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

Update on systemic necrotizing vasculitis

The systemic necrotizing vasculitides are classified into vasculitic syndromes on the basis of the pattern of clinical and pathologic involvement. The vasculitides have certain common clinical and laboratory abnormalities. Systemic necrotizing vasculitis is diagnosed on the basis of clinical features, and the vascular nature of the disease is determined by biopsy of involved tissue or angiography. The outcome is dependent on the extent of visceral involvement. Vascular inflammation influences the physiologic features of the vessel and may trigger vasoconstriction. Although glucocorticoids combat the inflammation, they may augment vasoconstriction and platelet aggregation. These effects must be considered in designing a management approach and in evaluating the cause and management of ischemic complications.

Recovery from sensorineural deafness in Wegener's granulomatosis

Wegener's granulomatosis may present with deafness or other aural symptoms. This report describes two patients with histological evidence of Wegener's granulomatosis who developed reversible sensorineural hearing loss during the course of their illness. The first patient showed complete recovery of a sensorineural hearing loss averaging 50 dB after ten months treatment with cyclophosphamide and high-dose prednisolone. The second patient, who was on maintenance haemodialysis, achieved a 40 dB improvement in sensorineural hearing loss within two weeks of adding cyclophosphamide to pre-existing corticosteroid therapy. These findings suggest that the prognosis of sensorineural hearing loss in Wegener's granulomatosis can be improved with suppression of the vasculitic process by early treatment with combined cytotoxic-immunosuppressive therapy.

Limbal allergic granulomatosis

Four limbal diseases characterised by granuloma formation as part of an allergic response are discussed. A series of histological specimens from patients with Wegener's granulomatosis were re-examined. Genuine granulomatous disease at the limbus is rare, only occurring in two patients, whilst secondary, more non-specific limbal active chronic inflammation was more common. Comparisons between this disease, Churg Strauss allergic angiitis, some varieties of Mooren's ulcer and allergic granulomatous nodules were made. The role of the mast cell in promoting this eosinophilic leucocytic mediated group of disease is discussed briefly.

[Wegener's granulomatosis and pregnancy. A case]

Pregnancy concomitant with Wegener's granulomatosis is extremely rare: so far, only four cases have been published. The authors report a fifth case where the disease appeared during the post-partum period, a situation which has already been noted in two of the published cases. Interruption of a subsequent pregnancy was followed by a flare-up of the disease resulting in the patient's death. This suggests that post-partum and post-abortum are probably instrumental in the onset and deterioration of Wegener's granulomatosis. The two patients previously reported who received immunosuppressants combined with corticosteroids had no flare-up after delivery. It seems permissible to prescribe such a therapeutic combination before and after delivery or abortion, especially since the fear of foetal toxicity from these drugs seems to be exaggerated.

Infectious complications of cyclophosphamide treatment for vasculitis

Fifteen patients with Wegener's granulomatosis, polyarteritis nodosa, or isolated angiitis of the central nervous system were treated with cyclophosphamide according to a widely used regimen. Seventeen clinical episodes of infection were observed over 201 patient-months of cyclophosphamide therapy, and 2 patients died of pneumonia. Notably, neither the incidence of leukopenia nor the dosage or duration of cyclophosphamide or corticosteroid therapy correlated well with infection, which occurred most frequently in men over 60 years of age. Patients with Wegener's granulomatosis appeared to be at greater risk of infection than those with the other forms of vasculitis. These results suggest that this treatment regimen may not be as safe as was previously thought.

Detection and quantitation of anti-neutrophil cytoplasm antibodies in Wegener's granulomatosis by ELISA using affinity-purified antigen

Autoantibodies directed against cytoplasmic components of neutrophil granulocytes and monocytes (ACPA) have previously been described as a disease-specific marker for Wegener's granulomatosis (WG). We have developed an ELISA for determining and quantifying ACPA using an affinity-purified antigen preparation. The antigen was purified from supernatants of human neutrophils stimulated with phorbol ester to induce degranulation, by means of affinity chromatography with naturally occurring human autoantibodies. The established ELISA was sufficiently specific and sensitive, and the ACPA concentrations obtained with it correlated significantly with the ACPA titres determined by an indirect immunofluorescence technique (Spearman's rank correlation coefficient = 0.85, P less than 0.001, n = 105 WG patients). This ELISA provides precise ACPA quantitation and should prove valuable for monitoring disease activity in WG.

Legionella pneumonia complicating Wegener's granulomatosis

We describe a previously healthy man who presented with features consistent with Wegener's granulomatosis. While undergoing investigation, he developed acute respiratory failure, thought to represent progression of his vasculitis. Open lung and sinus biopsies were performed to obtain the diagnosis. Vasculitis was confirmed on the paranasasl biopsy, and the lung biopsy showed pneumonia due to Legionella pneumophila, an association not previously reported in Wegener's granulomatosis. If immunosuppressive therapy had been started without making the diagnosis of Legionella pneumonia on lung biopsy, the patient might well have succumbed to the infection.

Renal biopsy and antineutrophil antibodies in the diagnosis and assessment of Wegener's granuloma

Seventeen patients with Wegener's granuloma (WG), all of whom had renal biopsies taken at presentation, are reviewed. In conjunction with nasal or transbronchial biopsies renal biopsies aided diagnosis and also yielded prognostic information. The detection of antineutrophil cytoplasm antibodies in the serum of patients with WG is a useful supplementary diagnostic tool.

The pulmonary biopsy in the early diagnosis of Wegener's (pathergic) granulomatosis: a study based on 35 open lung biopsies

We reviewed open lung biopsies from 35 patients with Wegener's (pathergic) granulomatosis in order to study the histogenesis of the pulmonary lesions and to identify the early lesions. The process of pathergic necrosis is fundamental in the production of extravascular and vascular lesions and was divided into micronecrotic and macronecrotic types. Micronecrosis, usually with neutrophils (microabscesses), constitutes the early phase in the development of the pathognomonic organized palisading granuloma. The palisading granuloma differs from the compact granuloma of tuberculoid type, which occurs in infections and sarcoidosis but not in Wegener's (pathergic) granulomatosis. There is a progression of disease from micronecrosis to macronecrosis (widespread necrosis) and then to fibrosis. Macronecrosis surrounded by palisading histiocytes or diffuse granulomatous tissue indicates active disease, whereas necrosis surrounded by fibrous tissue indicates previously active disease. Most cases have a combination of micronecrosis, and fibrosis. We established the relative diagnostic value of various histologic features. Arteritis and phlebitis as classically described in Wegener's granulomatosis were present in most but not all cases. We believe that Wegener's granulomatosis primarily affects both vascular and extravascular collagen and reticulum and that vasculitis represents a primary necrosis of walls of blood vessels. We believe that the concept of Wegener's granulomatosis as a vasculitis is too restrictive and does not include many cases with only extravascular histologic changes.

Approach to the patient with diffuse lung disease

When evaluating diffuse lung infiltrates, the clinician should place special emphasis on the acuity of symptoms, nonpulmonary complaints and findings, environmental exposures, and risk factors for immunosuppressive diseases. Certain radiographic features, such as the distribution of opacities, hilar adenopathy, Kerley-B lines or pneumothorax, or pulmonary function tests demonstrating air flow limitation also narrow the differential diagnosis. One can direct the subsequent workup based on the narrowed differential diagnosis, the pace of disease, the activity of the ongoing inflammatory-immune process, and the age, overall medical condition, and wishes of the patient. Unless a specific diagnosis (for example, hypersensitivity pneumonitis, the treatment of which is withdrawal of the offending agent) can be made, therapy of noninfectious diffuse lung disease is quite unsatisfactory. Immunosuppressive therapy is indicated to arrest the active inflammatory process with the hope that objective signs of improvement will occur after a 3- to 12-month course. Important areas of basic research in pulmonary fibrosis include cell-cell and cell-matrix interactions in the lung interstitium and delineation of fibroblast biology and cytokine-mediated lung connective tissue pathology. More successful therapies will probably evolve from better understanding of the molecular and cellular biology of the lung fibrogenic process.

Spontaneous and induced immunoglobulin synthesis and anti-neutrophil cytoplasm antibodies in Wegener's granulomatosis: relation to leukocyte subpopulations in blood and active lesions

Using a reverse plaque forming cell (PFC) assay the production of immunoglobulin (Ig) by peripheral blood mononuclear cells (MNCs) in vitro was studied in 12 patients with Wegener's granulomatosis (WG). Spontaneous IgG production was increased in two of six untreated patients. The IgG response of MNCs from eight untreated patients to pokeweed mitogen (PWM) and Epstein-Barr virus (EBV) stimulation was significantly depressed. The IgM and IgA production followed the individual pattern of IgG. Blood B-cell and T-cell subset concentrations were normal before therapy, whereas the monocyte concentration was increased in four of six patients. Titers of anti-neutrophil cytoplasm autoantibodies (ANCAs) did not correlate with spontaneous or induced Ig production nor with blood leukocyte subset concentrations. Biopsy specimens from upper respiratory tract lesions in seven untreated patients showed numerous macrophages, activated T lymphocytes, and plasma cells, suggesting a pathogenetic role of these cells in the development of lesions and local production of ANCAs.

Extensive cerebral infarction due to involvement of both anterior cerebral arteries by Wegener's granulomatosis

The central nervous system is often affected in Wegener's granulomatosis (WG), but massive cerebral infarction due to occlusion of branches of the anterior cerebral arteries (ACA) by granulomatous lesions or thrombosis, or both, has seldom been reported. A case is reported here of a 67 year old man with WG complicated by generalised necrotising vasculitis in the lung, kidney, and gastrointestinal tract, and cerebral infarction in the territory of both anterior cerebral arteries, probably caused by thrombosis and a contiguous invasion of granulomatous lesion from the nasal cavity.

The eosinophilic variant of Wegener's granulomatosis

Four cases of an unusual histologic variant of Wegener's granulomatosis, diagnosed by open lung biopsy, are described. In addition to pathergic necrosis, granulomatous inflammation, and vasculitis, intense stromal eosinophilia was observed in the absence of peripheral blood eosinophilia or clinical asthma. A microangiitis was also present in all four cases. Clinically, all patients presented with systemic disease and responded to immunosuppressive therapy including steroids and cyclophosphamide. This form of Wegener's disease poses problems in its distinction from allergic angiitis and granulomatosis, and the differential diagnosis of these two entities is discussed.

Cyclophosphamide-induced bladder toxicity in Wegener's granulomatosis

In a series of 111 patients with Wegener's granulomatosis who were given cyclophosphamide therapy, hemorrhagic cystitis, diagnosed on the basis of gross hematuria or at cystoscopy (or both), developed in 17 (15%). Most of these patients recovered uneventfully, with or without the discontinuation of cyclophosphamide, but 4 patients suffered a significant loss of blood, and bladder carcinoma developed in 3. New microhematuria also occurred in 52 patients (47%). The dose and duration of cyclophosphamide were greater in the group that had urotoxicity. Long-term followup of patients with hemorrhagic cystitis is mandatory for the detection of late recurrences or the development of bladder malignancy. New therapies are being directed at protecting the bladder from urotoxicity during cyclophosphamide treatment.

[Spontaneous course of Wegener's granulomatosis]

Two cases of Wegener's granulomatosis are reported. During the 5 and 9 years course of the disease complete remissions and the disappearance of pulmonary opacities were found without specific treatment. Since 1970 cytotoxic drugs, e.g. cyclophosphamide, are frequently used for the treatment of Wegener's granulomatosis. The evaluation of the follow-up showed in these patients that in most cases the side-effects of the therapy, and not the primary disease, limited the life-expectancy. This especially applies for patients with mild forms of Wegener's granulomatosis, in which the initiation of a cytotoxic therapy should carefully be evaluated.

Cyclophosphamide-induced hemorrhagic cystitis. A review of 100 patients

Cyclophosphamide is an alkylating agent used intravenously or orally in the treatment of both malignant and nonneoplastic diseases. A known adverse effect of such treatment is hemorrhagic cystitis. A series of 100 patients with hemorrhagic cystitis induced by cyclophosphamide was studied. Major symptoms were gross hematuria (78%) and irritative voiding symptoms (45%). Microhematuria developed in 93% of patients. Hemorrhagic cystitis developed at significantly lower doses and shorter durations of therapy in patients treated intravenously than in patients treated orally. Cystectomy was required in nine patients and bladder cancer developed in five. Urine cytologic study, urinalysis, and cystoscopy are important in the diagnosis of hemorrhagic cystitis, and these studies plus periodic excretory urography are important for surveillance. In addition, new methods of protecting against the urotoxicity are available.

Wegener's granulomatosis in north India. An analysis of eleven patients

Eleven patients with Wegener's granulomatosis were seen at this Institute over a period of 20 years. There were six men and five women. The average age of presentation was 38.3 years, and the mean duration of symptoms was 10.5 months. Constitutional symptoms (82%), cough (82%), ocular symptoms (64%), arthralgias (55%), rhinorrhoea (55%), haemoptysis (45%), nasal granuloma (45%), otorrhoea (36%), sinusitis (36%), skin lesions (27%), and renal failure (27%) were the clinical manifestations encountered. All patients had an elevated ESR, and 55% had leucocytosis. Proteinuria and haematuria were observed in 64% and 55% respectively. Chest radiographs were abnormal in 82%. In four patients the disease had a fulminant course and the patients died before adequate treatment was given. Two patients received corticosteroids alone and have since been lost to follow up. Five (45%) received adequate cytotoxic therapy and have done well for 8-46 months (mean, 24.8 months) after diagnosis. Wegener's granulomatosis in India is apparently similar to that seen elsewhere, but the high incidence of tuberculosis interferes with early diagnosis and treatment.

The necrotising vasculitides

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Management of noninfectious corneal ulcers

Noninfectious corneal ulcers can occur as an isolated ocular problem (e.g., sequela of eye injury, Mooren's ulcer) or they may be associated with various collagen vascular or other autoimmune diseases, sometimes being the presenting sign of the disease. Conditions that affect the integrity of the ocular surface epithelium (exposure keratitis, neurotrophic keratitis, keratomalacia, recurrent corneal erosions) may also lead to development of sterile corneal ulcers. Rarely, these ulcers occur as a complication following cataract surgery. With recent advances in the understanding of the causes and pathophysiology of corneal melting, rapid and effective medical and surgical treatment is often able to halt relentless destruction of the cornea. Since treatment varies vastly depending on the underlying cause of the ulceration, prompt and accurate diagnosis is of critical importance. This review presents guidelines for the diagnosis of corneal ulcers, and a stepwise approach to their medical and surgical treatment.

Wegener's granulomatosis presenting with erosive arthritis

We describe a patient with Wegener's granulomatosis who presented with erosive arthritis. The patient's multisystem disease responded to cyclophosphamide treatment, and the erosions healed. Our findings suggest that Wegener's granulomatosis should be added to the differential diagnosis of diseases associated with erosive arthritis.

Wegener's granulomatosis: isolated involvement of the trachea and larynx

A 26 year old man with subacute hoarseness and stridor was shown to have Wegener's granulomatosis isolated to the trachea and larynx. Although isolated laryngeal Wegener's is unusual, a review of the literature suggests that early treatment with cyclophosphamide is warranted.

'Pulsed' immunosuppressive therapy in the treatment of immunologically induced corneal and scleral disease

'Pulsed' immunosuppressive therapy, using methylprednisolone with or without cyclophosphamide, has effectively controlled severe destructive corneal and scleral disease that had been unresponsive to oral steroids. Thirty-seven patients have been treated in this manner and the results, complications and possible mechanism of action are discussed.

Wegener's granulomatosis involving the breast. Report of three cases and review of the literature

Three cases of necrotizing granulomatous vasculitis of the Wegener's type involving the breast are described. In each, the presumed diagnosis was localized or metastatic carcinoma. The breast lesion and other manifestations of Wegener's granulomatosis developed concomitantly in one patient, and the breast lesion appeared several months before classic pulmonary symptoms in another. In the third patient, not only were her upper and lower airway symptoms explained only in retrospect, but even the significance of the breast biopsy findings was clarified only after other aspects of Wegener's granulomatosis developed. All patients ultimately demonstrated a good response to corticosteroids and cyclophosphamide therapy. Wegener's granulomatosis is a rare lesion affecting the breast but should nonetheless be considered in the evaluation of any breast mass.

Reversible valvulitis in Wegener's granulomatosis

A patient with Wegener's granulomatosis sustained a myocardial infarction. Subsequent echocardiography showed aortic valvulitis, which resolved with therapy with cyclophosphamide and prednisone.