We present a case of myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-associated vasculitis that demonstrated a systemic granulomatous lesion at autopsy. The patient initially showed anorexia, general malaise and anemia. Colon fiber was examined to detect the bleeding site, which revealed ischemic mucosal damage associated with venous fibrin thrombus. Because a high titer of MPO-ANCA was found, ANCA-associated vasculitis was suspected and the patient was started on steroid pulse therapy. However, anemia, renal failure and respiratory failure worsened and the patient died of sudden cardiac failure 2 days after the start of the therapy. An autopsy revealed systemic arteritis in multiple organs including the kidneys, liver, spleen, gastrointestinal system and genital organs that indicated fibrinoid necrosis accompanied by granulomatous reaction with multinucleated giant cells; the granulomatous reaction further extended along the splenic capsule. Glomerulonephritis and diffuse pulmonary damage, which are common in MPO-ANCA-associated vasculitis, were almost absent but parapleural fibrosis was present. The direct cause of death was presumed to be hemorrhagic shock due to rupture of an aneurysm in the gastric subserosa. As far as we know, this is the first case of a systemic granulomatous reaction in MPO-ANCA-positive vasculitis, although the cause of the granulomatous lesion is unknown.
Infection during critical limb ischemia (CLI) is a challenging issue. Plasma presepsin is a novel biomarker for infection, which is related to bacterial phagocytosis by macrophages. The purpose of this study was to investigate the validity of presepsin as an indicator and predictor for early detection of infectious CLI. A retrospective observational study was conducted among 20 CLI patients (Rutherford 5 and 6) on hemodialysis (HD). Twenty CLI patients on HD (mean age 70.7 6 5.6 years, male 85%) and 15 healthy patients on HD without CLI and infection (control group) were analyzed. All CLI patients received appropriate revascularization and plastic surgical treatment. CLI patients were classified into two groups: the healing group with complete epithelialization without discharge and the nonhealing group with infection signs. Plasma presepsin was measured and compared among the two groups and the control group using an automated immunoanalyzer, PATHFAST, based on a noncompetitive chemiluminescent enzyme immunoassay. The median plasma presepsin and its interquartile range were 1,320 (1,055-1,465) pg/mL in the control group, 1,320 (1,050-1,613) pg/mL in the healing group and 3,193 (2,519-3,832) pg/mL in the nonhealing group. The plasma presepsin concentrations were significantly higher in the nonhealing group compared with the control group (p < 0.001) and the healing group (p < 0.01). A receiver operating characteristic curve analysis revealed that presepsin had highest accuracy (0.979) among various inflammatory markers, including C-reactive protein and the white blood cell count. The diagnostic cutoff value of 2,083 pg/mL was able to distinguish the nonhealing group and healing group with a sensitivity of 100% and a specificity of 88.9%. Our results suggest that plasma presepsin may be useful for predicting "critical colonization" and "infection" in nonhealing CLI in HD patients, therefore, the definitive cutoff value may be used for determinating the indication for reintervention and/or major limb amputation. Foot gangrene due to critical limb ischemia (CLI) is a life-threatening complication in hemodialysis (HD) patients. The serum C-reactive protein (CRP) level and presence of gangrene are reported to be independent predictors for the failure of the endovascular treatment (EVT) in HD patients with CLI. 1-3 The risk factors of CLI include heart failure, infection, HD, and malnutrition. In the management of CLI, both revascularization and wound treatment are important. Despite successful revascularization with EVT and/or bypass surgery, poor infection control during wound treatment could result in major limb amputation or death. The survival rates with major limb amputation are quite poor: 51.9% at 1 year and 14.4% at 5 years. 4 Thus, infection control is a challenging issue in wound treatment. At present, predictors of the prognosis include the white blood cell (WBC) count and CRP level, and clinical observation and an assessment of the wound. Because the WBC count and CRP level could increase as a reflection ...
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