1
|
Trandafir CM, Balica NC, Horhat DI, Mot IC, Sarau CA, Poenaru M. Granulomatosis with Polyangiitis (GPA)-A Multidisciplinary Approach of a Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1837. [PMID: 36557039 PMCID: PMC9785195 DOI: 10.3390/medicina58121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
Granulomatosis with polyangiitis is an atypical, multisystem disease with unknown etiology that generally affects both genders equally, with a predominance in the Caucasian racial group for individuals in their fourth decade. The disease affects the small vessels of the respiratory system, lungs, and kidneys. ENT manifestations are common, but ocular involvement is also frequent and can occur as an initial harbinger of the disease. The signs and symptoms of the disease are non-pathognomonic and sometimes localized, but it carries a poor prognosis if left untreated. Early diagnosis of granulomatosis with polyangiitis can be difficult and is established by a clinical examination along with laboratory tests for anti-neutrophil cytoplasmic antibodies (ANCA) and anatomopathological exam results that showcase necrosis, granulomatous inflammation, and vasculitis. Although the ocular involvement is not life threatening, it can cause blindness and may also be a sign of the active form of this systemic fatal disease. Treatment strategies involving immunosuppression and adjuvant therapies improve the prognosis. In this article we present a rare case of a patient diagnosed with granulomatosis with polyangiitis in our ENT department in 2003, with a follow-up for19 years in our clinic.
Collapse
Affiliation(s)
- Cornelia M. Trandafir
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Nicolae Constantin Balica
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Delia I. Horhat
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Ion C. Mot
- Department of ENT, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| | - Cristian A. Sarau
- Department of Medical Semiology I, Victor Babeş University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Marioara Poenaru
- ENT Department, SCMUT Hospital Timisoara, Bd. Revolutiei No. 6, 300054 Timisoara, Romania
| |
Collapse
|
2
|
Sato-Akushichi M, Kinouchi R, Kawai N, Nomura K. Optic neuropathy secondary to granulomatosis with polyangiitis in a patient with Graves' disease: a case report. J Med Case Rep 2021; 15:618. [PMID: 34963497 PMCID: PMC8715570 DOI: 10.1186/s13256-021-03207-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
Background Dysthyroid optic neuropathy is the most commonly suspected diagnosis of optic neuropathy in Graves’ patients; however, other causes need to be ruled out. We present a unique case of optic neuropathy secondary to hypertrophic pachymeningitis with antineutrophil cytoplasmic antibody-associated vasculitis, which was suspected to be antithyroid drug related.
Case presentation A 79-year-old Japanese male presented with acute visual loss in the left eye. He had a 24-year history of Graves’ disease and was taking methimazole. Best-corrected visual acuity was 0.8 in the right eye and light perception in the left eye, and relative afferent pupillary defect in the left eye was seen. Ocular movement was normal, and there were no findings explaining visual loss in intermediate optic media and fundus in the left eye. Contrast-enhanced magnetic resonance imaging demonstrated thickened dura mater. Tests for myeloperoxidase-antineutrophil cytoplasmic antibody, proteinuria, and hematuria were positive; pulmonary nodule lesions and a blood clot in the left lower leg were also found. After excluding the presence of diseases that could lead to hypertrophic pachymeningitis, we diagnosed optic neuropathy due to hypertrophic pachymeningitis with granulomatosis with polyangiitis—a subtype of antineutrophil cytoplasmic antibody-associated vasculitis. Since he had history of using methimazole, antineutrophil cytoplasmic antibody-associated vasculitis was considered as drug related. We started high-dosage steroid pulse therapy followed by 1 mg/kg body weight daily of oral prednisolone, and subsequently tapered. Methimazole was stopped. Best-corrected visual acuity recovered to 0.9, 2 weeks after starting treatment. Though myeloperoxidase-antineutrophil cytoplasmic antibody remained negative, the symptom relapsed 6 months after treatment initiation. We gave a second high-dose steroid pulse therapy followed by prednisolone tapered together with methotrexate. Remission remained, and using 4 mg/week methotrexate without prednisolone, myeloperoxidase-antineutrophil cytoplasmic antibody was kept within the normal limit until now, 4 years after onset. Conclusion We present a case of optic neuropathy with hypertrophic pachymeningitis related to antineutrophil cytoplasmic antibody-associated vasculitis, which was suspected to be drug related. The patient had good visual recovery after quitting the drug and receiving immunosuppressive therapy with systemic steroids. Hypertrophic pachymeningitis with antineutrophil cytoplasmic antibody-associated vasculitis related to antithyroid drugs should be considered as a differential diagnosis for optic neuropathy in Graves’ patients in whom optic nerve compression is not obvious. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-021-03207-4.
Collapse
Affiliation(s)
- Miki Sato-Akushichi
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Reiko Kinouchi
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan. .,Medicine and Engineering Combined Research Institute, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Naoko Kawai
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kenichiro Nomura
- Department of Otolaryngology Head and Neck Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| |
Collapse
|
3
|
Clément M, Néel A, Toulgoat F, Weber M, Godmer P, Hutin P, Hamidou M, Lebranchu P. Inflammatory optic neuropathy in granulomatosis with polyangiitis can mimick isolated idiopathic optic neuritis. Eur J Ophthalmol 2019; 31:245-251. [PMID: 31744325 DOI: 10.1177/1120672119889008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We describe a clinico-radiological presentation of inflammatory optic neuropathy that mimicked optic neuritis. METHODS Retrospective single-center case series and literature review of optic neuropathy without orbital pseudotumor. RESULTS Five local patients fulfilled the inclusion criteria. Clinical presentation revealed rapidly progressive severe unilateral visual loss, retrobulbar pain (n = 4), and paralytic strabismus (simultaneous = 2, protracted = 2) without proptosis. Optic nerve abnormality was not appreciated on initial scan review. Patients did not have any general activity of the granulomatosis with polyangiitis. Upon follow-up magnetic resonance imaging and initial imaging review, all patients revealed orbital apex anomalies. Visual acuity improved in three patients who received high-dose intravenous glucocorticosteroids immediately. Relapse was frequent and visual outcome was poor (final vision > 20/40 in two patients only). Literature review identified 16 well-documented cases of granulomatosis with polyangiitis-related isolated optic neuropathies. Magnetic resonance imaging revealed no abnormality (n = 6), optic nerve and/or sheath involvement (n = 9), apex infiltration (n = 3), and/or pachymeningitis (n = 7). CONCLUSION Granulomatosis with polyangiitis is a rare yet potentially blinding cause of inflammatory optic neuropathy. Optic neuropathy in granulomatosis with polyangiitis may occur in the absence of systemic symptoms of disease activity and is challenging to distinguish from other inflammatory and non-inflammatory disorders affecting visual acuity. Several clinical and imaging clues suggest that optic neuropathy results from the development of an extravascular granulomatous process within the optic nerve sheath in the orbital apex, a place that is difficult to image. In a granulomatosis with polyangiitis patient with unexplained visual loss and a seemingly normal workup (fundoscopy, biology, and imaging), clinician should keep a high index of suspicion.
Collapse
Affiliation(s)
- Manon Clément
- Department of Ophthalmology, CHU Hôtel-Dieu, Nantes, France
| | - Antoine Néel
- Department of Internal Medicine, CHU Hôtel-Dieu, INSERM UMR 1064, Nantes, France.,Center for Research in Transplantation and Immunology, Nantes, France
| | | | - Michel Weber
- Department of Ophthalmology, CHU Hôtel-Dieu, Nantes, France
| | - Pascal Godmer
- Department of Internal Medicine, CH Vannes, Vannes, France
| | - Pascal Hutin
- Department of Infectious Diseases, CH Quimper, Quimper, France
| | - Mohamed Hamidou
- Department of Internal Medicine, CHU Hôtel-Dieu, INSERM UMR 1064, Nantes, France
| | - Pierre Lebranchu
- Department of Ophthalmology, CHU Hôtel-Dieu, Nantes, France.,UMR 6597 CNRS, Image Perception and Interaction team, Laboratory of Digital Sciences of Nantes, Nantes, France
| |
Collapse
|
4
|
Sasaki S, Asahara D, Kaneko K, Komatsumoto S. Successful Combination Therapy with Rituximab and Glucocorticoids for Autoimmune Optic Neuropathy. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:357-60. [PMID: 26057570 PMCID: PMC4463999 DOI: 10.12659/ajcr.894064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient: Female, 77 Final Diagnosis: Autoimmune optic neuropathy Symptoms: Vision loss in the left eye Medication: — Clinical Procedure: Treatment with Rituximab and Glucocortioids Specialty: Ophthalmology and Internal Medicine
Collapse
Affiliation(s)
- Shoichi Sasaki
- Department of Internal Medicine, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Daisuke Asahara
- Department of Ophthalmology, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Kaichi Kaneko
- Department of Internal Medicine, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Satoru Komatsumoto
- Department of Internal Medicine, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| |
Collapse
|
5
|
Iwanami H, Katoh H, Ohnaka Y, Nakajima M, Kawamura M. [Orbital apex syndrome without MRI lesion caused by ANCA-associated vasculitis]. Rinsho Shinkeigaku 2014; 54:158-161. [PMID: 24583592 DOI: 10.5692/clinicalneurol.54.158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 73-year-old man developed double vision and a progressive loss of visual acuity of the left eye over one week. Examination showed disturbances of the left II, III, IV, and VI cranial nerves, that is, an orbital apex syndrome. A brain MRI showed abnormal T2-high signals in the right maxillary sinus and the left mastoid cells without abnormalities in the left orbital apex and the surroundings. Laboratory examination showed an elevated erythrocyte sedimentation rate and a positive perinuclear anti-neutrophil cytoplasmic antibody (MPO-ANCA). After two courses of methyl-prednisolone pulse treatment, his external ophthalmoplegia fully recovered and he regained his left eye's sight. MPO-ANCA was negative and MRI abnormalities were disappeared after treatment. Two years later, the patient developed upper respiratory symptoms associated with an elevation of MPO-ANCA titer, and rapidly progressive renal failure. Renal biopsy specimen showed fibrinoid necrosis with periarteriolar neutrophil infiltration, which suggested that the patient suffered from ANCA-associated vasculitis probably of Wegener's granulomatosis or microscopic polyarteritis. ANCA-associated vasculitis may present with a focal neurological syndrome such as the orbital apex syndrome without a lesion detectable with MRI.
Collapse
Affiliation(s)
- Hiroaki Iwanami
- Department of Neurology, Showa University School of Medicine
| | | | | | | | | |
Collapse
|
6
|
Nagashima T, Matsumoto K, Murosaki T, Okada M, Iwamoto M, Makino S, Minota S. Posterior ischemic optic neuropathy in a patient with granulomatosis with polyangiitis (Wegener’s). Rheumatol Int 2012; 33:1915-6. [DOI: 10.1007/s00296-012-2427-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 03/11/2012] [Indexed: 10/28/2022]
|
7
|
Barbosa-Cobos RE, Recillas-Gispert C, Arellanes-García L. [Ocular manifestations of primary systemic vasculitis]. REUMATOLOGIA CLINICA 2011; 7 Suppl 3:S12-7. [PMID: 22119276 DOI: 10.1016/j.reuma.2011.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
A variety of ophthalmic manifestations can occur in patients who have systemic vasculitides and may be the presenting feature. Ocular involvement is frequently found and can result in significant morbidity, even in blindness. Early diagnosis and treatment may improve visual outcome. The management is challenging and requires a multidisciplinary approach. Treatment of ocular manifestations and systemic disease usually follows the same path. The mainstay of treatment is the use of systemic corticosteroids, usually combined with steroid-sparing immunosuppressive drugs. New, promising, emerging therapies rely on the development of biologic agents, which seem useful in the ocular manifestations of systemic vasculitides.
Collapse
Affiliation(s)
- Rosa Elda Barbosa-Cobos
- Servicio de Reumatología, Hospital Juárez de México, Col. Magdalena de Salinas, Delegación GA Madero, México DF, México
| | | | | |
Collapse
|
8
|
Central retinal artery occlusion in Wegener's granulomatosis: a diagnostic dilemma. J Ophthalmic Inflamm Infect 2011; 1:71-5. [PMID: 21484179 PMCID: PMC3102859 DOI: 10.1007/s12348-010-0003-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Accepted: 09/07/2010] [Indexed: 11/03/2022] Open
Abstract
PURPOSE To report a case of central retinal artery occlusion (CRAO) in a patient with biopsy-verified Wegener's granulomatosis (WG) with positive C-ANCA. METHODS A 55-year-old woman presented with a 3-day history of acute painless bilateral loss of vision; she also complained of fever and weight loss. Examination showed a CRAO in the left eye and angiographically documented choroidal ischemia in both eyes. RESULTS The possibility of systemic vasculitis was not kept in mind until further studies were carried out; methylprednisolone pulse therapy was then started. Renal biopsy disclosed focal and segmental necrotizing vasculitis of the medium-sized arteries, supporting the diagnosis of WG, and cyclophosphamide pulse therapy was administered with gradual improvement, but there was no visual recovery. CONCLUSION CRAO as presenting manifestation of WG, in the context of retinal vasculitis, is very uncommon, but we should be aware of WG in the etiology of CRAO. This report shows the difficulty of diagnosing Wegener's granulomatosis; it requires a high index of suspicion, and we should obtain an accurate medical history and repeat serological and histopathological examinations. It emphasizes that inflammation of arteries leads to irreversible retinal infarction, and visual loss may occur.
Collapse
|
9
|
Nguyen GT, Keltner JL. Steroid-Responsive Optic Neuropathy (SRON) in Anti-neutrophil Cytoplasmic Antibody–Negative Wegener Granulomatosis with False-Positive Indicators of Giant Cell Arteritis and Sarcoidosis. Neuroophthalmology 2010. [DOI: 10.3109/01658107.2010.518335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
10
|
Wegener's granulomatosis: clinical manifestations, differential diagnosis, and management of ocular and systemic disease. Surv Ophthalmol 2010; 55:429-44. [PMID: 20638092 DOI: 10.1016/j.survophthal.2009.12.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 12/05/2009] [Accepted: 12/16/2009] [Indexed: 11/22/2022]
Abstract
Wegener's granulomatosis (WG) is a systemic inflammatory disease whose histopathologic features often include necrosis, granuloma formation, and vasculitis of small-to-medium-sized vessels. WG involves many interrelated pathogenic pathways that are genetic, cell-mediated, neutrophil-mediated, humoral, and environmental. WG most commonly involves the upper respiratory tract, lungs, and kidneys, but has been reported to affect almost any organ. Ophthalmologic involvement is an important cause of morbidity in WG patients, occurring in approximately one-half of patients. The presence of unexplained orbital inflammatory disease, scleritis, peripheral ulcerative keratitis, cicatricial conjunctivitis, nasolacrimal duct stenosis, retinal vascular occlusion, or infrequently uveitis should raise the question of possible WG. A thorough clinical examination, laboratory testing, radiologic imaging, and histologic examination are essential to diagnosing WG and excluding potential mimics. Previously a uniformly fatal disease, treatment with cytotoxic and immunosuppressive agents has greatly improved survival. Treatment-related morbidity is a serious limitation of conventional therapies, leading to numerous ongoing studies of alternative agents.
Collapse
|
11
|
Cooley M, Pless M, Stone JH. A 58-year-old woman with a droopy left eye and vision loss. ACTA ACUST UNITED AC 2009; 61:1133-9. [PMID: 19644910 DOI: 10.1002/art.24605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
12
|
Bibliography. Current world literature. Neuro opthalmology. Curr Opin Ophthalmol 2008; 19:541-4. [PMID: 18854700 DOI: 10.1097/icu.0b013e328317c7c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Current world literature. Curr Opin Neurol 2008; 21:615-24. [PMID: 18769258 DOI: 10.1097/wco.0b013e32830fb782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|