Introduction
Eosinophilic granulomatosis with polyangiitis (EGPA) is a relatively rare necrotizing vasculitis resembling polyarteritis nodosa, which causes asthma, nasal involvement, peripheral nerve disturbance, heart and renal disorders, lymphadenopathy, cutaneous lesions like purpura and subcutaneous nodules with eosinophil infiltration into perivascular area and prominent eosinophilia [
1,
2]. The annual incidence of EGPA in Japan is 2.4 per million a year [
3]. Prognosis is relatively poor, as 30–40% of patients experience relapse and mortality is 5–10% [
4,
5]. In terms of classification of vasculitis, EGPA is a less common type of antineutrophil cytoplasmic antibody (ANCA)-related vasculitis, and 30–50% of EGPA cases are positive for ANCA [
6]. EGPA in the presence of heart and gastrointestinal lesions, and proteinuria, showed higher relapse rate [
5]. Corticosteroid is essentially used for the treatment of this disease, and according to the severity of visceral damage, cyclophosphamide, azathioprine and biologic agents are concomitantly given to improve cardiac, gastrointestinal and neurological involvement [
7,
8]. To prevent irreversible damage in organs and nerves, treatment for EGPA should be commenced as soon as possible. However, there is a delay of 5–24 days from the onset because no reliable biomarker currently exists and the diagnosis of EGPA needs to be made on the basis of general consideration of clinical course and the laboratory data [
8‐
10].
Skin involvement occurs in two-thirds of patients with EGPA, and when located at the area of the peripheral neuropathy, it is one of the clinical clues to diagnose EGPA [
5,
11]. In this study, we sought to determine whether the presence of cutaneous involvement was associated with diagnosis of EGPA and decision of treatment by retrospectively analyzing manifestations, laboratory data and the factors that affected disease activity and treatment.
Discussion
In this study, the presence of purpura was significantly associated with CRP, IL-5 and high BVAS score, suggesting that cutaneous lesions reflected high disease activity of EGPA (Tables
2,
3). Multivariate analysis showed that CRP was the most related marker to purpura (Table
3).
Cutaneous lesions as clinical manifestations in EGPA include purpura, which occurs in 25% of patients and is frequently found in their legs, nodules, urticaria, livedo and ulcers [
14]. A French cohort of 383 patients also showed that, of the 39.7% of patients with skin lesions, purpura occurred in 22.5%, urticaria in 9.9%, subcutaneous nodules in 9.7%, livedo reticularis in 3.9% and gangrenous necrotic lesions in 3.7% [
4]. In our patients, purpura mainly developed in all patients with cutaneous involvement, and urticaria or livedo-like lesions were partly found in some cases. Leukocytoclastic vasculitis was the major findings in skin pathology, and 27% showed massive eosinophil infiltration indicating eosinophilic inflammation in EGPA.
IL-5 is a cytokine that belongs to the
β common chain family and mediates the differentiation and migration of eosinophil from blood to target tissue [
15]. Th2 cells, mast cells, CD34
+ progenitor cells, invariant natural killer T cells, group 2 innate lymphoid cells and eosinophils are major cellular sources of IL-5 [
15,
16]. This cytokine stimulates eosinophil precursors to synthesize granule proteins, such as major basic protein (MBP), eosinophil-derived neurotoxin (EDN), eosinophil peroxidase (EPX) and eosinophil cationic protein (ECP) [
17]. IL-5 inhibits eosinophil adhesion to bone marrow sinus endothelium, resulting in mobilization of eosinophils to the peripheral tissues in conjunction with eotaxin. At the inflammation site, the recruited eosinophils are activated and degranulated to release the enzymes that cause tissue damage. Finally, dying eosinophils release self-DNA that forms extracellular DNA nets, which accelerates eosinophilic inflammation [
17,
18]. As a result, systemic vasculitis in the skin, kidney, nerve, nasal cavity, and lung occurs along with the increased CRP in EGPA. Therefore, high CRP in patients with cutaneous lesions was thought to be a result of active eosinophilic inflammation of EGPA in relation to elevated IL-5.
Eosinophils in the peripheral blood produce massive IL-25 in EGPA [
19]. IL-25 is also released from damaged epithelial cells, along with IL-33, as an alarmin [
6]. These two cytokines stimulate type 2 innate lymphoid cells to induce IL-5 [
6,
20]. Activated antigen-presenting cells, such as DC and IL-33, activate IL-33 receptor-expressing Th2 cells (i.e. pathogenic Th2 cells) to produce IL-5 [
21,
22]. In this way, eosinophils promote and enhance Th2 response in the inflammatory site.
This study has certain limitations. First, the number of the eligible patients was small and second, this was a retrospective study conducted in a single center. Treatment strategy of each patient was dependent on a patient’s choice or a doctor’s decision. The results of this study do not offer the best choice, such as PSL monotherapy or the addition of IVCY or mepolizumab, for each case based on the presence or absence of purpura, although the presence of purpura indicated the disease activity of EGPA. A multicenter prospective cohort study may reveal the requirement of immunosuppressants or biologics for EGPA with purpura as the diagnosis. Moreover, as mepolizumab inhibits IL-5 directly, the efficacy of this biologic agent would elucidate how IL-5 is involved in the development of cutaneous lesions.
We have concluded that a cutaneous lesion like purpura is an important index indicating robust inflammation in connection with increased IL-5 and eventually high disease activity of EGPA. Further study with more patients enrolled may provide better choices of combination of PSL, IVCY, IVIG, and anti-IL-5 therapy on the basis of clinical and laboratory findings.
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