Publish in this journal
Journal Information
Vol. 17. Issue 6.
Pages 318-321 (June - July 2021)
Visits
...
Vol. 17. Issue 6.
Pages 318-321 (June - July 2021)
Brief Report
Full text access
Cogan syndrome: Descriptive analysis and clinical experience of 7 cases diagnosed and treated in two third level hospitals
Síndrome de Cogan: análisis descriptivo y experiencia clínica de 7 casos diagnosticados y tratados en 2 hospitales de tercer nivel
Visits
...
Tomás Almorza Hidalgoa,
Corresponding author
tomas.almorza@hotmail.com

Corresponding author.
, Alfredo Javier García Gonzáleza, Santos Castañedab,c, Eva G. Tomerob,c, Jose Luis Pablos Álvareza,d
a Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, Spain
b Servicio de Reumatología, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
c Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
d Universidad Complutense Madrid, Madrid, Spain
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (1)
Table 1. Description of cases diagnosed with Cogan syndrome in 2 third level hospitals.
Abstract
Objective

Cogan’s syndrome (CS) is an inflammatory disease classified as variable vessel vasculitis. It is a rare disease with few published series, and therefore we reviewed our experience in the last ten years in two centres.

Materials and methods

Description of 7 diagnosed cases of CS, according to the classification criteria (typical or atypical), their clinical manifestations, treatments used and their complications. A comparative analysis was performed with the series and cases described in the literature.

Results

7 cases were included, three men and four women, with a mean age at diagnosis of 43 years, and an average disease duration of 47 months. Five patients met the typical characteristics according to the 1980 classical criteria, the rest being atypical cases, one due to the absence of interstitial keratitis and another due to a period between the onset of ocular and auditory-vestibular clinical symptoms greater than two years. All received immunosuppressants, methotrexate being the most commonly used, followed by azathioprine. In 5 cases, biological drugs were used, infliximab in 4 times and 2 tocilizumab. One patient died from bacterial endocarditis and septic shock.

Conclusion

The characteristics of the series presented are like those published to date, with clinical differences mainly in the involvement of large vessels. Given the low frequency, it seems necessary to create multicentre records to improve the evidence regarding the management of patients with Cogan´s Syndrome.

Keywords:
Cogan’s syndrome
Case series
Biologics
Glucocorticoids
Immunosuppressants
Resumen
Objetivo

El síndrome de Cogan (SC) es una enfermedad inflamatoria clasificada como vasculitis de vaso variable. Se trata de una enfermedad rara con escasas series publicadas por lo que revisamos nuestra experiencia en dos centros en los últimos diez años.

Material y métodos

Descripción de 7 casos diagnosticados de SC, atendiendo a los criterios de clasificación (típico o atípico), sus manifestaciones clínicas, tratamientos utilizados y sus complicaciones. Se realizó un análisis comparativo con las series y casos descritos en la literatura.

Resultados

Se incluyeron 7 casos, tres varones y cuatro mujeres, con una edad media al diagnóstico de 43 años, y un tiempo de evolución medio de 47 meses. Cinco pacientes cumplían las características típicas según los criterios clásicos de 1980, siendo el resto casos atípicos, uno por ausencia de queratitis intersticial y otro por un periodo entre la aparición de clínica ocular y auditivo-vestibular mayor de dos años. Todos recibieron inmunosupresores, siendo el más utilizado el metotrexato, seguido de la azatioprina. En 5 casos se utilizaron fármacos biológicos: infliximab en 4 ocasiones y en 2 tocilizumab. Un paciente falleció por endocarditis bacteriana y shock séptico.

Conclusión

Las características de la serie presentada son similares a las publicadas hasta ahora, con diferencias clínicas fundamentalmente en la afectación de grandes vasos. Ante la escasa casuística, parece necesario la creación de registros multicéntricos para mejorar la evidencia en cuanto al manejo de pacientes con Síndrome de Cogan.

Palabras clave:
Síndrome de Cogan
Serie de casos
Biológicos
Glucocorticoides
Inmunosupresores
Full Text
Introduction

Cogan syndrome (CS) is an inflammatory disease which was described for the first time in 1934 by Morgan and Baymgamer1 and, later by David G. Cogan in 1945.2 Classified as variable vessel vasculitis by Chapel-Hill in 2012,3 it is characterized by ocular, vestibular-auditory and vasculitis symptoms, generally of the large vessels.4 This is a rare disease which presents mainly in young Caucasian males,2 and may also affect children.4

Two well differentiated, typical and atypical CS3 phenotypes have been described within the disease spectrum. The first corresponds to those patients who present with non-syphilitic interstitial keratitis, associated, or not, with conjunctivitis or subconjuntival bleeding; vestibular symptoms similar to Ménière’s syndrome with progressive hearing loss up to deafness in months, with an interval between ocular and auditory-vestibular symptoms of under 2 years. Atypical CS is characterised by ocular symptoms without interstitial keratitis or for an interval between auditory-vestibular and ocular symptoms above 2 years.5

The causes of this disease are not well known and there are few pathological or experimental references that lead to the creation of a pathogenic hypothesis.3 CS is considered to be an immune mediated disease,6 but there are no auto-antibodies or markers of clinical use. Due to the low frequency of CS, clinical and therapeutic management of this disease is based on the observations of the few published series.7

Material and methods

We carried out a review of the diagnostic codes in the hospital databases of 2 third level centres, which attended to a total population of approximately 800,000 inhabitants between both, to identify the diagnosed CS cases in the last 5 years (Table 1), creating a descriptive analysis of a retrospective nature.

Table 1.

Description of cases diagnosed with Cogan syndrome in 2 third level hospitals.

Patient  Sex  Age  Age at diagnosis (years)  Disease duration (months)  Phenotype (reasons for atypical type)  AA  Auditory symptoms  Vestibular symptoms  Ocular symptoms  Joint symptoms  Aorta/large vessel symptoms  Association with IBD type  Corticoid bolus on diagnosis  Systemic treatments received  Complications  Death (cause) 
Man  54  49  62  Typical  No  Sensorineural deafness with cochlear involvement  Peripheral Vertigo  Interstitial keratitis  No  Aortitis.  No  Yes  1st line : CFM + PDN  Chronic HBV carrier.  No 
                      Left carotid      2nd line : MTX + PDN  Ischaemic heart failure.   
                            3rd line:  Aortic and mitral valvulopathy.   
                            AZA + PDN  Sensitive-motor polyneuropathy   
                            4th line:     
                            IFX + AZA + PDN     
Woman  63  63  Atypical (> 5 years between regions)  Anti-Ro+  Sudden deafness  No  LE anterior Uveitis.  No  No  No  Yes  1st line:  Uncontrolled HBP  No 
                  interstitial keratitis          AZA + PDN     
                            2nd line:     
                            MTX + PDN     
Male  48  46  25  Atypical (no interstitial keratitis  No  Bilateral Cofosis.  Peripheral vertigo  Bilateral anterior uveitis.  Sacroileitis  Aortitis ( abdominal aorta).  No    1st line:  Left facial paralysis.  Yes (endocarditis bacteriana) 
              Neurosensory deafness in left ear    Bilateral scleritis  Arthritis in right ankle  Iliac arteries      CFM + PDN  Mild leuconeutropenia   
                      Common carotids, bifurcation and external carotids      2nd line:  Steroid Diabetes   
                            MTX + PDN     
                            3rd line:     
                            TCZ + MTX + PDN     
Woman  48  42  73  Typical  ANA+ 1/40  Sensorineural deafness  Peripheral vertigo  Bilateral nodular Epiescleritis.  Bilateral ankle arthritis  Aortitis  No  No  1st line:  Carpal tunnel syndrome.  No 
                  Instertitial keratitis.          AZA + DZC  Mild hypertransaminasemia.   
                  LE anterior uveitis            Episodic lymphopenia   
Male  35  34  15  Typical  No  Left sensorineural deafness  Peripheral vertigo  Interstitial keratitis.  No  No  Ileitis terminal Crohn like foot-and-mouth disease  Yes  1st line:  Mild hypertransaminasemia  No 
                  Bilateral anterior unveils          MTX + PDN     
                            2nd line:     
                            IFX + MTX + PDN     
Woman  33  32  18  Typical  No  Bilateral tinnitus.  Peripheral vertigo  Interstitial keratitis. In RE.  No  No  No  Yes  1st line:  No  No 
              Severe RE deafness    Anterior uveitis in LE          MTX + PDN     
                            2nd line:     
                            IFX + PDN     
Woman  44  33  132  Typical  p-ANCA+ /anti -PR3  Bilateral hearing impairment  Right vestibular paresis  Interstitial keratitis.  Small joint arthritis  No  No  Yes  1st line:  Recurrent neutrophilic dermatitis.  No 
                  Bilateral interstitial          PDN + MTX, 2nd line: MMF  Sensorineural deafness   
                  keratitis          3rd line:     
                            IFX, TCZ     

AA: auto-antibodies; ANA: antinuclear antibodies; ANCA: anti-neutrophil cytoplasmic antibodies; AZA: azatioprine; CFM: ciclophosphamide; DZC: deflazacort; IBD: inflammatory bowel disease: IFX: infliximab; LE: left eye; MMF: micophenolate mofetil; MTX: methotrexate; PDN: prednisone; RE: right eye; TCZ: tocilizumab.

Age at diagnosis and duration of disease was recorded, together with the main clinical, therapeutic and evaluative aspects, in accordance with the classification criteria.

Auto-antibody profiles found in the patients were described and the data of involvement of large vessels studied through the use of positron emission tomography to computerised tomography (PET/CT) in all patients. The association, described in the literature, with inflammatory bowel disease, 8 and joint involvement were recorded to a lesser extent in the published series.9

We then performed a description of treatment used, including steroids, immunosuppressant and biologic treatments, recording the frequency of each of them and the complications associated with them, as well as the most relevant data on evolution and outcomes.

Results and discussion

Seven diagnosed cases of CS (Table 1) were described, 5 of them with the typical phenotype and 2 atypical, due, in one case, to the absence of interstitial keratitis and in the second to a period of over 2 years before the appearance of the ocular and auditory-vestibular symptoms.

Mean age at diagnosis was 42 years (32-63) with a mean follow-up from diagnosis of 47 months (7-132). The predominant ocular manifestation was the interstitial keratitis, present in 5 of the 7 cases, and with the additional presence of anterior uveitis in 5 cases (3 of them bilateral), as well as scleritis/epiescleritis in 2 patients, with no conjunctivitis in any case. In previously published series symptoms have been described in the before-mentioned ocular regions, although with a lower proportion of uveitis, and the rest of the symptom percentages being similar to those in our series.7,8

All the patients presented with auditory symptoms (deafness or hearing loss), which is in keeping with the published series.2 In this respect, there was a non response to treatment, with no improvement in the audiometric controls after treatment. The presence of vestibular symptoms (a typical trait of this disease)2,7,10,11 were constant, except in one case, where the course of the disease was not as prolonged (7 months from diagnosis), classified as atypical CS.

All patients were studied using PET/CT, with observation of large vessel symptoms in 3 cases, a higher proportion than that descried in the literature3,6,10 probably related to the systematic search for vascular involvement in our series. Imaging tests for diagnosis or follow-up was not clearly established. In our patients no subsequent complications, such as occlusive phenomena or the development of aneurisms, were recorded.

Three patients presented with joint symptoms, 2 with ankle arthritis, one with sacroiliac joints and another affecting the small joints in the hands. These symptoms presented to a similar extent to that published up until now, where arthromyalgias were described in approximately 15%–35% of cases, depending on the series.7,8

One of the patients presented with an intestinal symptom compatible with inflammatory bowel disease (IBD), which was diagnosed through biopsy. The relationship between CS and the presence of IBD has already been reported in previous publications and may be part of the clinical spectrum of CS symptoms,8,9 albeit uncommon.

Experimental data exist which describe the presence of class IgG and IgA auto-antibodies aimed against inner ear tissues and corneal tissues in patients with CS,6,11 which present similarities with the SSA/Ro and CD148 auto-antigens.6,12 These auto-anti-bodies are not normally used in clinical practice. In some patients with CS, anti-neutrophil cytoplasmic anti-bodies ANCA)12 have also been described (in our series one of the patients presented with antinuclear anti-bodies by virtue of 1/40, another patient presented with positive anti-To antibodies, and one patient presented with positive anti-PR3 antibodies, with no other clinical symptoms or associated diseases.

Regarding treatments used most frequently in the published series, corticoid therapy is the baseline initial treatment, with frequent use of corticoid pulses.13,14 in our series corticoid pulses were used in all cases. In addition to corticotheapy methotrexate was the most used immunosuppressant (6 cases), followed by azatioprine (3 cases), in a similar proportion to previously described cases.

Biologic therapies have been in use since 2000 to treat both ocular and auditory symptoms, particularly in refractory patients, with the most used agents being the anti-TNF, mostly infliximab (IFX),14,15 used in 4 of the 7 patients. Tocilizumab was used in 2 patients.

Finally, the evolution of patients in our series during the study period was diverse. The area with the best prognosis was ophthalmologic, with recovery or improvement in all cases. The auditory–vestibular area in contrast presented with torpid evolution, despite treatments administrated (corticoids, standard immunosuppressant’s or biologic therapies).

In our patients only one serious complication was recorded, a death from septic shock by bacterial endocarditis, in the patient who had received tocilizumab, after having previously been in fist line treatment with cyclophosphamide and second line treatment with methotrexate, together with a high corticoid dose.

Conclusions

As far as we know, this is the most numerous patient series with CS to be described on a national level, and shows general similar characteristics to published series. Joint symptoms and particularly large vessel symptoms could be more frequent in this disease than described, and based on our observation, their systematic search could bring to light silent cases.

In the absence of quality evidence, therapeutic guidelines are unallied, highlighting the need for multicentre records for this type of low incidence diseases.

Conflict of interests

The authors have no conflict of interests to declare.

References
[1]
O. Singer.
Cogan and Behcet syndromes.
Rheum Dis Clin North Am, 41 (2015), pp. 75-91
[2]
A. Greco, A. Gallo, M. Fusconi, G. Magliulo, R. Turchetta, C. Marinelli, et al.
Cogan’s syndrome: an autoimmune inner ear disease.
Autoimmun Rev, 12 (2013), pp. 396-400
[3]
I. Pagnini, M.E. Zannin, F. Vittadello, M. Sari, G. Simonini, R. Cimaz, et al.
Clinical features and outcome of Cogan syndrome.
J Pediatr, 160 (2012), pp. 303-307
[4]
P. Mora, G. Calzetti, S. Ghirardini, P. Rubino, S. Gandolfi, J. Orsoni.
Cogan’s syndrome: state of the art of systemic immunosuppressive treatment in adult and pediatric patients.
Autoimmun Rev, 16 (2017), pp. 385-390
[5]
I.D. Adriana, T.C. Mihaela, B. Mehdi, D.S. Algerino, S. Cornel.
Cogan`s syndrome.
Rom J Ophthalmol, 59 (2015), pp. 6-13
[6]
C. Lunardi, C. Bason, M. Leandri, et al.
Autoantibodies to inner ear and endothelial antigens in Cogan’s syndrome.
[7]
M.B. Gluth, K.H. Baratz, E.L. Matteson, C.L.W. Driscoll.
Cogan syndrome: a retrospective review of 60 patients throughout a half century.
Mayo Clin Proc, 81 (2006), pp. 483-488
[8]
M. Scharl, P. Frei, M. Fried, G. Rogler, S.R. Vavricka.
Association between Cogan’s syndrome and inflammatory bowel disease: a case series.
J Crohn’s Colitis, 5 (2011), pp. 64-68
[9]
A. Grasland.
Typical and atypical Cogan’s syndrome: 32 cases and review of the literature.
Rheumatology (Oxford), 43 (2004), pp. 1007-1015
[10]
A. Kessel, Z. Vadasz, E. Toubi.
Cogan syndrome — pathogenesis, clinical variants and treatment approaches.
Autoimmun Rev, 13 (2014), pp. 351-354
[11]
G.M. Espinoza, A. Prost.
Cogan’s syndrome and other ocular vasculitides.
Curr Rheumatol Rep, 17 (2015), pp. 50-53
[12]
R. Stephan, B. Ariella, K. Christoph, V. Anne, S.R. Vavricka, T. Greuter, et al.
Cogan’s syndrome in patients with inflammatory bowel disease — a case series.
J Crohns Colitis, 9 (2015), pp. 886-890
[13]
O.E. Tayer-shifman, O. Ilan, H. Tovi.
Cogan’ s syndrome — clinical guidelines and novel therapeutic approaches.
Clin Rev Allerg Immunol, 47 (2014), pp. 65-72
[14]
M.F.A.B.F. Wermelinger, P.M.V.A. Helbling.
Case Report. A novel therapeutic option in Cogan diseases? TNF-blockers.
Rheumatol Int, 27 (2007), pp. 493-495
[15]
C. Durtette, E. Hachulla, M. Resche-Rigon, T. Papo, T. Zénone, B. Lioger, et al.
Cogan syndrome: characteristics, outcome and treatment in a French nationwide retrospective study and literature review.
Autoimmun Rev, 16 (2017), pp. 1219-1223

Please cite this article as: Almorza Hidalgo T, García González AJ, Castañeda S, Tomero EG, Pablos Álvarez JL. Síndrome de Cogan: análisis descriptivo y experiencia clínica de 7 casos diagnosticados y tratados en 2 hospitales de tercer nivel. Reumatol Clin. 2021;17:318–321.

Copyright © 2020. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Idiomas
Reumatología Clínica (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?