Localized Granulomatous with Polyangiitis (GPA): Varied Clinical Presentations and Update on Treatment

When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis

BACKGROUND

Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients.

OBJECTIVE

Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics.

METHODS

Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review.

RESULTS

467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review.

CONCLUSION

GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.

Ocular Involvement of Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis (GPA), formerly referred to as Wegener's disease, is a form of ANCA-associated vasculitis. It manifests mainly in the kidneys and the upper respiratory tract, but ocular involvement is not uncommon. In this article, four cases with ocular manifestations are presented with comprehensive photographic documentation. We describe the way to proper diagnosis, which may be long, the possible treatment, and the final outcomes. Our patients had the following ocular manifestations of GPA: retinal vasculitis, anterior necrotizing scleritis, medial orbital wall and orbital floor erosion with middle face deformation, compressive optic neuropathy due to retrobulbar inflammatory mass, and the abscess of the eyelids, inflammatory intraorbital mass causing exophthalmos and diplopia. This manuscript includes the description of severe forms of GPA, the initial signs and symptoms, relapses, and difficulties in achieving remission. The extraocular involvement is described with diagnostic modalities and laboratory findings. One of the reported cases was diagnosed by an ophthalmologist on the basis of ocular symptoms in the early stages of the disease. Our outcomes are compared with those discussed in the literature.

An atypical presentation of granulomatosis with polyangiitis: A case report

Granulomatosis with polyangiitis (GPA) is a systemic vasculitis that is associated with antineutrophil cytoplasmic antibodies (c-ANCA). It classically presents with sinonasal, pulmonary and renal involvement. We are presenting a case of a 32-year-old male who presented with septal perforation, crusting and nasal obstruction. He had been operated on twice for sinonasal polyposis. Relevant investigations revealed that he was actually suffering from GPA. The patient was started on remission induction therapy. A combination of methotrexate and prednisolone was started with a 2-weekly follow-up. The patient had experienced his symptoms for 2 years before presentation. This case highlights the importance of correlating ENT and pulmonary symptoms to reach the correct diagnosis.

Unmet needs in ANCA-associated vasculitis: Physicians' and patients' perspectives

In recent years, clinical research has increased significantly and therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis have improved. However, there are still unanswered questions and unmet needs about AAV patients. The purpose of this review is to examine the frontiers of research related to emerging biomarkers eventually predicting relapse, and new therapeutic approaches, not to mention new quality of life assessment tools. Identifying predictors of relapse may help optimize therapeutic strategies, minimize disease recurrence, and reduce treatment-related side effects. In addition, it is important to recognize that patients may suffer long-term consequences of the disease and its treatment, which, although life-saving, is often associated with significant side effects. Our goal, therefore, is to highlight what has been achieved, the pitfalls, and what still needs to be done, comparing the views of physicians and patients.

RNA Sequencing of Idiopathic Subglottic Stenosis Tissues Uncovers Putative Profibrotic Mechanisms and Identifies a Prognostic Biomarker

Idiopathic subglottic stenosis (iSGS) is a localized airway disease that almost exclusively affects females. Understanding the molecular mechanisms involved may provide insights leading to therapeutic interventions. Next-generation sequencing was performed on tissue sections from patients with iSGS (n = 22), antineutrophil cytoplasmic antibody-associated vasculitis (AAV; n = 5), and matched controls (n = 9) to explore candidate genes and mechanisms of disease. Gene expression changes were validated, and selected markers were identified by immunofluorescence staining. Epithelial-mesenchymal transition (EMT) and leukocyte extravasation pathways were the biological mechanisms most relevant to iSGS pathogenesis. Alternatively activated macrophages (M2) were abundant in the subepithelium and perisubmucosal glands of the airway in iSGS and AAV. Increased expression of the mesenchymal marker S100A4 and decreased expression of the epithelial marker epithelial cell adhesion molecule (EPCAM) further supported a role for EMT, but to different extents, in iSGS and antineutrophil cytoplasmic antibody-associated subglottic stenosis. In patients with iSGS, high expression of prostate transmembrane protein, androgen induced 1 (PMEPA1), an EMT regulator, was associated with a shorter recurrence interval (25 versus 116 months: hazard ratio = 4.16; P = 0.041; 95% CI, 1.056-15.60). Thus, EMT is a key pathogenetic mechanism of subglottic stenosis in iSGS and AAV. M2 macrophages contribute to the pathogenesis of both diseases, suggesting a shared profibrotic mechanism, and PMEPA1 may be a biomarker for predicting disease recurrence in iSGS.

Ossified diagnosis: sarcoidosis masquerading as metastatic breast cancer

A 40-year-old woman was referred to the Breast Unit with a solid lump in her right breast. Investigations revealed an invasive lobular carcinoma. The patient underwent a right-sided mastectomy and sentinel lymph node (LN) biopsy, which confirmed axillary LN involvement. The postsurgery staging CT showed unusual enlargement of mediastinal and hilar LN bilaterally. This was consistent with positron emission tomography/CT and MRI, which further established the presence of several bone lesions. Determining the pathology within the LN and bones was pivotal in providing an accurate diagnosis and deciding subsequent management. However, histopathological analysis of the initial endobronchial ultrasound-guided fine-needle aspiration biopsy of mediastinal LN failed to identify definitive metastatic breast cancer cells. The case was extensively discussed in several multidisciplinary team meetings. Collective evidence, including clinical presentation, comparative imaging analysis, and further biopsies confirmed sarcoidosis with bone involvement-mimicking metastatic disease.

Granulomatous interstitial nephritis in granulomatosis with polyangiitis mimicking leprosy: A case report

Granulomatous polyangiitis (GPA) is a small vessel vasculitis commonly affecting the upper and lower respiratory tracts and kidneys. About 90% of the cases are associated with ANCA, namely, PR3-ANCA and MPO-ANCA. Herein, we describe a patient of GPA who presented with anasarca, sensory neuropathy, recurrent upper airway congestion, epistaxis, and rapidly progressive glomerulonephritis. Granulomatous interstitial nephritis and necrotizing granulomatous inflammation of the nasal septum were found on biopsy of the kidney and nasal septum, respectively both of which are rare findings. PR3-ANCA and MPO-ANCA were negative. Fulfilling the ACR criteria, this case of GPA proves that biopsy is still the gold standard of diagnosis.