Skip to main content

Advertisement

SpringerLink
Log in

Vasculitis for the internist: focus on ANCA-associated vasculitis

  • IM - REVIEW
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

Vasculitides comprise several diseases affecting vessels of different sizes, mainly arteries, but also capillaries and veins. Antineutrophil cytoplasm antibody-associated vasculitides (AAVs) belong to the systemic necrotizing small-vessel vasculitis group that comprises granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Internists often see AAV patients, and although their outcomes are usually good, the disease can be responsible for morbidity and mortality. Herein, after reviewing the literature, we concentrate on selected aspects important for the internist, including classification, diagnostic dilemmas, treatment novelties, and follow-up.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Jennette JC (2013) Overview of the 2012 revised International Chapel Hill Consensus Conference nomenclature of vasculitides. Clin Exp Nephrol 17:603–606. doi:10.1007/s10157-013-0869-6

    Article  PubMed  PubMed Central  Google Scholar 

  2. Fraison J-B, Sève P, Dauphin C et al (2016) Kawasaki disease in adults: observations in France and literature review. Autoimmun Rev 15:242–249. doi:10.1016/j.autrev.2015.11.010

    Article  PubMed  Google Scholar 

  3. Pagnoux C, Carette S, Khalidi NA et al (2015) Comparability of patients with ANCA-associated vasculitis enrolled in clinical trials or in observational cohorts. Clin Exp Rheumatol 33:S-77–83

    PubMed  PubMed Central  Google Scholar 

  4. Audemard-Verger A, Pillebout E, Guillevin L et al (2015) IgA vasculitis (Henoch-Shönlein purpura) in adults: diagnostic and therapeutic aspects. Autoimmun Rev 14:579–585. doi:10.1016/j.autrev.2015.02.003

    Article  CAS  PubMed  Google Scholar 

  5. Jachiet M, Flageul B, Deroux A et al (2014) The clinical spectrum and therapeutic management of hypocomplementemic urticarial vasculitis: data from a French nationwide study of 57 patients. Arthritis Rheumatol (Hoboken, NJ). doi:10.1002/art.38956

    Google Scholar 

  6. Quartuccio L, Isola M, Corazza L et al (2014) Validation of the classification criteria for cryoglobulinaemic vasculitis. Rheumatology (Oxford) 53:2209–2213. doi:10.1093/rheumatology/keu271

    Article  Google Scholar 

  7. Comarmond C, Pagnoux C, Khellaf M et al (2013) Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): clinical characteristics and long-term followup of the 383 patients enrolled in the French Vasculitis Study Group cohort. Arthritis Rheum 65:270–281. doi:10.1002/art.37721

    Article  PubMed  Google Scholar 

  8. Chaigne B, Guillevin L (2016) Unsolved questions and concerns about treatment of anti-neutrophil cytoplasm antibody-associated vasculitides. Clin Exp Rheumatol 34:S121–S128

    PubMed  Google Scholar 

  9. Kussmaul A, Maier R (1866) Uber eine bisher nicht beschriebene eigenthumliche arterienerkran-kung (periarteritis nodosa), die mit morbus brightii und rapid fortschreitender allgemeiner muskellahmung einhergeht. Dtsch Arch Klin Med 1:484–518

  10. Wohlwill F (1923) Über die nur mikroskopisch erkennbare Form der Periarteritis nodosa. Virchows Arch Pathol Anat Physiol 246:36

    Article  Google Scholar 

  11. Wegener F (1987) On generalised septic vessel diseases. By Friedrich Wegener, 1937 (translation). Thorax 42:918–919

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Hunder GG, Arend WP, Bloch DA et al (1990) The American College of Rheumatology 1990 criteria for the classification of vasculitis. Introduction. Arthritis Rheum 33:1065–1067

    Article  CAS  PubMed  Google Scholar 

  13. Fries JF, Hunder GG, Bloch DA et al (1990) The American College of Rheumatology 1990 criteria for the classification of vasculitis. Summary. Arthritis Rheum 33:1135–1136

    Article  CAS  PubMed  Google Scholar 

  14. Chaigne B, Terrier B, Thieblemont N et al (2016) Dividing the Janus vasculitis? Pathophysiology of eosinophilic granulomatosis with polyangitis. Autoimmun Rev 15:139–145. doi:10.1016/j.autrev.2015.10.006

    Article  CAS  PubMed  Google Scholar 

  15. Sinico RA, Di Toma L, Maggiore U et al (2005) Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. Arthritis Rheum 52:2926–2935. doi:10.1002/art.21250

    Article  CAS  PubMed  Google Scholar 

  16. Lyons PA, Rayner TF, Trivedi S et al (2012) Genetically distinct subsets within ANCA-associated vasculitis. N Engl J Med 367:214–223. doi:10.1056/NEJMoa1108735

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Damoiseaux J, Csernok E, Rasmussen N et al (2016) Detection of antineutrophil cytoplasmic antibodies (ANCAs): a multicentre European Vasculitis Study Group (EUVAS) evaluation of the value of indirect immunofluorescence (IIF) versus antigen-specific immunoassays. Ann Rheum Dis. doi:10.1136/annrheumdis-2016-209507

    PubMed  Google Scholar 

  18. Csernok E, Moosig F (2014) Current and emerging techniques for ANCA detection in vasculitis. Nat Rev Rheumatol 10:494–501. doi:10.1038/nrrheum.2014.78

    Article  CAS  PubMed  Google Scholar 

  19. Yates M, Watts RA, Bajema IM et al (2016) EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 75:1583–1594. doi:10.1136/annrheumdis-2016-209133

    Article  CAS  PubMed  Google Scholar 

  20. Aasarød K, Bostad L, Hammerstrøm J et al (2001) Renal histopathology and clinical course in 94 patients with Wegener’s granulomatosis. Nephrol Dial Transplant 16:953–960

    Article  PubMed  Google Scholar 

  21. Devaney KO, Travis WD, Hoffman G et al (1990) Interpretation of head and neck biopsies in Wegener’s granulomatosis. A pathologic study of 126 biopsies in 70 patients. Am J Surg Pathol 14:555–564

    Article  CAS  PubMed  Google Scholar 

  22. Schnabel A, Holl-Ulrich K, Dalhoff K et al (1997) Efficacy of transbronchial biopsy in pulmonary vasculitides. Eur Respir J 10:2738–2743

    Article  CAS  PubMed  Google Scholar 

  23. Travis WD, Hoffman GS, Leavitt RY et al (1991) Surgical pathology of the lung in Wegener’s granulomatosis. Review of 87 open lung biopsies from 67 patients. Am J Surg Pathol 15:315–333

    Article  CAS  PubMed  Google Scholar 

  24. Berden AE, Ferrario F, Hagen EC et al (2010) Histopathologic classification of ANCA-associated glomerulonephritis. J Am Soc Nephrol 21:1628–1636. doi:10.1681/ASN.2010050477

    Article  PubMed  Google Scholar 

  25. Berden AE, Jones RB, Erasmus DD et al (2012) Tubular lesions predict renal outcome in antineutrophil cytoplasmic antibody-associated glomerulonephritis after rituximab therapy. J Am Soc Nephrol 23:313–321. doi:10.1681/ASN.2011040330

    Article  CAS  PubMed  Google Scholar 

  26. Hauer HA, Bajema IM, Hagen EC et al (2002) Long-term renal injury in ANCA-associated vasculitis: an analysis of 31 patients with follow-up biopsies. Nephrol Dial Transpl 17:587–596

    Article  Google Scholar 

  27. Hruskova Z, Honsova E, Berden AE et al (2014) Repeat protocol renal biopsy in ANCA-associated renal vasculitis. Nephrol Dial Transpl 29:1728–1732. doi:10.1093/ndt/gfu042

    Article  Google Scholar 

  28. Visconti L, Cernaro V, Ricciardi CA et al (2016) Renal biopsy: still a landmark for the nephrologist. World J Nephrol 5:321–327. doi:10.5527/wjn.v5.i4.321

    Article  PubMed  PubMed Central  Google Scholar 

  29. Rasmussen N, Jayne D, Abramowicz D et al (1995) European therapeutic trials in ANCA-associated systemic vasculitis: disease scoring, consensus regimens and proposed clinical trials. European Community Study Group on Clinical Trials in Systemic Vasculitis ECSYSVASTRIAL. Clin Exp Immunol 101(Suppl 1):29–34

  30. Hellmich B, Flossmann O, Gross WL et al (2007) EULAR recommendations for conducting clinical studies and/or clinical trials in systemic vasculitis: focus on anti-neutrophil cytoplasm antibody-associated vasculitis. Ann Rheum Dis 66:605–617. doi:10.1136/ard.2006.062711

    Article  CAS  PubMed  Google Scholar 

  31. Rosenbaum JT, Choi D, Wilson DJ et al (2015) Orbital pseudotumor can be a localized form of granulomatosis with polyangiitis as revealed by gene expression profiling. Exp Mol Pathol 99:271–278. doi:10.1016/j.yexmp.2015.07.002

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Stone JH, Zen Y, Deshpande V (2012) IgG4-related disease. N Engl J Med 366:539–551. doi:10.1056/NEJMra1104650

    Article  CAS  PubMed  Google Scholar 

  33. Della-Torre E, Lanzillotta M, Campochiaro C et al (2016) Antineutrophil cytoplasmic antibody positivity in IgG4-related disease: a case report and review of the literature. Medicine (Baltimore) 95:e4633. doi:10.1097/MD.0000000000004633

    Article  Google Scholar 

  34. Rachapalli SM, Kiely PDW (2008) Cocaine-induced midline destructive lesions mimicking ENT-limited Wegener’s granulomatosis. Scand J Rheumatol 37:477–480. doi:10.1080/03009740802192043

    Article  CAS  PubMed  Google Scholar 

  35. Borner U, Landis BN, Banz Y et al (2012) Diagnostic value of biopsies in identifying cytoplasmic antineutrophil cytoplasmic antibody-negative localized Wegener’s granulomatosis presenting primarily with sinonasal disease. Am J Rhinol Allergy 26:475–480. doi:10.2500/ajra.2012.26.3825

    Article  PubMed  Google Scholar 

  36. Holle JU, Gross WL, Holl-Ulrich K et al (2010) Prospective long-term follow-up of patients with localised Wegener’s granulomatosis: does it occur as persistent disease stage? Ann Rheum Dis 69:1934–1939. doi:10.1136/ard.2010.130203

    Article  PubMed  Google Scholar 

  37. De Groot K, Rasmussen N, Bacon PA et al (2005) Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum 52:2461–2469. doi:10.1002/art.21142

    Article  PubMed  Google Scholar 

  38. Thickett DR, Richter AG, Nathani N et al (2006) Pulmonary manifestations of anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis. Rheumatology (Oxford) 45:261–268. doi:10.1093/rheumatology/kei217

    Article  CAS  Google Scholar 

  39. Callister MEJ, Baldwin DR, Akram AR et al (2015) British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 70(Suppl 2):ii1–ii54. doi:10.1136/thoraxjnl-2015-207168

    Article  PubMed  Google Scholar 

  40. Harper L (2013) L42. Morbidity in patients with ANCA-associated vasculitis. Presse Med 42:612–616. doi:10.1016/j.lpm.2013.01.040

    Article  PubMed  Google Scholar 

  41. Shang W, Ning Y, Xu X et al (2015) Incidence of cancer in ANCA-associated vasculitis: a meta-analysis of observational studies. PLoS One. doi:10.1371/journal.pone.0126016

    Google Scholar 

  42. Jones RB, Tervaert JWC, Hauser T et al (2010) Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis. N Engl J Med 363:211–220. doi:10.1056/NEJMoa0909169

    Article  CAS  PubMed  Google Scholar 

  43. Stone JH, Merkel PA, Spiera R et al (2010) Rituximab versus cyclophosphamide for ANCA-associated vasculitis. N Engl J Med 363:221–232. doi:10.1056/NEJMoa0909905

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Guillevin L, Pagnoux C, Karras A et al (2014) Rituximab versus azathioprine for maintenance in ANCA-associated vasculitis. N Engl J Med 371:1771–1780. doi:10.1056/NEJMoa1404231

    Article  PubMed  Google Scholar 

  45. Jones RB (2014) Rituximab in the treatment of anti-neutrophil cytoplasm antibody-associated vasculitis. Nephron Clin Pract 128:243–249. doi:10.1159/000368580

    Article  CAS  PubMed  Google Scholar 

  46. Alberici F, Smith RM, Jones RB et al (2015) Long-term follow-up of patients who received repeat-dose rituximab as maintenance therapy for ANCA-associated vasculitis. Rheumatology (Oxford) 54:1153–1160. doi:10.1093/rheumatology/keu452

    Article  Google Scholar 

  47. Holle JU, Dubrau C, Herlyn K et al (2012) Rituximab for refractory granulomatosis with polyangiitis (Wegener’s granulomatosis): comparison of efficacy in granulomatous versus vasculitic manifestations. Ann Rheum Dis 71:327–333. doi:10.1136/ard.2011.153601

    Article  CAS  PubMed  Google Scholar 

  48. Specks U, Merkel PA, Seo P et al (2013) Efficacy of remission-induction regimens for ANCA-associated vasculitis. N Engl J Med 369:417–427. doi:10.1056/NEJMoa1213277

    Article  CAS  PubMed  Google Scholar 

  49. Puéchal X, Pagnoux C, Perrodeau É et al (2016) Long-term outcomes among participants in the WEGENT trial of remission-maintenance therapy for granulomatosis with polyangiitis (Wegener’s) or microscopic polyangiitis. Arthritis Rheumatol (Hoboken, NJ) 68:690–701. doi:10.1002/art.39450

    Article  Google Scholar 

  50. Miloslavsky EM, Specks U, Merkel PA et al (2015) Outcomes of nonsevere relapses in antineutrophil cytoplasmic antibody-associated vasculitis treated with glucocorticoids. Arthritis Rheumatol (Hoboken, NJ) 67:1629–1636. doi:10.1002/art.39104

    Article  CAS  Google Scholar 

  51. Jones RB, Furuta S, Tervaert JWC et al (2015) Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis: 2-year results of a randomised trial. Ann Rheum Dis 74:1178–1182. doi:10.1136/annrheumdis-2014-206404

    Article  CAS  PubMed  Google Scholar 

  52. Walsh M, Faurschou M, Berden A et al (2014) Long-term follow-up of cyclophosphamide compared with azathioprine for initial maintenance therapy in ANCA-associated vasculitis. Clin J Am Soc Nephrol 9:1571–1576. doi:10.2215/CJN.00100114

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Turnbull J, Harper L (2009) Adverse effects of therapy for ANCA-associated vasculitis. Best Pract Res Clin Rheumatol 23:391–401. doi:10.1016/j.berh.2009.04.002

    Article  PubMed  Google Scholar 

  54. Conway R, Low C, Coughlan RJ et al (2015) Risk of liver injury among methotrexate users: a meta-analysis of randomised controlled trials. Semin Arthritis Rheum 45:156–162. doi:10.1016/j.semarthrit.2015.05.003

    Article  CAS  PubMed  Google Scholar 

  55. Siramolpiwat S, Sakonlaya D (2017) Clinical and histologic features of Azathioprine-induced hepatotoxicity. Scand J Gastroenterol. doi:10.1080/00365521.2017.1311936

    PubMed  Google Scholar 

  56. Roberts DM, Jones RB, Smith RM et al (2015) Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun 57:60–65. doi:10.1016/j.jaut.2014.11.009

    Article  CAS  PubMed  Google Scholar 

  57. Mélet J, Mulleman D, Goupille P et al (2013) Rituximab-induced T-cell depletion in patients with rheumatoid arthritis: association with clinical response. Arthritis Rheum. doi:10.1002/art.38107

    PubMed  Google Scholar 

  58. Martin-Garrido I, Carmona EM, Specks U, Limper AH (2013) Pneumocystis pneumonia in patients treated with rituximab. Chest 144:258–265. doi:10.1378/chest.12-0477

    Article  CAS  PubMed  Google Scholar 

  59. Walsh M, Flossmann O, Berden A et al (2012) Risk factors for relapse of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum 64:542–548. doi:10.1002/art.33361

    Article  CAS  PubMed  Google Scholar 

  60. Slot MC, Tervaert JWC, Boomsma MM, Stegeman CA (2004) Positive classic antineutrophil cytoplasmic antibody (C-ANCA) titer at switch to azathioprine therapy associated with relapse in proteinase 3-related vasculitis. Arthritis Rheum 51:269–273. doi:10.1002/art.20234

    Article  CAS  PubMed  Google Scholar 

  61. Thai L-H, Charles P, Resche-Rigon M et al (2014) Are anti-proteinase-3 ANCA a useful marker of granulomatosis with polyangiitis (Wegener’s) relapses? Results of a retrospective study on 126 patients. Autoimmun Rev 13:313–318. doi:10.1016/j.autrev.2013.11.003

    Article  CAS  PubMed  Google Scholar 

  62. Shi Y-Y, Li Z-Y, Zhao M-H, Chen M (2015) The CD4 lymphocyte count is a better predictor of overall infection than the total lymphocyte count in ANCA-associated vasculitis under a corticosteroid and cyclophosphamide regimen: a retrospective cohort. Medicine (Baltimore) 94:e843. doi:10.1097/MD.0000000000000843

    Article  CAS  Google Scholar 

  63. Goupil R, Brachemi S, Nadeau-Fredette A-C et al (2013) Lymphopenia and treatment-related infectious complications in ANCA-associated vasculitis. Clin J Am Soc Nephrol 8:416–423. doi:10.2215/CJN.07300712

    Article  CAS  PubMed  Google Scholar 

  64. Stegeman CA, Tervaert JW, de Jong PE, Kallenberg CG (1996) Trimethoprim-sulfamethoxazole (co-trimoxazole) for the prevention of relapses of Wegener’s granulomatosis. Dutch Co-Trimoxazole Wegener Study Group. N Engl J Med 335:16–20. doi:10.1056/NEJM199607043350103

    Article  CAS  PubMed  Google Scholar 

  65. Zycinska K, Wardyn KA, Zielonka TM et al (2009) Co-trimoxazole and prevention of relapses of PR3-ANCA positive vasculitis with pulmonary involvement. Eur J Med Res 14(Suppl 4):265–267

    Article  PubMed  PubMed Central  Google Scholar 

  66. Guillevin L, Guittard T, Bletry O et al (1987) Systemic necrotizing angiitis with asthma: causes and precipitating factors in 43 cases. Lung 165:165–172

    Article  CAS  PubMed  Google Scholar 

  67. Konishi M, Koarada S, Yamaguchi K et al (2011) Case of microscopic polyangiitis and giant cell arteritis after influenza vaccination. Nihon Rinsho Meneki Gakkai Kaishi 34:154–161

    Article  PubMed  Google Scholar 

  68. Stassen PM, Sanders J-SF, Kallenberg CGM, Stegeman CA (2008) Influenza vaccination does not result in an increase in relapses in patients with ANCA-associated vasculitis. Nephrol Dial Transpl 23:654–658. doi:10.1093/ndt/gfm640

    Article  Google Scholar 

  69. Duggal T, Segal P, Shah M et al (2013) Antineutrophil cytoplasmic antibody vasculitis associated with influenza vaccination. Am J Nephrol 38:174–178. doi:10.1159/000354084

    Article  CAS  PubMed  Google Scholar 

  70. Holvast A, Stegeman CA, Benne CA et al (2009) Wegener’s granulomatosis patients show an adequate antibody response to influenza vaccination. Ann Rheum Dis 68:873–878. doi:10.1136/ard.2008.092924

    Article  CAS  PubMed  Google Scholar 

  71. Holvast A, de Haan A, van Assen S et al (2010) Cell-mediated immune responses to influenza vaccination in Wegener’s granulomatosis. Ann Rheum Dis 69:924–927. doi:10.1136/ard.2009.112813

    Article  CAS  PubMed  Google Scholar 

  72. Groh M, Puéchal X, Terrier B et al (2016) VAC-04—Echec de la vaccination antipneumococcique en phase d’attaque du traitement des vascularites à ANCA: l’étude pneumovas pilote 1. Med Mal Infect 46:111. doi:10.1016/S0399-077X(16)30530-3

    Article  Google Scholar 

  73. Sangle SR, Vounotrypidis P, Briley A et al (2015) Pregnancy outcome in patients with systemic vasculitis: a single-centre matched case-control study. Rheumatology (Oxford) 54:1582–1586. doi:10.1093/rheumatology/kev018

    Article  Google Scholar 

  74. Huong DL, Amoura Z, Duhaut P et al (2002) Risk of ovarian failure and fertility after intravenous cyclophosphamide. A study in 84 patients. J Rheumatol 29:2571–2576

    CAS  PubMed  Google Scholar 

  75. Grygiel-Górniak B, Puszczewicz M (2015) Granulomatosis with polyangiitis in pregnancy—clinical implications and treatment possibilities. Eur Rev Med Pharmacol Sci 19:2331–2335

    PubMed  Google Scholar 

  76. Pagnoux C, Le Guern V, Goffinet F et al (2011) Pregnancies in systemic necrotizing vasculitides: report on 12 women and their 20 pregnancies. Rheumatology (Oxford) 50:953–961. doi:10.1093/rheumatology/keq421

    Article  Google Scholar 

  77. Guillevin L, Pagnoux C, Seror R et al (2011) The Five-Factor Score revisited: assessment of prognoses of systemic necrotizing vasculitides based on the French Vasculitis Study Group (FVSG) cohort. Medicine (Baltimore) 90:19–27. doi:10.1097/MD.0b013e318205a4c6

    Article  Google Scholar 

  78. Bourgarit A, Le Toumelin P, Pagnoux C et al (2005) Deaths occurring during the first year after treatment onset for polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: a retrospective analysis of causes and factors predictive of mortality based on 595 patients. Medicine (Baltimore) 84:323–330

    Article  Google Scholar 

  79. Pagnoux C, Quéméneur T, Ninet J et al (2015) Treatment of systemic necrotizing vasculitides in patients aged sixty-five years or older: results of a multicenter, open-label, randomized controlled trial of corticosteroid and cyclophosphamide-based induction therapy. Arthritis Rheumatol (Hoboken, NJ) 67:1117–1127. doi:10.1002/art.39011

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France

    Benjamin Chaigne & Loïc Guillevin

Authors
  1. Benjamin Chaigne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Loïc Guillevin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Loïc Guillevin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Statements of human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

None.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chaigne, B., Guillevin, L. Vasculitis for the internist: focus on ANCA-associated vasculitis. Intern Emerg Med 12, 577–585 (2017). https://doi.org/10.1007/s11739-017-1683-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-017-1683-z

Keywords

Search

Navigation