lesions are localized in the visceral arteries supplying blood to the internal organs. This group of pathologies includes nodular periarteritis, Kawasaki disease.
Vasculitis of small vessels. Inflammation develops in intraparenchymatous arteries, arterioles. The most common variants are arteritis associated with antineutrophil cytoplasmic antibodies, microscopic polyangiitis, Wegener’s granulomatosis.
Symptoms of arteritis
The clinical picture is diverse, since vascular damage is possible in any area of the body, and the signs of the disease will correspond to this localization. At the same time, all types of arterial inflammation have common nonspecific symptoms of intoxication: fever, decreased appetite, weakness. Often there is a skin syndrome, which includes hemorrhagic rash, small ulcers, necrosis.
Common symptoms of arteritis include muscle and joint pain, polyneuropathy — local or widespread loss of sensitivity, paresthesia, motor disorders. In the case of inflammation of the vessels of the gastrointestinal tract, abdominal pain, diarrhea, repeated vomiting are bothering. When the urinary system is affected, there is pain in the lower back, a decrease in the amount of urine. Ischemia of the heart is manifested by rhythm disturbances, pressing pains in the chest.
When assessing clinical symptoms, attention is paid to pathognomonic signs that provide valuable information for differential diagnosis. Takayasu arteritis is characterized by severe heart damage (myocarditis, hypertension) in combination with symptoms of central nervous system pathology: instability of posture and gait, syncopal states, deterioration of cognitive abilities.
For giant cell temporal arteritis, the involvement of a visual analyzer in the process is typical: patients complain of double vision, periodic blurring of vision, pain in the eyeballs. An important sign of the disease is considered to be the thickening and soreness of the arteries in the temporal region, occasionally there is redness of the skin of this area. Symptoms, as a rule, are supplemented by manifestations of damage to the cerebral cortex.
Nodular periarteritis refers to arteritis with the most diverse and nonspecific clinical picture: with this disease, signs of damage to any internal organs, soft tissues, musculoskeletal system are possible. Kawasaki disease is characterized by a red macular rash, mucosal lesions, conjunctivitis. More than half of the cases are accompanied by cervical lymphadenopathy, 35% of patients have joint pain.
With Wegener’s granulomatosis, the respiratory tract is most often involved in the process, laryngotracheobronchial stenosis develops, pneumonia, lung infarctions. A similar clinical picture occurs with eosinophilic granulomatosis (Charge-Strauss syndrome). Arteritis, which occurs as a result of vascular damage by immune complexes, is manifested by glomerulonephritis, renal insufficiency.
Complications
Given the polymorphism of the clinical symptoms of arteritis, the negative consequences of diseases are also very diverse. When the coronary arteries are involved in the process, there is a risk of myocardial infarction, life-threatening arrhythmias. When large arteries are damaged, aortic insufficiency and heart failure often form, and inflammation of the abdominal aorta is fraught with mesenteric ischemia, ischemia of the lower extremities.
Complications from the nervous system include transient ischemic attacks, strokes, epileptiform seizures, optic nerve atrophy. Advanced kidney damage is accompanied by the development of renal vascular aneurysms, kidney infarction, acute or chronic renal failure. On the part of the respiratory system, pulmonary hypertension, eosinophilic pneumonia often occurs.
Diagnostics
The examination of the patient begins with the collection of complaints and anamnesis, which allows you to make a preliminary diagnosis, to assume the causes of arteritis. Physical examination includes assessment of the skin and mucous membranes, determination of the main indicators of the respiratory, cardiovascular system. To verify the diagnosis, a detailed laboratory and instrumental examination is required. The following methods are used:
Instrumental examination. Assessment of the cardiovascular system is carried out using ECG, echocardiography, chest radiography. Ultrasound and urography are performed to examine the kidneys. The study of the structural and functional features of the brain is performed using CT, MRI, ultrasound of cerebral vessels.
Invasive diagnostic methods. For a detailed study of the state of the arterial endothelium, finding signs of inflammation and thrombosis, angiography with contrast is indicated. A biopsy of the affected tissues together with vessels for morphohistological examination has the maximum diagnostic significance.
Standard blood tests. Leukocytosis, eosinophilia, increased ESR are non—specific manifestations of the inflammatory process. A biochemical study is considered more informative: determination of C-reactive protein, urea and creatinine, proteinograms, liver samples. Kidney dysfunction is detected by changes in the clinical analysis of urine.
Immunological studies. Since most arteritis is autoimmune in nature, an immunogram is deciphered for detailed diagnosis. From a diagnostic point of view, we are interested in the presence of ANCA, antinuclear antibodies, and other symptoms of systemic rheumatic diseases.
Microbiological tests. To detect infectious pathologies as a provoking factor of inflammation of the arterial wall, bacteriological studies are necessary (sowing a smear from the pharynx, sputum, urine, blood). Modern highly informative methods are serological reactions (ELISA, RIF, RNGA), polymerase chain reaction.
Treatment of arteritis
Conservative therapy
The basis of arteritis therapy is drug methods, which are aimed at correcting immunological disorders, stabilizing the general condition of the patient, preventing complications. A personalized pharmacotherapy scheme is selected taking into account the type of arteritis, the presence of concomitant pathologies. The following groups of drugs are used:
Corticosteroids. First-line medications for suppressing hyperergic reactions of the immune system, reducing the production of autoantibodies and proinflammatory cytokines. Depending on the severity of the condition, pulse therapy and / or a long-term hormonal medication regimen is prescribed.
Cytostatics. Medications are used as an adjunct to corticosteroid therapy to enhance the immunosuppressive effect, to achieve clinical and laboratory remission faster.
Biological preparations. Monoclonal antibodies that inactivate proinflammatory factors show good efficacy for relieving acute symptoms of arteritis. Such drugs have a sparing effect, compared with cytostatics.
Antiplatelet agents. Vasodilating agents, drugs from NSAID groups are effective for the correction of blood clotting parameters. In order to eliminate and prevent thrombosis, drugs from the anticoagulant group are recommended.
Antimicrobial agents. Antibiotics, antiviral, and antiprotozoal medications are required to eliminate infections that cause secondary arteritis.
In case of autoimmune inflammation of the arteries, extracorporeal blood purification is performed to reduce the number of circulating immune complexes, autoantibodies, and cytokines. For this purpose, methods of plasmapheresis, cryoaferesis, cascade filtration of plasma are used. In case of renal insufficiency, patients are transferred to hemodialysis, which ensures the elimination of toxic metabolites from the body.
Surgical treatment
Since the lesion of the arteries is fraught with thickening of their walls or blockage by a thrombus, with a critical decrease in blood flow in the damaged area of the vessel, surgical intervention is indicated. Taking into account the localization of the stenosed area, endarterectomy, percutaneous angioplasty, bypass bypass surgery are possible. With concomitant damage to the valve apparatus of large vessels (aorta, pulmonary artery), valves are replaced.
Prognosis and prevention
With timely detection of arteritis, provision of complex therapeutic measures, the prognosis is favorable. Taking into account the fact that most cases of vascular inflammation occur against the background of other pathologies, the prognosis is also determined by the degree of severity and the possibility of compensation for the underlying disease. With a prolonged course of vasculitis, ischemia of the affected tissues occurs, which reduces the chances of full recovery.
The prevention of secondary arteritis is based on early diagnosis and therapy of diseases that can become a trigger factor for its development. It is also recommended that patients comply with anti-epidemic measures, avoid unreasonable medication intake, and exclude excessive insolation. Since the etiopathogenesis of primary arteritis is insufficiently studied, only secondary prevention of complications in patients with pre-existing pathology is possible.
