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

Prospective study of radioimmunoassay for antibodies against neutrophil cytoplasm in diagnosis of systemic vasculitis

The diagnosis and management of Wegener's granulomatosis and microscopic polyarteritis are complicated by the lack of specific diagnostic tests. The diagnostic performance of a solid-phase radioimmunoassay, which detects the autoantibodies against neutrophil cytoplasm present in these disorders, was assessed in a prospective study of patients with suspected vasculitis and/or rapidly progressive nephritis. The assay had a sensitivity and specificity of 96% when carried out in combination with a specific inhibition stage and indirect immunofluorescence staining of alcohol-fixed normal neutrophils.

Corticosteroid agents in renal disease

Corticosteroid agents have a major role in the treatment of several renal disorders which have an immune basis. They remain the treatment of choice for minimal-change glomerulonephritis, inducing remission in over 90% of patients. The role of corticosteroid therapy in patients with membranous glomerulonephritis remains controversial, although an extensive controlled trial indicated benefit from a two-month course of alternate-day therapy. Intravenously-administered methylprednisolone has been shown to benefit rapidly progressive crescentic glomerulonephritis; the benefit is probably comparable to that which is obtained with immunosuppression and plasma exchange. Corticosteroid therapy has improved dramatically the prognosis of glomerulonephritis that is associated with systemic lupus erythematosus and the various forms of vasculitis (excluding Wegener's granulomatosis), although the concomitant use of immunosuppressive therapy in these disorders reduces the required doses of corticosteroid drugs. For the last 20 years prednisolone and azathioprine have been standard therapy to prevent renal allograft rejection. However, corticosteroid agents are used currently in much lower doses or have been replaced by cyclosporin A.

Selective effects of cyclophosphamide therapy on activation, proliferation, and differentiation of human B cells

The immune function of B lymphocytes from 12 patients with nonneoplastic immune-mediated diseases receiving chronic low-dose (2 mg/kg per d) cyclophosphamide (CY) was evaluated. There was a selective and differential suppressive effect of CY therapy on the various stages of the B cell cycle including activation, proliferation, and differentiation. The proliferative responses to Staphylococcus aureus Cowan strain I (SAC) and mitogenic concentrations of anti-mu were suppressed. In contrast, B cells that have been presumably activated in vivo proliferated with a normal pattern when exposed to B cell growth factor in vitro. Chronic low-dose CY therapy also suppressed B cell differentiation. Secretion of immunoglobulin by B cells following in vitro triggering with SAC and a T cell supernatant was suppressed in CY-treated patients. Moreover, differentiation of the large in vivo-activated B cells (which do not require an in vitro activation signal) in the presence of appropriate T lymphocyte supernatant was also suppressed. This selective suppression of B cell function at multiple points in the B cell cycle may be responsible for the efficacy of CY therapy in certain antibody and immune complex-mediated diseases.

Takayasu's arteritis associated with crescentic glomerulonephritis

We describe the initial course and followup of a 16-year-old white female patient who presented in 1983 with aortitis and rapidly progressive renal failure. Renal biopsy revealed crescentic glomerulonephritis. Segmental occlusions of the distal aorta and both common iliac arteries were demonstrated on aortography. Initially, her renal function and arterial occlusions markedly improved with pulse prednisolone therapy, but 34 months later, the glomerulonephritis and aortitis worsened. This case report, the first of its kind, documents both the association of Takayasu's arteritis with crescentic glomerulonephritis and a marked, though incomplete, response to pulse therapy.

Coexistent Wegener's granulomatosis and anti-glomerular basement membrane disease

Wegener's granulomatosis and Goodpasture's syndrome represent two major causes of a pulmonary-renal syndrome. We describe the clinical course and morphologic features of a patient in whom pulmonary manifestations of Wegener's granulomatosis developed and were followed six months later by anti-glomerular basement membrane disease. Although we regard this as a unique and probably fortuitous association, a genetic predisposition or a secondary form of anti-GBM disease cannot be excluded.

Henoch Schonlein purpura presenting with pulmonary haemorrhage

A young woman presented with arthralgia, a rash and dramatic haemoptysis, and renal involvement was indicated by proteinuria, haematuria and a rising serum creatinine. A systemic vasculitic disorder was suspected initially, but the diagnosis of Henoch-Schonlein purpura was established by the finding of mesangial IgA deposits on renal biopsy. Immunofluorescent study of renal biopsy material is vital to diagnosis where the clinical features of Henoch-Schonlein purpura and those of the systemic vasculitides with renal involvement prove to be indistinguishable.

Prostatic involvement in Wegener's granulomatosis

Prostatic involvement is an unusual complication of Wegener's granulomatosis. We report two cases with this complication and emphasize the importance of recognizing this manifestation in diagnosis and management of the disease condition.

Multiple unusual manifestations of Wegener's granulomatosis: breast mass, microangiopathic hemolytic anemia, consumptive coagulopathy, and low erythrocyte sedimentation rate

We describe a patient who presented with multiple unusual manifestations of Wegener's granulomatosis, including a breast mass, microangiopathic hemolytic anemia, and consumptive coagulopathy. Erythrocyte sedimentation rate (Westergren), usually elevated in the course of this disease, persistently remained low in this patient. We found that C-reactive protein levels were, in this case, a more sensitive gauge of disease activity.

Vasculitis

Inflammatory changes in blood vessels are a prominent feature of several diseases, which can be categorized by the size of the vessels, the nature of the inflammatory exudate, and the specific organs involved. The clinical and laboratory findings are variable and frequently nonspecific. Therapy ranges from essentially just observation to high-dose steroids combined with immunosuppressive agents, but treatment must be individualized. Early and correct diagnosis is thus important, but because there is considerable overlap between diseases, especially in the leukocytoclastic vasculitis group, one should never delay initiation of therapy while one is trying to finalize the diagnosis, particularly when the patient may be deteriorating rapidly.

Wegener's granulomatosis in the elderly

Wegener's granulomatosis is a systemic necrotizing granulomatous vasculitis in which the average age at onset is in the forties. The disease has an excellent response to treatment with cyclophosphamide. We proposed that the tendency to accept multisystem disease in elderly patients (greater than or equal to 60 years old) and a reluctance to administer aggressive therapy would be reflected in the diagnosis and treatment of Wegener's granulomatosis in the elderly, and that as a consequence, the delay in diagnosis and implementation of therapy could result in a needlessly higher morbidity and mortality rate for this population of patients.

Polyangiitis overlap syndrome. Classification and prospective clinical experience

Ten patients were prospectively studied who had features of systemic vasculitis that could not be classified into one of the well-defined vasculitic syndromes. Since many of these syndromes had overlapping features of several distinct vasculitides, they were classified as the polyangiitis overlap syndrome. Cutaneous disease was common (nine of 10 patients) and, some patients, had been mistakenly diagnosed as "hypersensitivity" or isolated cutaneous vasculitis. The polyangiitis overlap syndrome is a systemic vasculitis, and all of the patients required therapy with cyclophosphamide (2 mg/kg per day). Nine of 10 patients were also treated with corticosteroids, which were administered initially on a daily basis followed by an alternate-day regimen. A complete remission was induced in all of the patients, with a mean follow-up duration of 58.4 months. In eight of 10 patients, remission was maintained following discontinuation of cyclophosphamide. The mean duration of remission was 45.9 months, with a mean interval after discontinuation of all therapy of 22.3 months. Two patients had relapses after the immunosuppressive therapy was discontinued; however, complete remissions were reinduced following reinstitution of therapy.

Wegener's granulomatosis in two sisters

We describe two sisters with necrotising granulomas. The intervals between the onset of symptoms and diagnosis were eight and nine years. The pathological findings showed necrotising granulomas in both patients, this being consistent with a diagnosis of pathergic (Wegener's) granulomatosis. The one patient that accepted treatment responded well to cyclophosphamide, though the facial lesions responded only to radiation therapy. Since the second was almost asymptomatic we conclude that relatives of patients with Wegener's disease should be investigated.

Intestinal perforation in Wegener's granulomatosis

Wegener's granulomatosis is a disease characterised by a necrotising vasculitis and granulomatous inflammation. The localised form involves the upper and/or lower respiratory tracts while in the commoner generalised form there is a widespread necrotising vasculitis and renal involvement. Intestinal involvement, which may be severe, has been detected at necropsy in 24% of cases. Gastrointestinal symptoms are uncommon, however, none being mentioned in a recent series of 87 cases. There has been only one reported case of intestinal perforation secondary to Wegener's granulomatosis. We report a case of small and large bowel perforations in a patient with Wegener's granulomatosis.

Pulmonary lesions in Wegener's granulomatosis: a clinicopathologic study of 22 autopsy cases

Pulmonary lesions in 22 autopsy cases of Wegener's granulomatosis (WG) were studied clinicopathologically, with special emphasis on the relation of the lesions to systemic vasculitis, glomerular changes, and clinical manifestations. The pulmonary lesions were divided, on the basis of morphologic characteristics, into four types: 1) the fulminant type, which was characterized by diffusely distributed acute exudative and proliferative alveolitis with prominent small vessel vasculitis (three cases); 2) the granulomatous type, the classic granulomatous lesion (seven cases); 3) the fibrous scar type (five cases); and 4) the mixed type, which had features of both acute exudative and scar-type lesions (seven cases). Clinically, lesions of the fulminant type had rapidly deteriorating courses, terminating in respiratory failure immediately following the onset of the pulmonary manifestations, whereas those of the fibrous scar type had protracted courses. The systemic vasculitis and glomerular lesions in the cases of the fulminant type were almost exclusively fresh lesions. In contrast, the systemic lesions in the cases of the fibrous scar type were nearly always cicatricial. Thus, the morphologic features of the systemic lesions and the clinical profile in each case were well correlated with the pathologic classification of the pulmonary lesions. This correlation may support the assumption that the respiratory tract lesion plays an important role in the progression of systemic involvement in the disease. A comparative study of vascular lesions in various organs revealed some histologic differences between vasculitis in the lungs and that observed outside the respiratory tract; pathogenetic heterogeneity was thus suggested between lesions in the two locations.

Necrotizing systemic vasculitis with features of both Wegener's granulomatosis and Churg-Strauss vasculitis

We describe a patient who had nasal biopsy-demonstrated eosinophilic vasculitis and renal biopsy-demonstrated necrotizing glomerulonephritis with tissue eosinophilia. Despite corticosteroid therapy, the patient's renal function deteriorated, and nodular pulmonary infiltrates developed. Both conditions responded dramatically when cyclophosphamide was added to the treatment regimen. The renal disease activity was monitored with the aid of cytodiagnostic urinalysis, a technique of limited, albeit well-established, validity in monitoring renal allograft patients for signs of tissue rejection. This technique provided an improved, semi-quantitative method for examining urine sediment and, in this patient, was helpful as a measure of renal disease activity.

Presentation of Wegener's granulomatosis in young patients

We have reviewed 50 cases of Wegener's granulomatosis, seen at the New England Medical Center Hospital between 1970 and 1984, and were impressed that 10 (20%) of these patients were under 25 years of age, with ages ranging from 13 to 23 years. Closer examination of this younger group revealed striking differences in their presenting symptoms and organ involvement when compared to the older group of patients. The presentation of these young patients was varied, with no single predominant symptom. Patients presented with otalgia and otitis media or hearing loss, fulminant sinusitis, arthralgias, and even corneal ulcers. Only one patient had "typical" rhinitis and nasal congestion. This group also had a disproportionate number of patients with involvement of the oral cavity, skin, and trachea. Biopsy of these sites frequently demonstrated necrotizing vasculitis. Three of our 50 patients had intracranial involvement, leading to transient hemiplegia in the first, permanent hemiplegia in the second, and a seizure disorder in the third. Two of these patients were in the younger age group. The proportion of patients with limited and generalized Wegener's granulomatosis was the same in both the younger and older age groups. All the younger patients, however, had manifestations of the disease in the head and neck, while four of the older patients had no symptoms in the upper respiratory tract. The number of young patients in our study emphasizes the fact that Wegener's granulomatosis, indeed, occurs in the younger patient and with a greater frequency than previously supposed. This study suggests that in the teenager and young adult, with an unusual constellation of symptoms of the head and neck and accompanying systemic problems, a diagnosis of Wegener's granulomatosis should be seriously considered.

Failure of cyclophosphamide to prevent cerebritis in Wegener's granulomatosis

Two patients with diffuse cerebritis due to Wegener's granulomatosis are described. The cerebritis developed despite prolonged treatment with cyclophosphamide. This may be the first report of such an occurrence. Both patients had excellent functional recovery with intravenous corticosteroids.

Diagnostic and therapeutic approach to the patient with vasculitis

This article presents an approach to the diagnosis and therapy of patients with vasculitis. Effective treatment of patients with vasculitis requires a systemic approach to diagnosis and classification of disease, evaluation of the extent of organ system involvement, and an exclusion of underlying treatable diseases.

Nocardiosis mimicking Wegener's granulomatosis

A 45-year-old man presented with persistent nasal discharge and later developed arthropathy, cutaneous vasculitis, a macular rash and radiographic lung opacities. Early relapse after starting immunosuppressive therapy consisted of new cavitating lung opacities, as seen in Wegener's granulomatosis, and subcutaneous nodules. Lymph node biopsy showed Nocardia asteroides. One month after high dose cotrimoxazole the chest X-ray was normal.

Wegener's granulomatosis with bilateral necrotizing scleritis, polyarthritis and renal failure efficiently treated with immunosuppressive therapy

A case report of a female patient with Wegener's granulomatosis is presented. After an initial involvement of the upper respiratory tract in the form of a sinusitis, there followed a severe necrotizing bilateral scleritis necessitating the enucleation of the left eye ball. Renal involvement developed as late as 24 months after the onset of the disease and led to renal failure within three months. Throughout the duration of her disease, the patient had joint symptoms in the form of episodes of migratory nondeforming polyarthritis. The administration of corticosteroids alone in daily doses up to 60 mg prednisone failed to control the progression of the disease, while immunosuppressive therapy with cyclophosphamide combined with methylprednisolone pulse therapy and haemodialysis resulted in a marked improvement of renal function and in the subsidence of the ocular and articular symptoms.

The spectrum of diseases associated with necrotizing glomerulonephritis and its prognosis

Necrotizing glomerulonephritis (NGN) represents small-vessel vasculitis in the kidney. To assess the diseases associated with necrotizing glomerular changes and their prognosis we studied all 32 patients who had this histologic finding on kidney biopsy from 1969 to 1982 and compared them to those patients who had crescentic, diffuse, or focal and segmental glomerulonephritis without necrosis (n = 29). The diseases associated with NGN were systemic lupus erythematosus (n = 6/15), Henoch-Schönlein purpura (n = 3/4) Goodpasture's syndrome (n = 4/7), Wegener's granulomatosis (n = 6/6), polyarteritis (n = 4/5), infective endocarditis (n = 2/3), and idiopathic rapidly progressive glomerulonephritis (n = 7/21). Necrotizing glomerulonephritis occurred significantly more often in the vasculitides than in all the other disorders put together. The most difficult diagnosis problem occurred in patients with renal disease and pulmonary hemorrhage (n = 9), in three of whom diagnosis was uncertain even after autopsy (two autopsies done within one month and one within three months of presentation). A fourth patient had a linear staining for IgG along the glomerular basement membrane (GBM) on kidney biopsy but was subsequently diagnosed as having Wegener's granulomatosis. Comparison of patients with without NGN revealed no difference in outcome (death or dialysis) one year after biopsy (38% v 43%) or in serum creatinine levels one year later (4.6 v 4.8 mg/dL). The prognostic effect of NGN was not obscured by unequal distribution of other adverse prognostic factors in the two groups. The most important prognostic characteristics we identified for outcome were serum creatinine at biopsy (chi 2 = 24.0, P less than .0004) and the sum of activity and chronicity indexes on biopsy (chi 2 = 12.7, P = .0004). These variables were similarly distributed in patients with and without necrosis, mean serum creatinine levels at biopsy being 4.3 v 4.2 mg/dL and sum of indexes 7.8 v 8.0. Other factors such as clinical diagnosis and therapy were not important prognostically and therefore could not explain our results. We conclude that NGN in patients with active proliferative glomerulonephritis has multiple causes. Diagnostic difficulties occurred in those with anti-GBM-negative pulmonary hemorrhage. The appearances of small-vessel vasculitis in the kidney did not appear to have prognostic significance.

Unusual cardiac complications of Wegener's granulomatosis

Wegener's granulomatosis most commonly involves the sinuses, lungs and kidneys with necrotizing granulomatous vasculitis. In 12 percent of a large series of patients with Wegener's granulomatosis there was cardiac involvement, largely manifested by pericarditis and coronary arteritis. We present three patients with this disease who developed unusual cardiac complications. Patient 1 had renal failure requiring hemodialysis, pericardial tamponade requiring pericardiocentesis, and later developed constrictive pericarditis requiring pericardiectomy. Patient 2 developed pericarditis and high grade atrioventricular block, and patient 3 developed pericarditis and atrial tachycardia resistant to pharmacologic and transesophageal atrial pacing methods. All three patients greatly improved with cyclophosphamide therapy. The rhythm disturbances seen in patients 2 and 3 were attributed to coronary arteritis. The renal failure in patient 1 was due to Wegener's granulomatosis, but whether the constrictive pericarditis was due to uremic pericarditis or the pericarditis of Wegener's granulomatosis is uncertain. As patients with Wegener's granulomatosis live longer with cyclophosphamide therapy and because inpatient arrhythmia monitoring and recording has become more widespread, these uncommon manifestations of Wegener's granulomatosis may be seen more often.

Diagnosis of Wegener's granulomatosis by transbronchial biopsy

We performed transbronchial biopsies in a patient with a large cavitary lung lesion and obtained tissue diagnostic of Wegener's granulomatosis. Fiberoptic bronchoscopic examination with transbronchial biopsy may be indicated as the first diagnostic test in the evaluation of patients with suspected Wegener's granulomatosis.

Polyarteritis group of systemic vasculitis--new diagnostic criteria

We have used new diagnostic criteria to define patients with the polyarteritis nodosa (PAN) group of vasculitis. These were the combination of a necrotising glomerulitis without diffuse deposits of immunoglobulins or complement components in a patient presenting with systemic disease and multi-organ involvement. Twenty-two patients who fulfilled these criteria presented to our unit between 1975 and 1982. The diagnosis of PAN was confirmed by traditional histological criteria in eight. We anticipate that the use of these criteria will lead to earlier diagnosis and thereby improve the management of this potentially lethal disorder.

Segmental necrotizing glomerulonephritis: diagnostic, prognostic, and therapeutic significance

Renal biopsies from 50 patients with segmental necrotizing glomerulonephritis (SNGN) were divided into three groups on the basis of initial clinical information: (group A) Wegener's granulomatosis (WG)--14 patients; (group B) SNGN without renal vasculitis (RV)--21 patients; and (group C) SNGN with RV--15 patients. Renal biopsy findings did not distinguish the SNGN in WG from non-WG patients. However, focal endocapillary proliferation was more common in non-WG groups B (48%) and C (33%) than in WG (7%). In addition, GBM deposits of both IgG and C3 were present in 35% of biopsies in group B and 33% in group C in comparison to only 7% in WG. Glomerular fibrin deposition was common in all groups (54% group A, 70% group B, and 100% group C), suggesting that coagulation plays a role in the development of SNGN. Histologic parameters of severity and chronicity of the SNGN were inconsistent predictors of outcome, although an increased percentage of crescents in the non-WG groups correlated with a poorer prognosis. Chronic renal failure developed in 46% of group A patients, 65% group B, and 73% group C. After clinical follow-up, 15 patients had WG, 15 patients had documented or suspected systemic vasculitis (SV), and idiopathic SNGN was present in 20 patients. Sixty-six percent of patients with SV had RV, and 62% of biopsies with RV were from patients with SV. Chronic renal failure developed in 78% of patients with idiopathic SNGN and 57% patients with SV. These findings confirm that SNGN carries a poor prognosis, independent of its association with WG or SV. Fourteen of the 15 WG patients were treated with alkylating agents, and the development of chronic renal failure appeared to be related to delays in diagnosis and therapy. In the non-WG groups, presentation in acute renal failure with high serum creatinine and long duration of symptoms was predictive of development of chronic renal failure. Therapy in the non-WG patients consisted of alkylating agents (seven patients), steroids (20 patients), and dialysis only (seven patients). The seven non-WG patients treated with alkylating agents had clinical responses similar to WG patients, and cyclophosphamide therapy appeared to be most beneficial to patient outcome. Results of this retrospective study stress the importance of early diagnosis and, although based on small numbers of patients, suggest that aggressive chemotherapy should be recommended for SNGN, independent of its association with biopsy-proven WG or documented SV.

Mechanisms of action and clinical applications of cytotoxic drugs in rheumatic disorders

Failure to suppress disease activity in certain rheumatic disorders such as systemic lupus, polyarteritis nodosa, or Wegener's granulomatosis may significantly heighten the probability of a fatal outcome. In other rheumatic disorders (for example, rheumatoid or psoriatic arthritis) the disease left unchecked may indeed be severely crippling but rarely is it fatal. Thus the decision on whether to add a cytotoxic drug often evolves into a benefit-to-risk analysis, a decision in which the patient must also be intimately involved. There are two few well-controlled studies of the use of cytotoxic agents to make dogmatic statements regarding their use in the treatment of rheumatic disorders. Nevertheless, a review of the literature, some of which has been cited above, does permit one to make some reasoned judgments in choosing a drug for a particular disease (Table 2).

Pulmonary haemorrhage complicating Wegener's granulomatosis and microscopic polyarteritis

The incidence and characteristics of pulmonary haemorrhage in a series of 89 patients with systemic vasculitis were analysed. Pulmonary haemorrhage occurred in 32 of these patients and was associated with haemoptysis in all 32, alveolar shadowing in the chest radiograph in 28, and a significantly raised transfer coefficient in 30. Pulmonary haemorrhage usually resolved with treatment by immunosuppressive drugs but was the cause of death in 11 patients. In contrast with patients with antibasement membrane antibodies there was no correlation between pulmonary haemorrhage and cigarette smoking. Pulmonary haemorrhage is a cause of serious morbidity in patients with systemic vasculitis.

Bronchocentric granulomatosis with glomerulonephritis

Bronchocentric granulomatosis is a chronic pulmonary disease treated with short-term therapy with corticosteroids, and the disease has an excellent prognosis. We describe a patient, and review an additional case from the literature, in whom bronchocentric granulomatosis was accompanied by glomerulonephritis. A misdiagnosis of Wegener's granulomatosis was made, and therapy with cyclophosphamide was either considered or given in each of these cases. We emphasize the need for careful histopathologic evaluation of open lung biopsies in patients suspected of having Wegener's granulomatosis in order to rule out the possibility of bronchocentric granulomatosis with concurrent renal disease, and thus avoid the unnecessary use of cytotoxic agents.

Wegener granulomatosis in pediatric patients

Wegener granulomatosis is more easily recognized as a distinct clinical entity than other vasculitides because the initial clinical features frequently include granulomatous vasculitis of the upper and lower respiratory tract and glomerulonephritis. Although the disease has been lethal in the past, prolonged survival and avoidance of end-stage kidney disease can now be expected when cyclophosphamide therapy is introduced early in the course. We report four children with Wegener granulomatosis in whom the initial clinical findings suggested Henoch-Schönlein purpura. In two of the patients Wegener granulomatosis was not recognized until after end-stage kidney disease had developed. The course in these patients emphasizes the need for attention to even scant evidence of inflammation of the upper or lower respiratory tract in patients with glomerulonephritis. Appropriate diagnostic studies may then lead to recognition of Wegener granulomatosis and the prompt institution of appropriate treatment.

Pulmonary manifestations of the rheumatic diseases

The collagen vascular diseases represent a heterogeneous group of multisystem disorders with a wide range of clinicopathologic features. Although these diseases represent distinct clinical entities, a great deal of overlap exists between them. For example, the diffuse interstitial fibrosis of SLE, RA, DM-PM, PSS, and MCTD are indistinguishable clinically, radiographically, and histologically. Conversely, the pulmonary manifestations of the various vasculitides all differ significantly from each other in their clinicopathologic presentation, as well as in their response to therapy. For diagnostic purposes, histologic evidence will usually be required for the pulmonary manifestations of the rheumatic diseases. Therapy must then be individualized for each of these entities, as the protocol and response are variable.

Correlation of disease activity in systemic vasculitis with serum C-reactive protein measurement. A prospective study of thirty-eight patients

In a prospective study over 2 years, serum C-reactive protein (CRP) concentration and erythrocyte sedimentation rate were measured serially in thirty-eight patients with various types of necrotizing systemic vasculitis. The CRP concentration was always elevated in patients with active vasculitis and fell rapidly in association with clinical remission induced by immunosuppression. During periods of complete remission, in the absence of any intercurrent condition, the value remained within the normal range. In contrast the sedimentation rate responded more slowly to changes in disease activity and did not necessarily reflect the level of inflammation at a particular time. These results, together with the commercial availability of rapid and precise assays for CRP, indicate that serial measurement of the serum CRP fills the urgent need for an objective index of the activity of the systemic vasculitides and their response to therapy.

Wegener's granulomatosis: clinical features and outcome in seventeen patients

Seventeen patients with Wegener's granulomatosis are reviewed. Eleven males and six females, with a mean age of 46.9 +/- 4.5 years, were followed for 35.7 +/- 9.0 months. Mean duration from time of onset of symptoms to diagnosis was 8.5 +/- 3.1 months. Constitutional symptoms (100%), lower respiratory tract involvement (93%), renal involvement (87%), and upper respiratory tract involvement (80%) were the most frequent clinical manifestations. Arthritis (60%), dermal vasculitis (60%), and inflammatory ocular disease (40%) were also common. Elevated ESR (94%), anemia (70%), and lymphopenia (77%) were frequent laboratory findings prior to treatment. Five patients had renal failure at presentation and two patients progressed from no renal involvement at presentation to renal failure at diagnosis, while five patients progressed from renal involvement without impairment at diagnosis to end-stage renal failure. Seven patients died; six of these deaths were related to active Wegener's granulomatosis. The patients with a severe systemic vasculitis, and renal involvement had a poor outcome while predominant respiratory disease had a good prognosis.