Wegener's granulomatosis: prospective clinical and therapeutic experience with 85 patients for 21 years

The diagnosis of Wegener's granulomatosis from transbronchial biopsy specimens

It is widely believed that thoracotomy is necessary to obtain biopsy specimens adequate for the histopathologic demonstration of pulmonary Wegener's granulomatosis (WG). We report five patients with WG who were diagnosed by transbronchial biopsy (TBB). In three cases, a diagnosis of WG was made by TBB alone. In the other two patients, subsequent open lung biopsies confirmed the TBB findings but did not add essential diagnostic information. Our experience suggests TBB may be appropriate as the initial diagnostic procedure in selected cases of suspected WG. This approach requires an understanding of the diverse histologic features of WG and the correlation of clinical and pathologic data.

Paediatric Wegener's granulomatosis: two case histories and a review of the literature

Wegener's granulomatosis is a rare disease in children, with only 37 previous cases described in the literature. We report two new cases, one in an 11-year-old child who presented with cavitating nodules in the right upper lung field as well as a maxillary sinusitis and nasal perforation, and the other in a 16-year-old female who initially presented with a purulent maxillary sinusitis and only later developed an orbital pseudotumour.

Purely granulomatous Wegener's granulomatosis: a new concept for an old disease

In summary, PGWG corresponds to an early phase of WG, presenting only with extravascular granuloma. Primarily, ENT, eye, or lung tissues are involved, but any organ may be affected. The diagnosis is made by typical palisading granuloma associated with elevated c-ANCA levels in the patients' serum. The concept of an early granulomatous lesion (PGWG) facilitates the early diagnosis of WG and leads to classification of different forms of disease according to the multistep evolution hypothesis: first PGWG, then localized or limited forms of the disease, and ultimately generalized vasculitis with renal involvement (classical WG). The concept of PGWG forms the basis for future therapeutic trials where folate antagonists are restricted to PGWG, while immunosuppressive treatment is required for the other stages of WG.

Perianal ulcer: an unusual presentation of Wegener's granulomatosis. Report of a case

A 46-year-old man, without remarkable past medical history, had a perianal ulcer that appeared spontaneously two months before presentation. At admission, the ulcer was painless, measuring 4 to 5 cm in diameter and showing detachment and a slightly papillomatous aspect at the edge but without induration of the base. Microscopic examination revealed cutaneous ulceration with a well-developed inflammatory response, a few small vessels with intraluminal thrombosis or necrotizing walls, and isolated microscopic granulomata. No infectious disease was detected. The diagnosis of Wegener's granulomatosis was made six months later, when the disease was clinically evident in three principal sites: upper airways, lung, and kidney. At that time, serum antineutrophil cytoplasmic autoantibodies were detected with indirect immunofluorescence microscopy. There has been an excellent response to immunosuppressive therapy. Review of the literature revealed no similar reports.

Acral granulomatous dermatosis

A 17-year-old boy developed an acral granulomatous dermatosis which resembled clinically acrodermatitis continua of Hallopeau. The histology showed dermal and subcutaneous abscess formation with granulomas. The lesions responded to systemic corticosteroid therapy, with residual atrophy and contractures of the fingers.

Oral presentation of Wegener granulomatosis

Although the mouth is often involved in Wegener granulomatosis, oral lesions as the initial sign are rare. This case report documents the importance of considering Wegener granulomatosis in patients with unique oral lesions. The most common lesion is a friable-granular-hyperplastic gingivitis associated with alveolar resorption and tooth mobility. The disease may remain localized to the mouth for several weeks or months before multiorgan involvement occurs. Gingival enlargement is a direct manifestation of Wegener granulomatosis, and it may be pathognomonic. Failure to recognize the clinical lesions can result in delayed diagnosis and treatment, with potentially fatal results.

Subglottic stenosis in Wegener's granulomatosis: development during cyclophosphamide treatment with response to carbon dioxide laser therapy

A patient with Wegener's granulomatosis rapidly developed a circumferential subglottic stenosis while on a cyclophosphamide regimen that had caused resolution of systemic symptoms and pulmonary infiltrates. The stenosis developed in the area of previously noted tracheal ulceration and responded satisfactorily to carbon dioxide laser therapy.

Pulmonary Wegener's granulomatosis. A clinical and imaging study of 77 cases

We studied 77 patients with biopsy-proven WG and pulmonary manifestations, to characterize the nature and frequency of the clinical, imaging and endoscopic features of this condition. Pulmonary symptoms were cough, mild dyspnea, hemoptysis and chest pain. Five patients had no pulmonary symptoms. Imaging features consisted of nodules, infiltrates and pleural opacities. A CT scan proved useful by disclosing cavities in opacities or opacities which were not seen on an x-ray film. Fiberoptic bronchoscopy was performed in 74 patients, and it was macroscopically abnormal in 55 percent (showing bronchial inflammation or stenosis or both or isolated hemorrhage). Six patients presented with alveolar hemorrhagic syndrome. Four patients had a pleural exudate rich in polymorphonuclear leukocytes. The WG was limited to the lung in seven patients. Sixteen patients died because of active disease or iatrogenic complications (two). An improved knowledge of clinical and imaging features of WG could help the clinician reach an earlier diagnosis.

Salivary gland involvement in Wegener's granulomatosis

When salivary gland enlargement occurs in association with other ENT symptoms, Wegener's granulomatosis should be considered in the differential diagnosis. An early anti-neutrophil cytoplasmic antibody (ANCA) test may aid diagnosis. Effective medical treatment exists and, once the diagnosis has been made, therapeutic excision of the affected gland may be unnecessary. The fourth and fifth cases in the literature of salivary gland involvement in Wegener's granulomatosis are reported.

Autoantibodies to GBM and neutrophil cytoplasm in rapidly progressive glomerulonephritis

The incidence of autoantibodies to glomerular basement membrane (AGBMA) and neutrophil cytoplasmic antigens (ANCA) in the initial sera of 889 consecutive patients with a suspected diagnosis of rapidly progressive glomerulonephritis, was determined by prospective study. Forty-seven (5%) were positive for AGBMA alone, 246 (28%) were positive for ANCA alone, 576 (65%) had neither autoantibodies while 20 (2%) had both. Clinical and pathological data collected from patients with both autoantibodies suggested the coexistence of anti-glomerular basement membrane disease and systemic vasculitis. Together, assays for AGBMA and ANCA are important in the diagnosis and management of rapidly progressive glomerulonephritis and may help its further classification.

Mediastinal tumour as the presenting manifestation of Wegener's granulomatosis

A 42-year-old man presented with a mediastinal tumour. On histological examination, tuberculosis was evoked, but no definitive conclusion could be drawn. The patient thereafter developed throat ulcerations and rapidly progressing renal insufficiency due to necrotizing glomerulonephritis. After reviewing the histological material, it was concluded that all of these manifestations were related to Wegener's granulomatosis. The presentation of Wegener's granulomatosis as a mediastinal tumour is very rare, but this form of the disease must be recognized, as early treatment with cyclophosphamide is essential for a favourable outcome.

Localised Wegener's granulomatosis--a difficult and delayed diagnosis. Clinical report and literature review

A case of localised Wegener's granulomatosis presenting with central nervous system symptoms and signs is described. The difficulties of early diagnosis are high-lighted and the diagnostic criteria of the disease are discussed.

Microscopic polyarteritis: a forgotten aetiology of haemoptysis and rapidly progressive glomerulonephritis

A 76 year old white woman died from massive pulmonary haemorrhage nine days after she was admitted to Parkland Memorial Hospital for evaluation of haemoptysis and rapidly progressive glomerulonephritis. The differential diagnosis of haemoptysis with rapidly progressive glomerulonephritis is presented with particular emphasis on Wegener's granulomatosis and microscopic polyarteritis. Necropsy showed a small vessel necrotising vasculitis associated with a focal segmental necrotising glomerulonephritis consistent with microscopic polyarteritis.

Hemodialysis does not always protect against recurrence of Wegener's granulomatosis

Hemodialysis may protect against disease activity in Wegener's granulomatosis. We report here a 41-year-old woman with Wegener's granulomatosis, in whom renal transplantation was performed after a 10-month period of hemodialysis during which no signs of disease activity were detected. Recurrence of disease did, however, take place 2 years after renal allograft transplantation despite immunosuppressive therapy with cyclosporine A and prednisone. Reinstitution of hemodialysis and graftectomy did not improve the patient's condition but plasmapheresis and treatment with cyclophosphamide and prednisone eliminated all signs of disease within a fortnight. A proposal for better maintenance of these patients is made.

Anti-endothelial cell antibodies in patients with Wegener's granulomatosis and micropolyarteritis

Anti-endothelial cell antibodies (AECA) have been detected by cell surface radioimmunoassay in nine out of 15 patients with micropolyarteritis (MPA) and in two out of five patients with Wegener's granulomatosis. AECA mostly belonged to the IgG isotype and were present in the active phase of the diseases. These antibodies were not detectable in 10 sera from patients with essential mixed cryoglobulinaemia, suggesting that they were not a mere epiphenomenon consequent to the inflammatory vascular injury. The binding activity was not related to ABH antigens or to HLA class I antigens displayed by resting human endothelial cells in culture and was not influenced by removing immune complexes. Absorption of the anti-neutrophil cytoplasmic antibodies (ANCA), present in MPA and Wegener's granulomatosis sera, did not affect the endothelial binding. AECA-positive sera did not display lytic activity against endothelial cells, neither alone nor after addition of fresh complement or normal human peripheral blood mononuclear cells. Although AECA are not cytolytic for endothelial cell monolayers in vitro, the reactivity against intact endothelial cells suggests their possible involvement in in vivo pathological processes affecting vascular structures in small vessel primary vasculitides.

Pitfalls with anti-neutrophil cytoplasmic antibodies (ANCA)

A 39-year-old Ugandan student is described presenting with general malaise, fever and a pulmonary infiltrate. Open lung biopsy showing infarction and positive ANCA lead to a diagnosis of Wegener's granulomatosis and a treatment with immunosuppressive drugs was instituted. Five weeks after admission, however, sputum cultures turned out to be positive for Mycobacterium tuberculosis. The importance of ANCA-interpretation and the possibility of false positive results is discussed.

Wegener's granulomatosis, subglottic stenosis and antineutrophil cytoplasm antibodies

Wegener's granulomatosis is difficult to diagnose, especially when the presentation is unusual, restricted to an isolated region. We report four cases of recurrent subglottic stenosis posing difficulty in diagnosis. In each case the finding of anti-neutrophil cytoplasm antibodies (ANCA) strongly suggested an underlying vasculitic pathology, Wegener's granulomatosis. We discuss reasons for the difficulty in diagnosis in the past, the possible role of the ANCA assay in such patients, and suggest it should be more widely used in the future.

A review of the rational use of corticosteroids

Understanding of the use of corticosteroids has been aided by knowledge of their effect on cellular protein synthesis and by an appreciation of how modification of their molecular structure alters their pharmacological action. Their ability to modulate the immune response and to diminish inflammation make them useful in rheumatology, respiratory diseases, allergies, endocrine and metabolic disorders, blood disorders, gastro-intestinal diseases, neurological and muscular diseases, renal diseases, cardiovascular disorders and skin diseases. They have been widely tried empirically and, sometimes, they have proved unequivocally effective. Often there has been a need for cooperative clinical trials to establish their efficacy, and initial enthusiasm for corticosteroids has been tempered by a better appreciation of their limitations, especially in infections and ophthalmology. Those areas where either controlled trials or other persuasive evidence has established a place for their use are reviewed.

Wegener's granulomatosis autoantibodies identify a novel diisopropylfluorophosphate-binding protein in the lysosomes of normal human neutrophils

Anti-neutrophil cytoplasmic autoantibodies (ANCA) specifically associated with Wegener's granulomatosis were found to be directed against a saline-soluble glycoprotein triplet that migrates on SDS gels as distinct bands of Mr 29,000, 30,500, and 32,000 and is present in the azurophilic granules. This antigen was specifically recognized by all cytoplasmic-staining (C)-ANCA-positive sera from patients with Wegener's disease. C-ANCA antigen bound [3H]diisopropylfluorophosphate, which indicates that it is a serine protease, but it could clearly be distinguished from the serine proteases elastase and cathepsin G. Stimulation of cytochalasin B-treated neutrophils with FMLP induced release of C-ANCA antigen. This indicates that in vivo C-ANCA might interact with the C-ANCA antigen after its release upon inflammatory stimulation. We further demonstrate that in some perinuclear staining (P-ANCA) patients' sera autoantibodies against other myeloid lysosomal enzymes can be detected, such as antimyeloperoxidase and antielastase. C-ANCA and P-ANCA thus represent a novel class of autoantibodies directed against myeloid lysosomal enzymes. The originally described Wegener-specific C-ANCA show an apparently uniform specificity for the 29,000 serine protease. In contrast, P-ANCA may recognize myeloperoxidase as well as elastase and/or other antigens.

Immune-complex vasculitis: role of complement and IgG-Fc receptor functions

Vasculitis contributes a major component to the pathogenesis of rheumatic diseases and glomerulonephritis. A common feature of these diseases is the presence of serum immune complexes (IC) which may be deposited in blood vessel walls. The modification of the size and solubility of IC by the classical and alternative complement pathways, and the recent demonstration of the role of cellular complement receptors and IgG-Fc receptors in the handling of IC, now allow a better understanding of the pathogenesis of the severe forms of vasculitis. When complement deficiencies are present, the handling of IC is impaired, and vasculitis results. New blood tests for Factor VIII-related antigen, alkaline ribonuclease, plasma thrombospondin, and anti-neutrophil cytoplasmic antibody correlate with the presence of selected types of vasculitis. In addition, tissue thromboplastin release after application of defined tourniquet pressure can also detect subtle blood vessel injury. These new tests may allow diagnosis without risky organ biopsies. Advances in the diagnosis and treatment of vasculitis will also be discussed.

Ear, nose, and throat symptoms in subacute Wegener's granulomatosis

The standard description of Wegener's granulomatosis emphasises renal failure and thus a distorted impression may be given. Subacute and even chronic cases occur, and in these patients the presentation is varied and often insidious, leading to delay in diagnosis. Twenty two such patients (13 women and nine men) with a mean age of 44 years were seen in our connective tissue disease clinic. The mean duration of symptoms before diagnosis was 3.6 years and the mean duration of disease 5.9 years (19 years in one patient). All patients had malaise and ear, nose, and throat symptoms, and most had joint pains. Impaired renal function was seen in seven patients only. Tissue biopsy was diagnostic in half of the patients, and appreciably high titres of antineutrophil cytoplasmic antibodies were detected in only nine of 18 patients in whom these were measured. The most useful investigations were neutrophil counts, chest radiographs, and computed tomography of the sinuses and orbits. The most effective treatment was with intravenous pulses of cyclophosphamide. No deaths occurred. At the time of writing two patients were in remission and no longer being treated and 18 patients were in partial remission on continued treatment. Patients with subacute forms of Wegener's granulomatosis present with a variety of clinical features and the insidious presentation often leads to delay in diagnosis. A history of ear, nose, and throat symptoms was universal in our patients.

Wegener's granulomatosis presenting as acute respiratory failure with anti-neutrophil-cytoplasm antibodies

Anti-neutrophil-cytoplasm antibodies recently have been reported as serologic markers of Wegener's granulomatosis. We describe two cases in which this test appeared to be of great value in the diagnosis of Wegener's granulomatosis presenting as acute respiratory failure, a clinical setting in which it may be the only diagnostic test that can be safely and easily performed.

Microscopic polyarteritis: clinical features and treatment

The clinical features, treatment and survival of 36 patients with microscopic polyarteritis diagnosed between 1957-1988 have been reviewed. All had a focal segmental necrotizing glomerulonephritis on renal biopsy with evidence of a small vessel vasculitis. Most had a prodromal illness of less than 1 month. Severity of renal disease varied from microscopic haematuria which has a good prognosis to acute oliguric renal failure which carries a high mortality. The prognosis of microscopic polyarteritis can be improved if the condition is recognized early and treated with steroids and cyclophosphamide.

Stage-adapted treatment of Wegener's granulomatosis. First results of a prospective study

Considering cyclophosphamide's severe side effects there is a need for a new, less toxic treatment protocol for Wegener's granulomatosis. Here we report the first results of a prospective study using cyclophosphamide pulse therapy (monthly application) (a) as an alternative treatment in seven cases of active generalized Wegener's granulomatosis, which either showed complications under continuous cyclophosphamide treatment or in which the partial remission was not steady, and (b) as the initial treatment in five newly diagnosed patients with active generalized disease. After complete remission had been achieved in all cases in group (a), but only two cases in group (b), we started treatment with trimethoprim/sulfamethoxazole (cotrimoxazole) to maintain remission. Three of 8 patients suffered from severe relapses 9, 11 and 12 months after discontinuation of cyclophosphamide. The 3 patients in group (b) who could not be brought into remission had to be put on continuous cyclophosphamide. In addition, we treated 3 patients with newly diagnosed locoregional disease with cotrimoxazole alone. Two of these patients responded promptly and have only minor symptoms after 13 and 27 months, respectively. In one patient the disease continued to progress in the upper respiratory tract, and treatment was switched to cyclophosphamide and prednisolone after a period of 3 months. From these results we believe that cyclophosphamide pulse therapy is a successful alternative treatment protocol after partial remission has been achieved with a daily administration of cyclophosphamide or if complications, e.g-. leukopenia, arise with the continuous use of this drug. As an initial treatment, however, bolus treatment still appears to be an experimental protocol.(ABSTRACT TRUNCATED AT 250 WORDS)

Alveolar hemorrhage in Wegener's granulomatosis

The authors describe massive, fatal alveolar hemorrhage in an 82-year-old woman in whom a diagnosis of Wegener's granulomatosis was made at postmortem examination. A literature review revealed a total of 18 case reports of this entity that were described in sufficient detail to permit abstraction of clinical characteristics. When compared with a large series of patients with more "typical" Wegener's granulomatosis, patients with alveolar hemorrhage had more evidence of systemic vasculitis and glomerulitis and less evidence of upper airway disease. Alveolar hemorrhage was associated with greater than 50% mortality, reflecting in part, the fulminant nature of this complication of Wegener's granulomatosis. All survivors had been treated with cytotoxic agents; those who died had either no specific therapy or were treated either with corticosteroids alone or died before cytotoxic therapy could be expected to be effective. Wegener's granulomatosis should be in the differential diagnosis for patients who present with alveolar hemorrhage with or without renal failure. An aggressive diagnostic approach and the earliest possible administration of cytotoxic drugs in combination with corticosteroids offer the best chance of survival in this fulminant condition.

Wegener's granulomatosis: false positive anti-neutrophil cytoplasmic antibody test

The anti-neutrophil cytoplasmic antibody (A.N.C.A.) test is a solid phase radioimmunoassay which detects auto-antibodies specific for Wegener's granulomatosis. The case of a young male is reported with a nasal septal perforation who was extensively investigated revealing no other clinical features, apart from a positive A.N.C.A. test, warranting a diagnosis of Wegener's granulomatosis. It is felt the case represents a false positive A.N.C.A. test and emphasises that the test, whilst useful, should be interpreted in the context of other diagnostic criteria.