Allergic vasculitis is an aseptic inflammation of the vascular wall caused by an allergic reaction to the effects of various infectious and toxic factors. The pronounced polymorphism of rashes and variants of the course has led to the fact that many of its forms are isolated as separate diseases, among which there is a global division into superficial and deep allergic vasculitis. Diagnosis requires a comprehensive approach taking into account the history, clinical features, laboratory and instrumental data, histology results. Treatment of allergic vasculitis is carried out with antihistamines, desensitizing and vascular agents, calcium preparations, antibiotics, glucocorticoids, etc.
ICD 10
L95 Skin-restricted vasculitis, not classified elsewhere
Meaning
Allergic vasculitis – immune vasculitis of small vessels, angiitis of the skin. Unlike systemic vasculitis, allergic vasculitis occurs with a predominant lesion of the vessels located in the skin and subcutaneous tissue, often without involving the vessels of internal organs in the process. There are no exact data on the incidence. It can develop in people of any gender and at any age. The dependence of the frequency of cases on the age or gender of patients is observed in certain clinical forms of the disease. For example, hemorrhagic vasculitis is more common in children under 14 years of age, and Shamberg’s dermatosis occurs mainly in men.
Reasons of allergic vasculitis
Allergic vasculitis refers to diseases with multifactorial etiology. Most often, its development is caused by sensitization of the body by various infectious agents (staphylococci, streptococci, pathogenic fungi, viruses), developing against the background of chronic infectious foci of ENT organs (tonsillitis, otitis, sinusitis), genitourinary sphere (adnexitis, chronic pyelonephritis, cystitis), frequent ARIs, influenza, herpetic infections, viral hepatitis B, C, A. In many patients with allergic vasculitis, high titers of staphylococcal anti-atoxin and antistreptolysin-0, an increase in antistaphylococcal hemagglutinins are determined.
The next group of factors that provoke the development include medications (sulfonamides, antibiotics, oral contraceptives, analgesics, barbiturates, etc.) and chemicals (petroleum products, insecticides). The cause can be household and plant allergens, prolonged intoxication, radiation. A favorable background for the development can be metabolic abnormalities occurring in the body (diabetes mellitus, gout, obesity, atherosclerosis), vascular disorders (hypertension, varicose veins, heart failure) and diseases of somatic organs, primarily the liver: biliary cirrhosis, chronic hepatitis, alcoholic liver disease.
Pathogenesis
There are two periods in the development of vasculitis – early and late. In the first period, infectious and toxic factors cause the formation of CIC and their deposition in the vascular wall, activation of complement and mast cells with the release of inflammatory mediators. This leads to damage to the walls with the development of aseptic inflammation and increased permeability of the vessel. In the second (late) period, activation of T-lymphocytes with the release of cytokines is noted, which further aggravates the damaging effect. This is how hemorrhagic rash appears – a pathognomonic sign of allergic vasculitis. Many researchers of this problem point to the relationship between the severity and the number of immune complexes circulating in the blood.
Classification
The clinical classification of allergic vasculitis, which is used by modern rheumatology, is based on the caliber of the affected vessels. According to it , they allocate:
- Superficial allergic vasculitis is characterized by damage to capillaries, small venules and arteries of the skin. This group includes hemosideroses, hemorrhagic vasculitis, nodular necrotic vasculitis, allergic Ruther arteriolitis, smallpox-like acute lichenoid parapsoriasis and hemorrhagic leukoclastic microbid.
- Deep allergic vasculitis is accompanied by damage to the arteries and veins of medium and large caliber, passing in the subcutaneous fat and on its border with the dermis. Clinically manifested by various forms of acute and chronic nodular erythema.
Symptoms of allergic vasculitis
Hemosideroses
The group of hemosideroses includes clinical varieties caused by damage to the endothelium of precapillaries and capillaries with the deposition of hemosiderin – an iron-containing pigment that forms after the breakdown of hemoglobin. These variants are characterized by the appearance of petechial rashes, small yellow-brown spots and vascular asterisks on the skin. The rash in most cases is located in the distal parts of the extremities, more often on the legs. Rashes may be accompanied by itching of varying intensity. The general condition of patients, as a rule, is not disturbed. In some cases, the formation of a trophic ulcer is possible.
Hemosideroses include the following variants of allergic vasculitis:
- Majocca disease (annular telangiectatic purpura),
- eczematoid purpura (Dukas-Kapetana-kisa),
- Shamberg disease,
- itchy purple (Leventhal),
- purpurous pigmented lichenoid dermatitis (Gougereau-Blum syndrome),
- arcuate telangiectatic purpura (Touraine),
- white skin atrophy (Miliana),
- purpurous pigmented angiodermitis (Favre-Shae syndrome),
- orthostatic purpura and reticulated senile hemosiderosis.
In the diagnosis of hemosiderosis, a differential diagnosis with atopic dermatitis, toxicoderma, eczema, lichen planus is necessary.
Hemorrhagic vasculitis (Schenlein-Henoch disease)
This type of allergic vasculitis is manifested by damage to the endothelium not only of the vessels of the skin, but also of internal organs. In this case, aseptic inflammation of the vascular wall is accompanied by the formation of microthrombs. The following forms of hemorrhagic allergic vasculitis are distinguished:
- skin-articular with rashes in the form of hemorrhagic and erythematous spots and lesions of large joints by the type of arthritis;
- abdominal with sharp abdominal pain and intestinal bleeding; renal, occurring with symptoms of acute or chronic glomerulonephritis;
- lightning necrotic, often fatal due to multiple lesions of internal organs with the development of myocarditis, pleurisy, polyarthritis,
- gastrointestinal and nasal bleeding, glomerulonephritis; mixed.
Differential diagnosis of allergic vasculitis, occurring according to the type of Schenlein-Henoch disease, is carried out with multiform exudative erythema, drug-induced dermatitis, nodular periarteritis, hemorrhagic syndrome of infectious diseases.
Nodular necrotic vasculitis
This type is characterized by a chronic course with deterioration of the general condition. Skin manifestations are characterized by ulcerating nodular elements and erythematous spots with a hemorrhagic component. It requires differentiation from the papulonecrotic form of tuberculosis of the skin.
Allergic arteriolitis of Ruther
Allergic vasculitis of Ruther is characterized by polymorphism of rashes accompanied by a violation of the general well-being of the patient (headache, malaise, subfebrility, arthralgia, sometimes inflammatory changes in the joints). Rashes can be represented by papules, spots, pustules, vascular asterisks, blisters, vesicles, areas of necrosis and ulceration. According to the predominant elements of the rash, this type is divided into nodular-necrotic, hemorrhagic and polymorphic-nodular.
Erythema nodosum
Nodular erythema can have an acute and chronic course. With this type dense painful subcutaneous nodules and nodes are formed, localized mainly on the anterior surface of the shins. Node resolution occurs without destruction. Seals may remain in their place for a long time. The disease proceeds with a violation of the general condition, the appearance of symmetrical arthralgias and arthritis.
Diagnostics
Patients with suspected allergic vasculitis need to consult a rheumatologist. Due to the pronounced variety of manifestations and forms of allergic vasculitis, its diagnosis is a difficult task for a doctor. The anamnesis data, the clinical picture of the disease, the nature of the course, the age of the patient, the results of laboratory studies and histological examination of the material taken by skin biopsy are taken into account.
Of the laboratory diagnostic methods for allergic vasculitis, clinical blood and urine analysis, blood sugar analysis, biochemical liver tests, determination of ASO and CIC are used. The histological picture of allergic vasculitis is characterized by swelling and swelling of the endothelium of the cutaneous and subcutaneous vessels, its proliferation with narrowing of the lumen of the affected vessel, leukocyte infiltration of the vascular wall, deposition of hemorrhiderin in it, microthrombosis and the release of blood elements outside the vessel. The RIF allows to detect the deposition of immunoglobulins and antigen-antibody complexes in the wall of the affected vessel.
To identify chronic infectious foci in the body during the diagnosis of allergic vasculitis, urine, feces and a smear from the nasopharynx, gynecological examination of women, PCR studies for various infections, RPR test, examination by a phthisiologist are performed. Diagnosis of concomitant vascular disorders may require consultation with a cardiologist, phlebologist or vascular surgeon, ECG, angiography, ultrasound of arteries and veins.
Treatment of allergic vasculitis
Therapy of allergic vasculitis is carried out with desensitizing and antihistamines, calcium preparations. Vascular preparations aimed at improving vascular tone, reducing vessel permeability and thrombosis in its lumen are widely used. These include: hydroxyethylrutoside, ethamzylate, ascorbic acid+rutoside, pyricarbate, aminocaproic acid, horse chestnut extract, etc. In severe cases of allergic vasculitis, the use of glucocorticosteroids and cytostatics, extracorporeal hemocorrection (hemosorption, membrane plasmapheresis, etc.) is indicated. In the presence of infectious foci, their rehabilitation and systemic antibacterial therapy are necessary.
In the treatment of allergic vasculitis, external agents can also be used, mainly creams and ointments containing troxerutin, clostridiopeptidase, chloramphenicol, cattle blood extract, etc. If allergic vasculitis is accompanied by articular syndrome, locally prescribed anti-inflammatory ointments, bandages with dimethyl sulfoxide, ultraphonophoresis and magnetotherapy.
Literature
- Some cutaneous manifestations of systemic disease. / Wright JT.- 1980. link
- Pathology of allergic diseases. / Schwartz A. – 1989 link
- Skin-limited vasculitis: Clinical recommendations. – 2016.
- Skin vasculitis/ Mertsalova I.B.//Attending physician. – 2011.
- Hemorrhagic vasculitis in children/ Borisova E.V.// Pediatrics. G.N. Speransky Magazine – 2004.
