Vasculitis

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Vasculitis is a term used to describe a series of conditions in which there is inflammation of the blood vessels.

Vasculitis can be primary (occurring on its own), or secondary (as a result of infection, or in association with another condition such as rheumatoid arthritis).

The effects might be transient or result in longer-term damage to the vasculature.

Vasculitis is rare. Accounting for regional variation, around 3,000 people in the UK develop one of its various forms every year. The incidence for giant cell arteritis (GCA) is higher with around 13,000 people developing this each year.[1][2]

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  • Idiopathic (45-55%).
  • Infection (15-20%) - eg, Henoch-Schönlein purpura, septic vasculitis, upper respiratory tract flares of Wegener's granulomatosis, polyarteritis nodosa (PAN).
  • Inflammatory disease (15-20%) - eg, systemic lupus erythematosus (SLE), rheumatoid arthritis, Crohn's disease and ulcerative colitis.
  • Drug-induced (10-15%) - eg, sulfonamides, beta-lactams, quinolones, non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, thiazides, anti-influenza vaccines. Chemicals such as insecticides and petroleum products.
  • Neoplastic (<5%) - eg, as a result of a paraproteinaemia or lymphoproliferative disorder.

Many attempts have been made to classify this group of diseases and several classifications are in existence. The Chapel Hill Consensus Conference (CHCC) broadly classified the causes of vasculitis into infective and non-infective and then went on to classify the non-infective causes further.[3] 

Infective causes are considered as those where there is direct invasion by pathogens into the vascular wall, resulting in inflammation. Examples include rickettsial vasculitis, syphilitic aortitis, and aspergillus arteritis.

For non-infective causes, the CHCC classified vasculitis into:

Large vessel (eg, GCA) Single organ (eg, isolated aortitis)
Medium vessel (eg, Kawasaki disease) Systemic disease-associated (eg, rheumatoid)
Small vessel (eg, immune complex) Probably associated (eg, hepatitis B, hepatitis C)
Variable vessel (eg, Behçet's disease)  

Vasculitis can affect any system, producing a wide range of symptoms. Although unspecific symptoms such as arthralgia and lethargy may be present for some time, frequently the first noticeable sign of a vasculitis will be as a skin lesion and will therefore present as such.

  Small vessel vasculitis
(Sometimes referred to as hypersensitivity vasculitis or cutaneous leukocytoclastic vasculitis (LCV))
Medium-sized vessel vasculitis Large vessel vasculitis
(ie aorta and major branches)
Presentation
  • Palpable purpura 1-3 mm (may join to form plaques  ± ulcer)
  • Tiny papules
  • Splinter haemorrhages
  • Urticaria
  • Vesicles
  • Livedo reticularis (rare)
  • Ulcers
  • Digital infarcts
  • Nodules
  • Livedo reticularis
  • Papulo-necrotic lesions
  • Hypertension
    (damage to the renal vessels)
  • End-organ ischaemia (eg, TIA/CVE)
  • Hypertension
  • Aneurysms
  • Dissection ± haemorrhage or rupture
Differential diagnosis

Diagnosis of the skin lesion can provide information as to what calibre of vessel may be involved, potential diagnosis, and where else in the body evidence of vasculitis should be sought.[4][5] 

Full history should be taken, particularly with respect to:

  • Length of symptoms/signs
  • Recent illness
  • Recent exposure to drugs, vaccines and chemicals
  • Other symptoms - eg, arthralgia, cough, ENT symptoms, numbness and paraesthesia
  • Detailed review of all systems

In view of the systemic nature of many vasculitic diseases, a complete physical examination should be carried out including CNS and ENT examination.

Investigations should be tailored to the possible cause. For all patients suspected of having a vasculitic lesion consider:

  • FBC and differential cell count
  • U&Es
  • LFTs
  • Inflammatory markers
  • Urine culture, microscopy
  • Urine dip test for glucose, protein and blood
  • Hepatitis serology (types B and C are associated with PAN and mixed cryoglobulinaemia respectively)
  • Cryoglobulins
  • Complement levels
  • Rheumatoid factor
  • CXR

Also consider:

  • Echocardiogram and blood cultures if there is cardiac murmur present.
  • Antinuclear antibodies (ANAs) if there is medium-sized vessel involvement and any suggestion of connective tissue disease.
  • Skin biopsy taken during the acute stage.

There are several other conditions which may mimic cutaneous vasculitis and these must be considered when arriving at a diagnosis. Some of the more common ones include:

The treatment will vary considerably according to the underlying cause, the severity of symptoms and their duration. It may include:

  • Avoiding the precipitating factor, such as drugs or chemicals.
  • In general, corticosteroids are administered to control acute symptoms and laboratory evidence of systemic inflammation. After control is achieved, attempts may be made to taper dosing over a month.
  • Options such immunosuppression with cyclophosphamide, azathioprine, methotrexate or tumour necrosis factor blockade may be used.
  • Use of plasmaphoresis or intravenous immunoglobulin are options for refractory vasculitis. 
  • There is increasing evidence for biological agents in vasculitis.[6] 
  • Morbidity due to cumulative corticosteroid dose (as well as toxicity from immunosuppression) must be weighed in the long-term plan of care.

Surgical

Occasionally, surgery might be indicated. The aims of this depend on the area affected but may be to open up or divert blood flow around an area of blockage, take a sample (biopsy) or to repair an area of organ damage.

Examples include:

  • Stenting of stenotic vessels, which is increasingly used. Balloon dilatation has also been used to improve renovascular flow.
  • Patients with Wegener's granulomatosis may develop subglottic stenosis, which is amenable to balloon dilatation.
  • ESR may be used as a marker of disease activity.
  • Patients with elevated cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) titres may have normal levels during periods of disease control and increasing ones with disease activity.

This is related to the degree of end-organ involvement.

Complications are varied and are dependent on both the underlying cause, size of vessel and organs affected. They may include:

  • Renal insufficiency
  • Digital gangrene
  • Pulmonary haemorrhage
  • CNS infarction
  • Arterial or venous thrombosis
  • Subglottic stenosis

Further reading & references

  1. Smeeth L, Cook C, Hall AJ; Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990-2001. Ann Rheum Dis. 2006 Aug;65(8):1093-8. Epub 2006 Jan 13.
  2. Vasculitis; Arthritis Research UK
  3. Jennette JC, Falk RJ, Bacon PA, et al; 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013 Jan;65(1):1-11. doi: 10.1002/art.37715.
  4. Fiorentino DF; Cutaneous vasculitis. J Am Acad Dermatol. 2003 Mar;48(3):311-40.
  5. Hautmann G, Campanile G, Lotti TM; The many faces of cutaneous vasculitis. Clin Dermatol. 1999 Sep-Oct;17(5):515-31.
  6. Chen KR, Carlson JA; Clinical approach to cutaneous vasculitis. Am J Clin Dermatol. 2008;9(2):71-92.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
28/06/2013
Document ID:
1728 (v24)
© EMIS