Clinical pathologic conference case 1: Wegener's granulomatosis

A Wegener Granulomatosis Case Presented with Arthralgia

Granulomatosis with polyangitis (GPA/WG) (previously known as Wegener granulomatosis) is a multisystem systemic necrotizing non-caeseating granulomatous vasculitis affecting small to medium sized arteries, capillaries and veins, with a predilection for the respiratory system and kidneys. The average incidence of this disease is 40-55. 90% of the WG patients have pulmonary involvement. Wegener Granulomatosis is a disease with high mortality when its diagnosis and treatment is delayed. Although WG may have symptoms such as hemoptysis and hematuria, it should be noted that it may present with severe arthralgia and arthritis which may be in many connective tissue diseases and vasculitis. Male patient, 52 years old. Analgesic treatment was applied when he came to the center due to arthralgia two months ago, however, there was no change in his complaints and intra-articular injection treatment was applied on left knee and both shoulders. The symptoms did not regress and the patient lost 20 kg within the last two months. In urine analysis, 14-15 erythrocyte and 10-15 leucocyte detected in every field; 1 positive detected. The patient was hospitalized in order to make further examination upon the determination of CRP: 61mg/L and ESR: 82mm/hr in the next polyclinic control after three days. In the kidney biopsy report, “Pauci-immun glomerulonephritis” was primarily considered in the phenomenon. For the first three days 1 gr pulse and by the fourth day 1 mg/kg methylprednisolone and cyclophosphamide treatment was applied.

ANCA-negative Wegener's granulomatosis with multiple lower cranial nerve palsies

Wegener's granulomatosis (WG) is a systemic vasculitis affecting small and medium-sized vessels with granulomatous formation. Though it is known for respiratory tract and kidney involvement, neurologic manifestation has been also reported. Herein we report a patient who suffered pansinusitis with multiple lower cranial nerve palsies but reached remission by immunosuppressant after the diagnosis of WG. A 54-yr-old female visited with headache, hearing difficulty, and progressive bulbar symptoms. She experienced endoscopic sinus surgeries due to refractory sinusitis. Neurologic examination revealed multiple lower cranial nerve palsies. Vasculitic markers showed no abnormality. Nasal biopsy revealed granulomatous inflammation and vasculitis involving small vessels. Given cyclophosphamide and prednisolone, her symptoms were prominently improved. WG should be considered in the patient with multiple cranial nerve palsies, especially those with paranasal sinus disease. Because WG can be lethal if delayed in treatment, prompt immunosuppressant is warranted after the diagnostic tissue biopsy.