Wegener's granulomatosis presenting as a recurrence of chronic otitis media

Seronegative Granulomatosis With Polyangiitis With Isolated Lung Lesions: A Case Report

Granulomatosis with polyangiitis (GPA), previously referred to as Wegener's granulomatosis, is an uncommon form of necrotizing vasculitis that predominantly targets small and medium-sized blood vessels as a result of granulomatous inflammation. Granulomatosis with polyangiitis is defined by the existence of necrotizing granulomas in the upper respiratory tract, along with renal involvement, which includes necrotizing glomerulonephritis with extra capillary crescents. From a diagnostic perspective, there is a high correlation between GPA and proteinase-3 anti-neutrophil cytoplasmic antibody (PR3-ANCA) because of the release of inflammatory cytokines, reactive oxygen species (ROS), and lytic enzymes. While ANCA-positive serology is commonly used as the diagnostic criteria, we present a seronegative GPA case with isolated lung lesions. A 54-year-old woman was referred for an assessment of hemoptysis and alterations in her chest radiograph. The patient's laboratory results showed a positive QuantiFERON test but negative results for ANCA and antinuclear antibodies (ANA) tests. A chest CT scan showed the presence of several pulmonary nodules in both lungs, with some cavitation. A CT-guided biopsy was conducted on a nodule located in the lower lobe of the right lung. The results showed that the nodule had non-neoplastic chronic inflammation and an area of geographic necrosis. A second robotic-assisted left upper and lower lobe wedge resection was done, which showed white to tan granular lesions with necrotizing granulomatous inflammation and lymph nodes with anthracosis and a lot of histiocytes, which is typical of GPA. The patient received a six-month course of intravenous rituximab treatment.

Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic

We present the case of a 71-year-old woman with bilateral pneumonia who continued to deteriorate despite multiple courses of antibiotics. When dexamethasone was added to cover the possibility of COVID-19 pneumonia, she rapidly improved. Subsequently, she was found to have a strongly positive PR3 anti-nuclear cytoplasmic antibody (ANCA) and clinical features consistent with granulomatosis with polyangiitis (GPA) with upper respiratory tract and renal involvement. The case highlights how the COVID-19 pandemic can create new challenges in the diagnosis of GPA.

Granulomatosis with polyangiitis and facial palsy: Literature review and insight in the autoimmune pathogenesis

Granulomatosis with polyangiitis (GPA) is an autoimmune systemic necrotizing small-vessel vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). Oto-neurological manifestations of ANCA-associated vasculitis according to PR3-ANCA positivity and MPO-ANCA positivity are usually reported. Facial nerve palsy is usually reported during the clinical course of the disease but it might appear as the presenting sign of GPA. Necrotizing vasculitis of the facial nerve 'vasa nervorum' is nowadays the most widely accepted etiopathogenetic theory to explain facial damage in GPA patients. A central role for PR3-ANCA in the pathophysiology of vasculitis in GPA patients with oto-neurological manifestation is reported. GPA requires prompt, effective management of the acute and chronic manifestations. Once the diagnosis of GPA has been established, clinicians should devise an appropriate treatment strategy for each individual patient, based on current clinical evidence, treatment guidelines and recommendations.

Clinic manifestations in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis (WG), is an uncommon immunologically mediated systemic small-vessel vasculitis that is pathologically characterised by an inflammatory reaction pattern (necrosis, granulomatous inflammation and vasculitis) that occurs in the upper and lower respiratory tracts and kidneys. Although the aetiology of GPA remains largely unknown, it is believed to be autoimmune in origin and triggered by environmental events on a background of genetic susceptibility.In Europe, the prevalence of GPA is five cases per 100,000 population, with greater incidence in Northern Europe. GPA can occur in all racial groups but predominantly affects Caucasians. Both sexes are affected equally. GPA affects a wide age range (age range, 8-99 years).Granulomatosis with polyangiitis is characterised by necrotising granulomatous lesions of the respiratory tract, vasculitis and glomerulonephritis. Classically, the acronym ELK is used to describe the clinical involvement of the ear, nose and throat (ENT); lungs; and kidneys. Because the upper respiratory tract is involved in 70-100% of cases of GPA, classic otorhinolaryngologic symptoms may be the first clinical manifestation of disease. The nasal cavity and the paranasal sinuses are the most common sites of involvement in the head and neck area (85-100%), whereas otological disease is found in approximately 35% (range, 19-61%) of cases.Diagnosis of GPA is achieved through clinical assessment, serological tests for anti-neutrophil cytoplasmic antibodies (ANCA) and histological analysis. The 10-year survival rate is estimated to be 40% when the kidneys are involved and 60-70% when there is no kidney involvement.The standard therapy for GPA is a combination of glucocorticoids and cyclophosphamide. In young patients, cyclophosphamide should be switched to azathioprine in the maintenance phase.A multidisciplinary approach, involving otorhinolaryngologists, oral and maxillofacial surgeons, oral physicians, rheumatologists, renal and respiratory physicians, and ophthalmologists, is necessary for the diagnosis and therapeutic treatment of GPA. ENT physicians have a determining role in recognising the early onset of the disease and starting an appropriate therapy.

Reversible cochlear function with ANCA-associated vasculitis initially diagnosed by otologic symptoms

OBJECTIVE

To present 8 cases with hearing loss as an initial symptom of antineural cytoplasmic antibody (ANCA)-associated vasculitis (AAV) involving granulomatosis with polyangiitis (GPA) and to discuss the treatment and mechanisms of hearing outcomes after immunosuppressive therapy.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Eight patients were referred to our university hospital between 2004 and 2012 for intractable otitis media with acute progressive mixed (conductive and sensorineural) hearing loss and facial palsy.

INTERVENTION(S)

Diagnostics and treatment.

MAIN OUTCOME MEASURES

Otologic symptoms as initial manifestations of otitis media with AAV and cochlear function after treatment.

RESULTS

Eight cases (6 female and 2 male subjects; aged 54-73 yr; 6 MPO [myeloperoxidase]-ANCA-positive and 2 PR3 [proteinase 3]-ANCA-positive cases) were included. Progressive hearing loss was present in all patients, and facial palsy was present in 5 of 8 patients total. Patients with hearing levels better than 95 dB improved with good speech discrimination after immunosuppressive therapy, but the completely deaf could not be recovered. All patients have been successfully controlled for 1 to 8 years without any systemic disorders.

CONCLUSION

This study showed the difficulty of diagnosing localized AAV and the effectiveness of immunosuppressive therapy for hearing loss in the early stage. Based on these results, early-stage AAV would influence the stria vascularis in the cochlea. Otitis media with ANCA-associated vasculitis is a new entity among the causes of intractable otitis media and progressive hearing loss.

Otologic symptoms as initial manifestation of wegener granulomatosis: diagnostic dilemma

OBJECTIVE

To show 7 cases of Wegener granulomatosis (WG) with early aural symptoms and to discuss the problems of otologic manifestation in WG.

STUDY DESIGN

Retrospective case review.

SETTING

: Tertiary care university hospital.

PATIENTS

All patients were administered to the ENT University Department in Poznań in years 2002-2008 because of otitis media with effusion, facial palsy, sensorineural profound hypoacusis, hypoacusis combined with purulent discharge, and facial nerve palsy or progression of mixed type hypoacusis.

INTERVENTIONS

Diagnostics and treatment. MAIN OUTCOME MEASURESL: Otologic symptoms as initial manifestation of WG diagnostic dilemma.

RESULTS

The authors want to underline the young age of the patients, ranging from 32 to 46 years. The outcome of initially otologic cases, which developed generalized form of WG, was poor (the first patient died after 2 months, the second patient died after 7 days, the third had the pulmonary insufficiency in 2 months of observation, and the fourth had severe renal failure in 1 month), whereas the patients with localized disease have been successfully under control for 1 to 5 years.

CONCLUSION

As WG often presents otologic symptoms, as an initial sign in some cases, it is important to take WG into consideration in atypical inflammatory states of the ear. The otologic onset of WG is very insidious, and prompt diagnosis in early stage of disease is a challenge. Focal and localized disease in the aural region might possibly require less aggressive therapy than acute-onset multi-organ disease and is connected with better prognosis.

[Wegener granulomatosis - otologic, nasal, tracheobronchial and pulmonary involvement]

Wegener granulomatosis is a rare systemic idiopathic disease characterized by involvement of small vessels - medium and small arteries, venules, arterioles and ocasionally large arteries. This disease has predilection for the upper and lower respiratory tract and the kidney, with granulomatous inflamation and necrosis. Clinical manifestations and organ involvement of the disease vary widely. Early diagnosis and treatment may lead to a full recovery. Without treatment, Wegener's granulomatosis can be fatal. The authors present a case of a 33 year-old female, with severe disease, but with good outcome, after adequate diagnosis and treatment.

Granulomatose de Wegener: relato de caso

A Granulomatose de Wegener é uma doença sistêmica, idiopática e rara, com acometimento das pequenas artérias dos tratos respiratórios superior e inferior e rins, levando à necrose e granuloma estes órgãos. Neste trabalho relatamos e discutimos o caso de uma adolescente, do sexo feminino, de apresentação inicial atípica e com evolução favorável após o diagnóstico precoce e tratamento adequados.

Otologic manifestations of Wegener's granulomatosis

OBJECTIVE/HYPOTHESIS

To evaluate the clinical features, treatment, and outcomes of otologic manifestations in Wegener's granulomatosis (WG) treated at Hokkaido University Graduate School of Medicine, Sapporo, Japan.

STUDY DESIGN

We retrospectively reviewed 15 cases of WG with ear involvement.

METHODS

Twenty-five patients with WG were treated at Hokkaido University Graduate School of Medicine between 1992 and 2001. Fifteen of these patients had otologic symptoms. We evaluated the clinical course, method of therapy, and outcomes in all cases. Diagnosis of WG was made when the patients had clinical findings and a positive titer of cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA), or when there were clear histologic findings. We also present three case reports.

RESULTS

In 15 cases, the most frequent finding was chronic otitis media. Sensorineural hearing loss was present in 2 patients. In 7 patients whose otologic manifestations were the primary involvement of WG, all were confirmed positive for c-ANCA and were treated with glucocorticoids and immunosuppressive drugs. Three patients who could be treated within 1 month of symptom onset showed marked improvement.

CONCLUSIONS

In localized cases, biopsy specimens are often small, and it is frequently difficult to make a histologic diagnosis. The prognosis for hearing was poor when appropriate treatment was not given in the early stages of the disease. Therefore, WG should be included in the differential diagnosis in cases of atypical inflammatory states of the ear. Early diagnosis and appropriate treatment are important to prevent irreversible changes in the middle ear and inner ear.