Wegener granulomatosis: prostatic involvement and bladder outlet obstruction

Prostate involvement in granulomatosis with polyangiitis

To present a case of prostate involvement (PI) in granulomatosis polyangiitis (GPA) and analyse related published reports. We employed the following keywords for retrieving reports indexed by MEDLINE/PubMed and/or Scopus: "granulomatosis with polyangiitis", "Wegener granulomatosis" and "prostate involvement". Additional searches were performed through Google Scholar and HINARI. All cases that fulfilled the American College of Rheumatology criteria for GPA, standards of Chapel Hill Consensus Conference, and did not match with exclusion criteria were analysed and summarised. A 35-year-old man presented with complaints of stuffy nose, difficulty breathing through the nose, swelling and pain in the left half of the nose, low-grade fever, and discomfort. The nasal mucosal biopsy did not reveal any specific changes. During the inpatient treatment, he developed eye redness, tearing, dysuria, and decreased urinary stream. Prostate-specific antigen (PSA) was elevated (2.81 μg/L; normal values ≤ 1.4 μg/L for males below 40 years). Prostate biopsy findings were consistent with diagnosis of GPA, which was confirmed by detecting elevated anti-PR3 antibodies (4.1 IU; normal values < 1.0 IU). We analysed our case in view of the clinical course of 45 published cases of PI in GPA. PI in GPA is a rare clinical manifestation of the vasculitis. Patients with atypical clinical symptoms of GPA are at risk of delayed diagnosis. The awareness of variable clinical presentations of GPA, particularly specific affection of the prostate gland, is crucial for timely diagnosis.

Isolated Idiopathic Granulomatous (Giant Cell) Vasculitis of the Prostate

Vasculitis involving the prostate is uncommon and usually reflects systemic disease. Isolated prostatic vasculitis is very rare. Most of these cases are morphologically categorized as polyarteritis nodosa. We describe a 72-year-old man with idiopathic granulomatous vasculitis limited to the prostate. The vasculitis was identified incidentally upon microscopic examination of the suprapubic prostatectomy specimen removed for nodular hyperplasia. The transmural inflammation was centered on muscular arteries and veins and it was accompanied by narrowing of the lumen. Vasculitis was not associated with any secondary changes such as infarct or postinfarct fibrosis. Immunophenotyping of the vascular inflammatory infiltrate disclosed abundant macrophages and T-lymphocytes and virtual absence of B-lymphocytes. The patient is alive and well on no treatment for a follow-up period of 14 months. To our knowledge this is the second case report of prostatic involvement in localized idiopathic granulomatous vasculitis. It is important to distinguish cases of isolated granulomatous vasculitis in the prostate from systemic disease, because the latter implies a poor prognosis and requires an aggressive treatment.

Isolated Fibrinoid Arteritis of the Prostate

Four cases of apparently asymptomatic isolated fibrinoid arteritis in the prostate are described. All four cases occurred in elderly men with nodular hyperplasia. In all of these cases isolated fibrinoid arteritis was an incidental finding unrelated to the presenting symptoms. The histopathological appearance of the vasculitis was not sufficiently specific to exclude the possibility of systemic polyarteritis nodosa. However, there were no signs of generalized disease. Follow-up studies showed no evidence of disseminated vasculitis. Immunophenotyping of the vascular cellular infiltrate revealed abundant T lymphocytes, significant numbers of histiocytes, and virtual absence of B lymphocytes. The diagnosis of isolated arteritis depends on the exclusion of systemic disease, its excellent prognosis differing dramatically from the more common form of systemic polyarteritis nodosa. Information that isolated arteritis may occur in the prostate is of importance both to avoid misdiagnosis and to prevent unnecessary treatment. Int J Surg Patltol 4(3):00-00, 1997

Uncommon presentations of primary systemic necrotizing vasculitides: the Great Masquerades

INTRODUCTION

Systemic vasculitides are great masqueraders and at times their presenting manifestations can be very different from the usual recognized patterns. Such uncommon presentations of granulomatosis with polyangiitis (Wegener's granulomatosis), classical polyarteritis nodosa and unclassifiable vasculitides are described here with the relevant review of literature.

METHODS

All patients diagnosed as having systemic vasculitides and classified as having granulomatosis with polyangiitis (Wegener's granulomatosis), classic polyarteritis nodosa, microscopic polyangiitis and unclassifiable vasculitis according to EMEA consensus methodology and followed up prospectively from June 2007 to December, 2011 were included. Details of uncommon presentations of these disorders were identified.

RESULTS

Seventy-nine patients with systemic vasculitides were seen under our rheumatology services during this period. These included 45 patients with granulomatosis with polyangiitis (Wegener's granulomatosis), 18 with classic polyarteritis nodosa, five with microscopic polyangiitis, four with Churg-Strauss syndrome and seven with unclassifiable vasculitis. The uncommon presentations of granulomatosis with polyangiitis were a tumefactive subcutaneous mass in the thigh; prostatomegaly with obstructive uropathy and advanced renal failure; and predominant gastrointestinal (GI) vasculitis with thrombocytopenia and coagulopathy at presentation. The uncommon manifestations of classic polyarteritis nodosa were secondary antiphospholipid antibody syndrome and Budd-Chiari syndrome. One patient with massive lower GI bleeding required surgical resection of the large bowel which showed isolated necrotizing granulomatous GI vasculitis. Single organ vasculitis of the GI tract was diagnosed.

CONCLUSIONS

Systemic necrotizing vasculitides may present with uncommon manifestations and a high index of suspicion is required for early diagnosis and prompt treatment to prevent adverse outcomes.

Urogenital manifestations in Wegener granulomatosis: a study of 11 cases and review of the literature

We describe the main characteristics and treatment of urogenital manifestations in patients with Wegener granulomatosis (WG). We conducted a retrospective review of the charts of 11 patients with WG. All patients were men, and their median age at WG diagnosis was 53 years (range, 21-70 yr). Urogenital involvement was present at onset of WG in 9 cases (81%), it was the first clinical evidence of WG in 2 cases (18%), and was a symptom of WG relapse in 6 cases (54%). Symptomatic urogenital involvement included prostatitis (n = 4) (with suspicion of an abscess in 1 case), orchitis (n = 4), epididymitis (n = 1), a renal pseudotumor (n = 2), ureteral stenosis (n = 1), and penile ulceration (n = 1). Urogenital symptoms rapidly resolved after therapy with glucocorticoids and immunosuppressive agents. Several patients underwent a surgical procedure, either at the time of diagnosis (n = 3) (consisting of an open nephrectomy and radical prostatectomy for suspicion of carcinoma, suprapubic cystostomy for acute urinary retention), or during follow-up (n = 3) (consisting of ureteral double J stents for ureteral stenosis, and prostate transurethral resection because of dysuria). After a mean follow-up of 56 months, urogenital relapse occurred in 4 patients (36%). Urogenital involvement can be the first clinical evidence of WG. Some presentations, such as a renal or prostate mass that mimics cancer or an abscess, should be assessed to avoid unnecessary radical surgery. Urogenital symptoms can be promptly resolved with glucocorticoids and immunosuppressive agents. However, surgical procedures, such as prostatic transurethral resection, may be mandatory in patients with persistent symptoms.

Anti-MPO small-vessel vasculitis causing prostatis and nephritis

Microscopic polyangiitis is a necrotizing angiitis involving capillaries, venules, and arterioles. The vascular beds of various organs may be involved, causing varying presentations. To our knowledge, this is the first case of anti-myeloperoxidase (anti-MPO) antibody small-vessel vasculitis causing prostatic vasculitis. A 79 year-old nonsmoker American man presented with symptoms of fevers, malaise, weight loss, and cough. Urine analysis revealed hematuria. Blood tests were remarkable for an elevated prostate-specific antigen (PSA) and a serum creatinine of 3.1 mg/dl (baseline, 1.2 mg/dl). Computed tomography (CT) scan of the thorax revealed a 4.7-cm mass in the left lower lobe of the lung. Metastatic prostate cancer was suspected. Therefore, prostatic biopsy was performed. The biopsy revealed fibrinoid degeneration with vasculitic changes involving the arterioles. When evaluated by nephrology, his serum creatinine was 9.9 mg/dl. A renal biopsy was performed, which revealed focal segmental necrotizing glomerulopathy with microscopic vasculitis. All the serologies were normal, with the exception of low C4, and positive perinuclear antineutrophil cytoplasmic antibodies (ANCA) associated with anti-MPO. The patient was started on intermittent hemodialysis, steroids, and oral cytoxan. Despite treatment, with improvement of the respiratory and constitutional symptoms, the patient remained dialysis-dependent. He later decided to discontinue dialysis and subsequently expired. Vasculitic involvement of the prostate is an uncommon manifestation of microscopic polyangiitis. This bedazzling entity is challenging to diagnose and thus makes it difficult to treat in a timely manner.

Urogenital manifestations of Wegener granulomatosis

We report 8 patients with Wegener granulomatosis (WG) who suffered from symptomatic urogenital involvement including acute urinary retention related to prostatitis, orchitis, ureteral stenosis, bladder pseudotumor, and penile ulceration. Urogenital manifestations occurred as an isolated manifestation of WG in 4 patients, at the onset of the disease in 1 patient, and as the only symptom of relapse in 3. Data used to distinguish specific WG involvement from infection or cyclophosphamide urothelial toxicity are discussed. Four patients needed a surgical procedure consisting of suprapubic cystostomy for acute urinary retention, bilateral ureteral double J stents for bilateral ureteral stenosis, and prostate transurethral resection. Urogenital symptoms promptly resolved with medical therapy. High-dose corticosteroids and immunosuppressive drugs should be used as first-line therapy to avoid unnecessary surgery.