Review Mimics of primary systemic vasculitides The primary systemic vasculitides are well defined entities, but a number of diseases can imitate their clinical, laboratory, radiographic and histological features. The importance of awareness and recognition of these conditions lies in the initiation of correct therapy for the specific disease process and in the avoidance of unnecessary and potentially harmful immunosuppression. In this review, we have provided a comprehensive, but by no means complete, review of some of the imitators of the primary vasculitides. Every attempt must be made to establish the diagnosis before indicated therapy is commenced. This will help to avoid therapeutic misadventures when managing patients with these complex diseases. KEYWORDS: differential diagnosis n mimics n vasculitis Atul Khasnis & Eamonn Molloy† †Author for correspondence: Medscape: Continuing Medical Education Online Department of Rheumatology, Orthopedic and Rheumatology This activity has been planned and implemented in accordance with the Essential Areas and policies of Institute, Cleveland Clinic, the Accreditation Council for Continuing Medical Education through the joint sponsorship of 9500 Euclid Avenue A50, MedscapeCME and (Future Medicine Ltd). Cleveland, OH 44195, USA MedscapeCME is accredited by the Accreditation Council for Continuing Medical Education Tel.: +1 216 444 8834; (ACCME) to provide continuing medical education for physicians. Fax: +1 216 445 7569; MedscapeCME designates this educational activity for a maximum of 0.75 AMA PRA Category 1 [email protected] Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation at http://cme.medscape.com/ CME/futuremedicine; (4) view/print certificate. Learning objectives Upon completion of this activity, participants should be able to: n Identify reasons for distinguishing mimics from true primary vasculitides n Describe the difference between vasculitis associated with syphilis and TB n List inherited conditions that can be mimics of primary vasculitides n Identify drugs and toxins associated with mimics of primary vasculitides n Describe clinical features of antiphospholipid syndrome Financial & competing interests disclosure Editor Elisa Manzotti, Editorial Director, Future Science Group, London, UK. Disclosure: Elisa Manzotti has disclosed no relevant financial relationships. Author & Credentials Atul Khasnis, MD, Department of Rheumatology, Orthopedic and Rheumatology Institute, Cleveland Clinic, OH, USA Disclosure: Atul Khasnis has disclosed no relevant financial relationships. Eamonn Molloy, MD, MPH, Department of Rheumatology, Orthopedic and Rheumatology Institute, Cleveland Clinic, OH, USA Disclosure: Eamonn Molloy has disclosed no relevant financial relationships. CME Author Désirée Lie, MD, MSEd, Clinical Professor, Department of Family Medicine, University of California, Irvine, CA, part of USA; Director, Division of Faculty Development, UCI Medical Center, Irvine, CA, USA Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships. 10.2217/IJR.09.37 © 2009 Future Medicine Ltd Int. J. Clin. Rheumatol. (2009) 4(5), 597–609 ISSN 1758-4280 597 Review Khasnis & Molloy Mimics of primary systemic vasculitides Review The vasculitides are defined by histological Syphilis inflammation of blood vessels in various tissues. Syphilis is invoked most commonly in the dif- They are classified as primary or secondary and ferential diagnosis of the aortic and aortic branch have their identifiable causes such as infectious involvement of the large vessel vasculitides. agents, drug reactions, systemic autoimmune dis- Cardiovascular syphilis occurs as part of the eases or malignancy. However, in addition, there tertiary manifestations of syphilis, caused by the are myriad conditions that can mimic true vas- spirochete Treponema pallidum. Cardiovascular culitis clinically, on laboratory testing, on radi- syphilis presents with inflammation of the aorta ography and at histopathology. Distinguishing resulting in aortic wall thickening, aneurysm vascular inflammation from nonvasculitic dis- formation, aortic valvular incompetence and orders has significant therapeutic implications, coronary artery disease. Approximately 11% of since immunosuppressive therapy directed at the untreated patients progress to develop cardio- primary systemic vasculitides may be associated vascular syphilis [1]. Aortic aneurysms occur with significant toxicities, and a failure to recog- most commonly in the ascending aorta where nize a vasculitis mimic may delay the initiation they may be symptomatic (from pressure on the of effective therapy for the disorder in question. surrounding structures) but less commonly they For purposes of this review, the term ‘mimic’ will can affect the descending thoracic and abdomi- include conditions that may or may not result nal aorta where they are often asymptomatic. in true vascular inflammation (‘vasculitis’) but The prevalence of abdominal aortic aneurysms present similarly to the defined primary systemic varies and most commonly involves the supra- vasculitides. We will discuss the key categories renal aorta. Rare reported manifestations of of disease that may mimic the primary systemic cardiovascular syphilis include involvement of vasculitides, focusing on a few important entities the pulmonary arteries and great vessels arising in each category; however, a detailed discussion from the aortic arch, hepatic artery and renal of all potential vasculitis mimics is beyond the artery [2]. Histopathologically, syphilitic aorti- scope of this article. tis is characterized by the collection of lympho- cytes and plasma cells in the perivascular spaces Infections surrounding the vasa vasorum in the adventitia Diseases caused by infectious agents can mimic of the root of the aorta, a lack of ‘skip lesions’, any of the primary systemic vasculitides and plasma cell microabscesses and the rare occur- may affect vessels of all sizes. Acute bacterial or rence of fibrinoid necrosis and sclerotic lesions viral infections or chronic infections with bac- (sometimes mildly inflammatory) with or teria, viruses, mycobacteria, fungi or parasites without thrombosis [3]. The sensitivity of the may mimic vasculitis. While in many cases the Venereal Disease Research Laboratory (VDRL) infectious agents discussed can cause a true sec- test for cardiovascular syphilis is 73% and for ondary vasculitis rather than being a vasculitis the fluorescent treponemal antibody (FTA-ABS) mimic per se, they remain a critical exclusion in test sensitivity is 96%. Co-existent neuro syphilis the evaluation of a patient with suspected pri- may provide a clue to the diagnosis. Syphilis can mary systemic vasculitis, not least because of the also rarely confound the diagnosis of a small potential of causing significant harm to patients vessel vasculitic process affecting the lungs. with active infection if they are inappropriately Syphilitic involvement of the lungs resulting in treated with immunosuppressive therapy. For necrotizing vasculitis with gumma in the pul- example, syphilitic affection of the aorta results monary parenchyma presenting as mass lesions in true vascular inflammation but it is still has been reported [4]. considered to ‘mimic’ the primary large vessel vasculitides and is treated differently. The clini- Mycobacterial infections cal, imaging and histopathological appearance TB (caused by Mycobacterium tuberculosis) can of vascular disease caused by infectious agents result in granulomatous arteritis leading to vessel may resemble the primary systemic vasculitides. wall thickening, aneurysm formation and ste- However, infectious agents have been listed here noses that can affect the aorta and its branches, as a ‘mimic’ since they are distinct entities in thereby mimicking large vessel vasculitis [5]. terms of well-defined etiologies, pathogenic Moreover, vasculitis may be seen at histopa- mechanisms and therapeutic approaches. The thology in the region of tuberculous granulo- presence of true vascular inflammation in these mas. Involvement of the descending aorta or conditions has also led to their being classified renal artery may resemble Takayasu’s arteritis as ‘secondary’ vasculitides. (TAK), especially in clinical settings where this 598 Int. J. Clin. Rheumatol. (2009) 4(5) future science group Review Khasnis & Molloy Mimics of primary systemic vasculitides Review pattern of aortic involvement from TAK is com- ‘granular’ immune complex deposits (immuno- mon [6]. Four types of TB arterial disease have globulin and complement) on the subepithelial been described: or subendothelial glomerular basement mem- Miliary TB of the intima brane seen by electron microscopy and immuno- fluorescence[14] in contrast with GN, occurring TB polyps attached to the intima from primary systemic small vessel vasculitides, TB involving the vascular wall such as Wegener’s granulomatosis (WG) and microscopic polyangiitis, which are classically TB aneurysm [7] associated with few to absent immune deposits Tuberculous aortitis may be differentiated (referred to as pauci-immune GN). from TAK owing to its tendency to cause ero- sion of the vessel