Hypersensitivity Vasculitis Workup

  • Author: Jeffrey P Callen, MD; Chief Editor: William D James, MD   more...
 
Updated: May 2, 2012
 

Laboratory Studies

Evaluation of patients with hypersensitivity vasculitis (leukocytoclastic vasculitis) serves 2 purposes: to determine the presence of systemic disease and to identify an associated disorder, which aids in predicting the patient's prognosis. No established routine exists, and testing should be prompted by signs or symptoms.

  • A urinalysis should be performed in all patients to assess renal disease.
  • Some authors also include a complete blood cell count, an erythrocyte sedimentation rate, and a blood chemistry panel.
  • Check the stool for blood in patients with bowel symptoms.
  • Obtain serologic studies (eg, antinuclear antibody; antineutrophil cytoplasmic antibody [ANCA], ie, circulating ANCA, perinuclear ANCA, atypical ANCA; rheumatoid factor) for patients without an obvious disease cause. In children and perhaps in some adults, serologic testing for a possible streptococcal infection should be considered (Streptozyme or ASO titer).
  • Complement levels, including total hemolytic complement (CH100 or CH50), C3 levels, and C4 levels, may be obtained for patients suspected of having lupus erythematosus or patients who have urticarial vasculitis.
  • Include immunofixation electrophoresis (IFE), cryoglobulins, and hepatitis C antibody in tests for paraproteins for patients without otherwise identified disease. Hepatitis B has been associated with vasculitis in the past; however, it appears that the association may have occurred by virtue of co-infection with hepatitis C (previously termed non-A, non-B). The measurement of hepatitis B surface antigen may not be required in all cases. Cryoglobulins are often not obtained properly; a positive rheumatoid factor should suggest the possibility of cryoglobulins.
  • Perform HIV testing for patients at high risk for infection and possibly for those with otherwise unidentifiable cause of disease.
  • Consider obtaining direct immunofluorescence microscopy for selected patients. The presence of IgA occurs in Henoch-Schönlein purpura.
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Imaging Studies

Consider the following imaging studies:

  • Chest radiography is part of the routine evaluation.
  • Consider assessing the need for visceral angiography for patients with a severe vasculitic syndrome.
  • Perform cardiac ultrasonography and blood cultures for patients with fever and/or a heart murmur.
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Other Tests

Obtain pulmonary function tests for patients with hypocomplementemic urticarial vasculitis.

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Procedures

Perform a skin biopsy of a relatively fresh (preferably < 24 hours of duration) lesion in most, if not all, adult patients. Biopsies are often not performed in children with suspected vasculitis whose clinical presentation is classic. Consider performing a biopsy of muscle or a biopsy of visceral organs in patients with severe vasculitic syndromes; however, most patients with hypersensitivity vasculitis of the skin do not require such tests.

Obtaining a bone marrow sample may be useful if the peripheral smear is abnormal.

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Histologic Findings

A skin biopsy sample reveals the presence of vascular and perivascular infiltration of polymorphonuclear leukocytes with formation of nuclear dust (leukocytoclasis), extravasation of erythrocytes, and fibrinoid necrosis of the vessel walls. This process is dynamic; a biopsy sample of a lesion too early or too late in its evolution may not reveal these findings.

The picture of hypersensitivity vasculitis is a pattern that can occur in any vasculitic syndrome but may also occur in nonvasculitic diseases (eg, neutrophilic dermatoses), at the base of a biopsy sample of a leg ulceration, or in some insect bite reactions. Careful clinicopathologic correlation is necessary. Note the image below.

Histopathologic features of leukocytoclastic vascuHistopathologic features of leukocytoclastic vasculitis.
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Contributor Information and Disclosures
Author

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Celgene Honoraria Safety Monitoring Committee

Specialty Editor Board

Michelle Pelle, MD  Clinical Assistant Professor, Division of Dermatology, Department of Medicine, University of California, San Diego, School of Medicine

Michelle Pelle, MD is a member of the following medical societies: American Academy of Dermatology, California Medical Association, Medical Dermatology Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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Hypersensitivity vasculitis.
Henoch-Schönlein purpura.
Histopathologic features of leukocytoclastic vasculitis.
Urticarial vasculitis. These lesions differ from routine hives by lasting longer (often >24 h), being less pruritic, and often resolving with a bruise or residual pigmentation.
Erythema elevatum diutinum, a rare cutaneous vasculitis.
 
 
 
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