What is the initial workup for a patient with suspected vasculitis in the ER?

From the Guidelines

The initial workup for a patient with suspected vasculitis in the ER should include a comprehensive history and physical examination, followed by laboratory tests and imaging studies, with a focus on assessing inflammation, organ involvement, and potential biopsy sites, as recommended by the most recent guidelines 1.

Initial Evaluation

The workup should begin with a complete blood count (CBC), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) to assess for inflammation.

• Order urinalysis to check for hematuria or proteinuria suggesting renal involvement.
• Specific autoimmune markers should include antineutrophil cytoplasmic antibodies (ANCA), antinuclear antibodies (ANA), rheumatoid factor (RF), and complement levels (C3, C4).
• Additional tests may include hepatitis B and C serologies, cryoglobulins, and anti-glomerular basement membrane antibodies depending on clinical suspicion.

Imaging Studies

• Chest X-ray should be performed to evaluate for pulmonary involvement.
• Further imaging such as CT or MRI may be indicated based on affected organ systems, with consideration of the patient's clinical presentation and the potential for identifying biopsy sites 1.
• For patients with suspected large vessel vasculitis, ultrasound and MRI are recommended as first-line imaging modalities, with CT or PET as alternative options 1.
• In patients with suspected non-cerebral vasculitis, FDG-PET/CT whole body, MRI, and MRA can be used to assess vasculitic changes and identify potential biopsy sites 1.

Specialist Consultation and Biopsy

• Early consultation with rheumatology, nephrology, or other specialists is crucial for patients with suspected vasculitis.
• A positive biopsy is strongly supportive of a diagnosis of vasculitis, and biopsies should be performed to assist in establishing a new diagnosis and for further evaluation for patients suspected of having relapsing vasculitis 1.
• The choice of biopsy site and imaging modality should be individualized based on the patient's clinical presentation and the potential for identifying vasculitic changes.

From the Research

Initial Workup for Suspected Vasculitis in the ER

The initial workup for a patient with suspected vasculitis in the ER involves several diagnostic tests and procedures. The following are some of the key steps:

• Laboratory tests:
  • Complete Blood Count (CBC) to check for anemia, leukocytosis, or thrombocytosis
  • Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) to assess inflammation
  • Blood urea nitrogen (BUN) and creatinine to evaluate renal function
  • Liver function tests (LFTs) to assess liver involvement
  • Antineutrophil cytoplasmic antibody (ANCA) testing to diagnose ANCA-associated vasculitis
• Imaging studies:
  • Chest X-ray to evaluate for pulmonary involvement
  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scans to assess organ involvement
  • Angiography to evaluate vascular involvement, although its concordance with biopsy findings is limited 2
• Biopsy:
  • Renal biopsy to diagnose renal involvement and assess disease severity
  • Skin or nerve biopsy to diagnose cutaneous or peripheral nerve involvement
  • Cerebral biopsy to diagnose central nervous system vasculitis, although it is often challenging to diagnose 2

Treatment Considerations

Treatment for vasculitis depends on the severity and organ involvement. The following are some treatment considerations:

• Induction therapy:
  • Cyclophosphamide and corticosteroids are generally considered standard induction therapy for ANCA-associated vasculitis (AAV) 3, 4, 5
  • Rituximab, a chimeric anti-CD20 antibody, has emerged as a second-line therapy for refractory or relapsing AAV 3, 4, 5
• Maintenance therapy:
  • Azathioprine, mycophenolate mofetil, or methotrexate may be used as maintenance therapy to prevent relapse
  • Corticosteroids may be tapered or discontinued after induction therapy

Important Considerations

It is essential to note that the diagnosis and treatment of vasculitis can be complex and require a multidisciplinary approach. The following are some important considerations:

• Consultation with a rheumatologist or nephrologist may be necessary to guide diagnosis and treatment
• Close monitoring of disease activity and organ involvement is crucial to adjust treatment and prevent complications
• Patients with suspected vasculitis should be admitted to the hospital for further evaluation and treatment, especially if there is evidence of organ involvement or severe disease activity 6