Abstract
Systemic vasculitides are among the less common disorders encountered in routine rheumatology practice. The low incidence and heterogeneous presentation at onset can potentially lead to delayed diagnosis. Not recognizing these in the early phase may prove detrimental, as some vasculitis may progress to a catastrophic course with major morbidity or mortality. The causes of diagnostic delay may vary among different types of vasculitis and may also be disease-, patient-, or physician-related. Disease-related factors include the myriad presentations with diverse and non-specific symptoms, mimicking other conditions like infections. In addition, some forms have prolonged prodromal phases before evident organ damage. Limited awareness among healthcare professionals, particularly outside rheumatology, and a lack of readily available diagnostic tools contribute to missed diagnoses. Delays in seeking care due to non-specific symptoms or lack of access to specialist care can worsen outcomes. The economic burden also increases with delayed diagnosis and damage accrual when the disease remains unrecognized or untreated for prolonged periods. Although the causes of vasculitis are numerous, including secondary causes, in this review, we focus on diagnostic delays in primary vasculitides and suggest potential steps to identify and treat these diseases early. These include educating both healthcare professionals and the public about the signs and symptoms of vasculitis; expanding the rheumatology workforce and facilitating timely referrals; implementing readily available and reliable tests for early detection; and streamlining care and diagnostic pathways. Such measures have the potential to improve the overall outcomes of the disease, with prolonged remission, minimal damage accrual, and improved quality of life.
Similar content being viewed by others
References
Frazzei G, Van Vollenhoven RF, De Jong BA et al (2022) Preclinical autoimmune disease: a comparison of rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis and type 1 diabetes. Front Immunol 13:899372. https://doi.org/10.3389/fimmu.2022.899372
Van Der Linden MPM, Le Cessie S, Raza K et al (2010) Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 62:3537–3546. https://doi.org/10.1002/art.27692
Fuchs F, Morf H, Mohn J et al (2022) Diagnostic delay stages and pre-diagnostic treatment in patients with suspected rheumatic diseases before special care consultation: results of a multicenter-based study. Rheumatol Int 43:495–502. https://doi.org/10.1007/s00296-022-05223-z
Burgers LE, Raza K, van der Helm-Van Mil AH (2019) Window of opportunity in rheumatoid arthritis—definitions and supporting evidence: from old to new perspectives. RMD Open 5:e000870. https://doi.org/10.1136/rmdopen-2018-000870
Quartuccio L, Treppo E, Valent F, De Vita S (2021) Healthcare and economic burden of ANCA-associated vasculitis in Italy: an integrated analysis from clinical and administrative databases. Intern Emerg Med 16:581–589. https://doi.org/10.1007/s11739-020-02431-y
Degli Esposti L, Dovizio M, Perrone V et al (2023) Profile, healthcare resource consumption and related costs in ANCA-associated vasculitis patients: a real-world analysis in Italy. Adv Ther 40:5338–5353. https://doi.org/10.1007/s12325-023-02681-0
Ehrenstein B, Pongratz G, Fleck M, Hartung W (2018) The ability of rheumatologists blinded to prior workup to diagnose rheumatoid arthritis only by clinical assessment: a cross-sectional study. Rheumatology 57:1592–1601. https://doi.org/10.1093/rheumatology/key127
Jennette JC, Falk RJ, Andrassy K et al (1994) Nomenclature of Systemic Vasculitides. Arthritis Rheum 37:187–192. https://doi.org/10.1002/art.1780370206
Jennette JC, Falk RJ, Bacon PA et al (2013) 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 65:1–11. https://doi.org/10.1002/art.37715
Belizna CC, Hamidou MA, Levesque H et al (2008) Infection and vasculitis. Rheumatology 48:475–482. https://doi.org/10.1093/rheumatology/kep026
Ahmed S, Shenoy P, Danda D, Misra R (2019) Sustained remission in large-Vessel vasculitis: Do they ever burn out? Indian J Rheumatol 14:304. https://doi.org/10.4103/injr.injr_182_19
Kitching AR, Anders H-J, Basu N et al (2020) ANCA-associated vasculitis. Nat Rev Dis Primers 6:71. https://doi.org/10.1038/s41572-020-0204-y
Babigumira JB, Li M, Boudreau DM et al (2017) Estimating the Cost of Illness of Giant Cell Arteritis in the United States. Rheumatol Ther 4:111–119. https://doi.org/10.1007/s40744-017-0052-8
Ungprasert P, Koster MJ, Cheungpasitporn W et al (2020) Inpatient epidemiology and economic burden of granulomatosis with polyangiitis: a 10-year study of the national inpatient sample. Rheumatology 59:3685–3689. https://doi.org/10.1093/rheumatology/keaa069
Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD (2011) Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int 31:1409–1417. https://doi.org/10.1007/s00296-011-1999-3
Auanassova A, Yessirkepov M, Zimba O et al (2023) Physicians’ perceptions about antineutrophil cytoplasmic antibody-associated vasculitis: an online survey report in the time of the COVID-19 pandemic. Clin Rheumatol 42:831–837. https://doi.org/10.1007/s10067-022-06452-0
Poulton CJ, Nachman PH, Hu Y et al (2013) Pathways to renal biopsy and diagnosis among patients with ANCA small-vessel vasculitis. Clin Exp Rheumatol 31(1 Suppl 75):S32–S37
Takala JH, Kautiainen H, Malmberg H, Leirisalo-Repo M (2008) Wegener’s granulomatosis in Finland in 1981–2000: clinical presentation and diagnostic delay. Scand J Rheumatol 37:435–438. https://doi.org/10.1080/03009740802238366
Yacyshyn E, Johnson A, Rode M, Pagnoux C (2016) Patient-driven online survey on the clinical manifestations and diagnostic delay of granulomatosis with polyangiitis. Joint Bone Spine 83:599–600. https://doi.org/10.1016/j.jbspin.2015.07.014
Taimen K, Mustonen A, Pirilä L (2021) The delay and costs of diagnosing systemic vasculitis in a tertiary-level clinic. Rheumatol Ther 8:233–242. https://doi.org/10.1007/s40744-020-00266-9
for the Vasculitis Patient-Powered Research Network, Sreih AG, Cronin K et al (2021) Diagnostic delays in vasculitis and factors associated with time to diagnosis. Orphanet J Rare Dis 16:184. https://doi.org/10.1186/s13023-021-01794-5
Prior JA, Ranjbar H, Belcher J et al (2017) Diagnostic delay for giant cell arteritis—a systematic review and meta-analysis. BMC Med 15:120. https://doi.org/10.1186/s12916-017-0871-z
Popescu M-L, Predeteanu D et al (2017) Antineutrophil cytoplasmic antibody-associated vasculitis in “real life”—series of clinical cases in a Romanian reference center. Ro J Rheumatol 26:164–168. https://doi.org/10.37897/RJR.2017.4.5
Gudbrandsson B, Molberg Ø, Palm Ø (2017) TNF inhibitors appear to inhibit disease progression and improve outcome in Takayasu arteritis; an observational, population-based time trend study. Arthritis Res Ther 19:99. https://doi.org/10.1186/s13075-017-1316-y
Skaug HK, Fevang BT, Assmus J et al (2023) Giant cell arteritis: incidence and phenotypic distribution in Western Norway 2013–2020. Front Med 10:1296393. https://doi.org/10.3389/fmed.2023.1296393
Dirikgil E, Tas SW, Verburgh CA et al (2022) Identifying relevant determinants of in-hospital time to diagnosis for ANCA-associated vasculitis patients. Rheumatol Adv Pract 6:rkac045. https://doi.org/10.1093/rap/rkac045
Sahin S, Hopurcuoglu D, Bektas S et al (2019) Childhood-onset Takayasu arteritis: a 15-year experience from a tertiary referral center. Int J Rheum Dis 22:132–139. https://doi.org/10.1111/1756-185X.13425
Thakare DR, Mishra P, Rathore U et al (2023) Renal artery involvement is associated with increased morbidity but not mortality in Takayasu arteritis: a matched cohort study of 215 patients. Clin Rheumatol. https://doi.org/10.1007/s10067-023-06829-9
Tomelleri A, Campochiaro C, Sartorelli S et al (2019) Gender differences in clinical presentation and vascular pattern in patients with Takayasu arteritis. Scand J Rheumatol 48:482–490. https://doi.org/10.1080/03009742.2019.1581838
Misra DP, Aggarwal A, Lawrence A et al (2015) Pediatric-onset Takayasu’s arteritis: clinical features and short-term outcome. Rheumatol Int 35:1701–1706. https://doi.org/10.1007/s00296-015-3272-7
Clemente G, Hilario MO, Lederman H, Silva CA et al (2014) Takayasu arteritis in a Brazilian multicenter study: children with a longer diagnosis delay than adolescents. Clin Exp Rheumatol 32(3 Suppl 82):S128–S133
Vanoli M, Daina E, Salvarani C et al (2005) Takayasu’s arteritis: a study of 104 Italian patients. Arthritis Rheum 53:100–107. https://doi.org/10.1002/art.20922
Goel R, Kumar TS, Danda D et al (2014) Childhood-onset Takayasu arteritis—experience from a tertiary care center in South India. J Rheumatol 41:1183–1189. https://doi.org/10.3899/jrheum.131117
Heras-Recuero E, Landaeta-Kancev LC, Martínez De Bourio-Allona M et al (2023) Positron emission computed tomography spectrum of large vessel vasculitis in a tertiary center: differences in 18F-fluorodeoxyglucose uptake between large vessel vasculitis with predominant cranial and extracranial giant cell arteritis phenotypes. JCM 12:6164. https://doi.org/10.3390/jcm12196164
Sriskandarajah S, Aasarod K, Skrede S et al (2015) Improved prognosis in Norwegian patients with glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies. Nephrol Dial Transplant 30(Suppl 1):i67–i75. https://doi.org/10.1093/ndt/gfv008
Vinit J, Muller G, Bielefeld P et al (2011) Churg-Strauss syndrome: retrospective study in Burgundian population in France in past 10 years. Rheumatol Int 31:587–593. https://doi.org/10.1007/s00296-009-1275-y
Huang SP, Li X, Cao B et al (2022) Health care costs and utilization prior to diagnosis of antineutrophil cytoplasmic antibody vasculitis in medicare beneficiaries. JMCP 28:1292–1303. https://doi.org/10.18553/jmcp.2022.28.11.1292
Van Nieuwland M, Colin EM, Boumans D et al (2023) Diagnostic delay in patients with giant cell arteritis: results of a fast-track clinic. Clin Rheumatol. https://doi.org/10.1007/s10067-023-06739-w
Gorczyca D, Postępski J, Olesińska E et al (2014) The clinical profile of Kawasaki disease of children from three Polish centers: a retrospective study. Rheumatol Int 34:875–880. https://doi.org/10.1007/s00296-013-2836-7
Ugurlu N, Bozkurt S, Bacanli A et al (2015) The natural course and factors affecting severity of Behçet’s disease: a single-center cohort of 368 patients. Rheumatol Int 35:2103–2107. https://doi.org/10.1007/s00296-015-3310-5
Wang L-Y, Zhao D-B, Gu J, Dai S-M (2010) Clinical characteristics of Behçet’s disease in China. Rheumatol Int 30:1191–1196. https://doi.org/10.1007/s00296-009-1127-9
Sachetto Z, Mahayri N, Ferraz RH et al (2012) Behçet’s disease in Brazilian patients: demographic and clinical features. Rheumatol Int 32:2063–2067. https://doi.org/10.1007/s00296-011-1921-z
Pain CE, Beresford MW, Fortune F et al (2021) Behçet’s syndrome in children and young people in the United Kingdom and the Republic of Ireland: a prospective epidemiological study. Rheumatology 60:4728–4736. https://doi.org/10.1093/rheumatology/keab084
Daoud F, Rachdi I, Somai M et al (2021) Epidemiological, clinical, and therapeutic characteristics of Behçet’s disease: a monocentric study in Tunisia. Pan Afr Med J 40:13. https://doi.org/10.11604/pamj.2021.40.13.19146
Ezeonyeji AN, Borg FA, Dasgupta B (2011) Delays in recognition and management of giant cell arteritis: results from a retrospective audit. Clin Rheumatol 30:259–262. https://doi.org/10.1007/s10067-010-1616-y
McGonagle D, Bridgewood C, Ramanan AV et al (2021) COVID-19 vasculitis and novel vasculitis mimics. Lancet Rheumatol 3:e224–e233. https://doi.org/10.1016/S2665-9913(20)30420-3
Maronese CA, Zelin E, Avallone G et al (2022) Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic. Front Med 9:996288. https://doi.org/10.3389/fmed.2022.996288
Mv P, Auanassova A, Yessirkepov M et al (2023) New-onset systemic vasculitis following SARS-CoV-2 infection and vaccination: the trigger, phenotype, and outcome. Clin Rheumatol 42:2761–2775. https://doi.org/10.1007/s10067-023-06694-6
Dejaco C, Ramiro S, Duftner C et al (2018) EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis 77:636–643. https://doi.org/10.1136/annrheumdis-2017-212649
Schönau V, Vogel K, Englbrecht M et al (2018) The value of 18F-FDG-PET/CT in identifying the cause of fever of unknown origin (FUO) and inflammation of unknown origin (IUO): data from a prospective study. Ann Rheum Dis 77:70–77. https://doi.org/10.1136/annrheumdis-2017-211687
Zimba O, Doskaliuk B, Yatsyshyn R et al (2021) Challenges in diagnosis of limited granulomatosis with polyangiitis. Rheumatol Int 41:1337–1345. https://doi.org/10.1007/s00296-021-04858-8
Cansu DÜ, Özbülbül NI, Akyol G et al (2018) Do pulmonary findings of granulomatosis with polyangiitis respond to anti-tuberculosis treatment? Rheumatol Int 38:1131–1138. https://doi.org/10.1007/s00296-018-4027-z
Breuskin F, Polet M-A, Dorzee J et al (2003) Limited Wegener’s disease initially misdiagnosed as tuberculosis. Acta Clin Belg 58:245–247. https://doi.org/10.1179/acb.2003.58.4.006
Brahn E, Pegues DA, Yao Q, Craft N (2010) Mucocutaneous leishmaniasis masquerading as Wegener granulomatosis. J Clin Rheumatol 16:125–128. https://doi.org/10.1097/RHU.0b013e3181d52c96
Ye S, Yang C (2007) How could we make a diagnosis of Wegener’s granulomatosis? Clin Rheumatol 26:784–786. https://doi.org/10.1007/s10067-005-0196-8
Little MA, Nazar L, Farrington K (2004) Polymyalgia rheumatica preceding small-vessel vasculitis: changed spots or misdiagnosis? QJM 97:289–292. https://doi.org/10.1093/qjmed/hch055
Molnár A, Studinger P, Ledó N (2022) Diagnostic and therapeutic approach in ANCA-associated glomerulonephritis: a review on management strategies. Front Med 9:884188. https://doi.org/10.3389/fmed.2022.884188
Rathmann J, Segelmark M, Mohammad AJ (2023) Evaluation of the ACR/EULAR 2022 criteria for classification of ANCA-associated vasculitis in a population-based cohort from Sweden. Rheumatology (Oxford). https://doi.org/10.1093/rheumatology/kead516
Sherri A, Mortada MM, Makowska J, Lewandowska-Polak A (2023) Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment. Rheumatol Int. https://doi.org/10.1007/s00296-023-05461-9
Mirzaei A, Zabihiyeganeh M, Haqiqi A (2018) Differentiation of cocaine-induced midline destructive lesions from ANCA-associated vasculitis. Iran J Otorhinolaryngol 30(100):309–313
Gurler A, Boyvat A, Tursen U (1997) Clinical manifestations of BehÇet’s disease: an analysis of 2147 patients. Yonsei Med J 38:423. https://doi.org/10.3349/ymj.1997.38.6.423
Bang D, Lee JH, Lee ES et al (2001) Epidemiologic and clinical survey of Behçet’s disease in Korea: the First Multicenter Study. J Korean Med Sci 16:615. https://doi.org/10.3346/jkms.2001.16.5.615
Groh M, Blanche P, Calmus Y, Guillevin L (2012) Thiabendazole-induced acute liver failure requiring transplantation and subsequent diagnosis of polyarteritis nodosa. Clin Exp Rheumatol 30(1 Suppl 70):S107–S109
Barlow EL, Seddon O, Healy B (2016) PAN’s labyrinth: a multidisciplinary delayed diagnosis and patient’s perspective. BMJ Case Rep 2016:bcr2015213495. https://doi.org/10.1136/bcr-2015-213495
Halabi C, Williams EK, Morshed RA et al (2021) Neurological manifestations of polyarteritis nodosa: a tour of the neuroaxis by case series. BMC Neurol 21:205. https://doi.org/10.1186/s12883-021-02228-2
Karadag O, Bolek EC, Ayan G et al (2024) Clinical characteristics and outcomes of polyarteritis nodosa—an International Study. Arthritis Rheumatol. https://doi.org/10.1002/art.42817
Battafarano DF, Ditmyer M, Bolster MB et al (2018) 2015 American College of Rheumatology Workforce Study: supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res 70:617–626. https://doi.org/10.1002/acr.23518
Unger J, Putrik P, Buttgereit F et al (2018) Workforce requirements in rheumatology: a systematic literature review informing the development of a workforce prediction risk of bias tool and the EULAR points to consider. RMD Open 4:e000756. https://doi.org/10.1136/rmdopen-2018-000756
Misra DP, Agarwal V, Negi VS (2016) Rheumatology in India: a Bird’s eye view on organization, epidemiology, training programs and publications. J Korean Med Sci 31:1013–1019. https://doi.org/10.3346/jkms.2016.31.7.1013
Ahmed S, Zimba O, Gasparyan AY (2020) Moving towards online rheumatology education in the era of COVID-19. Clin Rheumatol 39:3215–3222. https://doi.org/10.1007/s10067-020-05405-9
Vodopivec I, Rizzo JF (2018) Ophthalmic manifestations of giant cell arteritis. Rheumatology 57:ii63–ii72. https://doi.org/10.1093/rheumatology/kex428
Tombetti E, Sarzi-Puttini P (2022) Takayasu arteritis: recent advances and clinical pitfalls. Beyond Rheumatol 4(2):400. https://doi.org/10.53238/br_20228_400
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no potential conflicts of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Auanassova, A., Yessirkepov, M., Zimba, O. et al. Diagnostic delays in systemic vasculitides. Rheumatol Int (2024). https://doi.org/10.1007/s00296-024-05582-9
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s00296-024-05582-9