Wegener's granulomatosis: a review of clinical features and an update in diagnosis and treatment

Causes of Oral Granulomatous Disorders: An Update and Narrative Review of the Literature

Granulomatous diseases include a diverse range of chronic inflammatory disorders with a wide variety of pathologies and clinical characteristics. In particular, the orofacial region can be affected by granulomatous conditions-whether as an isolated disease or as part of a systemic disorder. Regardless of the nature of the disease or its mechanism of development, precise diagnosis can be challenging, as etiopathogenesis may be driven by several causes. These include reactions to foreign bodies, infections, immune dysregulation, proliferative disorders,, medications, illicit drugs, and hereditary disorders. Granulomas can be identified using histopathological assessment but are not pathognomonic of a specific disease, and therefore require correlation between clinical, serological, radiographical, and histopathological findings. The purpose of this review is to provide a summary of the etiopathogenesis, clinical and histopathologic characteristics, and treatment of oral granulomatous disorders.

Granulomatosis With Polyangiitis and Concomitant Superinfection: A Defying Diagnosis and Management Approach

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis mainly involving the ear, nose, and upper and lower airways. Diagnosis is based on clinical manifestations, positive antineutrophil cytoplasmic antibodies (ANCA) serology, and histopathological findings. We report a case of inflammatory polyarthralgia with a high titer of rheumatoid factor (RF), which was revealed to be GPA after extensive diagnosis workup. However, the disease was complicated by superinfections, which delayed and limited immunosuppressive treatment. Methotrexate was at last initiated with antibiotic prophylaxis, and there was significant clinical improvement. This case underlines the importance of an adequate diagnosis workup and the difficulties that often arise when other entities are present.

A Rare Presentation of Wegener's Granulomatosis in ENT

Wegener's granulomatosis or Granulomatosis with polyangiitis is a rare multisystem autoimmune vasculitis disease which may become life threatening due to the various system involvement. Granular hyperplastic gingivitis, the so called "strawberry gingivitis" is a rare manifestation of this disease, yet pathognomic when present. Early diagnosis and treatment is very important.

Interstitial Granulomatous Dermatitis as the Initial Manifestation of Granulomatosis with Polyangiitis

Interstitial granulomatous dermatitis (IGD) is a rare dermatological disorder. It is most commonly associated with autoimmune disorders mainly lupus and rheumatoid arthritis. It has rarely been reported to present as a first manifestation of an underlying vasculitis. Here, we present a case of a 44-year-old woman who presented initially with a violaceous rash starting in her neck and trunk and extending to her limbs, but sparing the palms and soles. She was also found to have an acute kidney injury. A biopsy of the skin lesion confirmed the diagnosis of IGD, and a kidney biopsy showed findings consistent with granulomatosis with polyangiitis. To the best of our knowledge, this is the seventh reported case of IGD associated with systemic vasculitis.

Oral granulomatosis with polyangiitis a systematic review

OBJECTIVE

Granulomatosis with polyangiitis is an unusual multisystemic inflammatory disease, with vasculitis of small- and medium-sized vessels, with a predilection for upper lower airways and kidneys. The etiology remains unknown although it may originate from different stimuli, in genetically susceptible patients.

MATERIALS AND METHODS

A detailed database search was performed. The variables were demographics, localization, histopathological findings, antineutrophil cytoplasmic autoantibody, cytoplasmic (c-ANCA) tests, treatment, and follow-up.

RESULTS

Fifty-two cases were identified; the mean age was 49.6 years, with a range from 6 to 87 years. It was most frequently seen in females (57.7%). The most common race was white (59.6%). The most frequent location was in the maxillary gingiva (28.8%), followed by both the upper and lower gingiva (19.2%). The most common clinical presentation was "strawberry gingivitis" (61.5%). The main symptom was pain, in 50%. Regarding the c-ANCA test, it was positive in 71.2% of cases. The most common therapy was prednisone and cyclophosphamide, utilized in 51.9%. The average follow-up was 23.6 months, and 88.5% of patients were still alive at follow-up.

CONCLUSION

The diagnosis initially was difficult to establish, an early diagnosis and treatment are mandatory. If untreated the disease can be associated with morbidity and mortality. For the oral clinician, this disease needs to be addressed in the differential diagnosis of oral lesions.

Migrant cavitation as primary involvement in a particular case of granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, is a necrotizing granulomatous vasculitis of the small and medium vessels involving the upper respiratory tract, lungs, and kidneys. In this case report, we will describe the case of a 60-year-old man who presented to our observation with recurrent episodes of hemoptoe, fever, and mucopurulent sputum. The diagnosis was made by radiological and laboratory tests.

Granulomatosis with polyangiitis: Common and uncommon presentations

Granulomatosis with polyangiitis (GPA) is a multisystemic autoimmune small vessel vasculitis predominantly affecting the respiratory and renal systems. Other systems such as the central nervous system, orbital, cardiac and gastrointestinal systems may also be involved to a lesser degree. Although there are no imaging features that are pathognomonic for GPA, there are known radiological patterns suggestive of the disease and imaging plays an important role in diagnosis, assessment and monitoring of disease activity. This is more evident when combined with clinical features, biochemical values and histopathology results. This pictorial review aims to present both common and uncommon radiological features of GPA.

Oral Microbiota Profile in Patients with Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis

Microbiota has been associated with autoimmune diseases, with nasal Staphylococcus aureus being implicated in the pathogenesis of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). Little is known about the role of oral microbiota in AAV. In this study, levels of IgG antibodies to 53 oral bacterial species/subspecies were screened using immunoblotting in plasma/serum in pre-symptomatic AAV-individuals (n = 85), matched controls, and established AAV-patients (n = 78). Saliva microbiota from acute-AAV and controls was sequenced from 16s rDNA amplicons. Information on dental status was extracted from a national register. IgG levels against oral bacteria were lower in established AAV versus pre-AAV and controls. Specifically, pre-AAV samples had, compared to controls, a higher abundance of periodontitis-associated species paralleling more signs of periodontitis in established AAV-patients than controls. Saliva microbiota in acute-AAV showed higher within-sample diversity but fewer detectable amplicon-sequence variants and taxa in their core microbiota than controls. Acute-AAV was not associated with increased abundance of periodontal bacteria but species in, e.g., Arthrospira, Staphylococcus, Lactobacillus, and Scardovia. In conclusion, the IgG profiles against oral bacteria differed between pre-AAV, established AAV, and controls, and microbiota profiles between acute AAV and controls. The IgG shift from a pre-symptomatic stage to established disease cooccurred with treatment of immunosuppression and/or antibiotics.

Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies

Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.

Infliximab therapy of relapsing tracheal stenosis in a pediatric patient with granulomatosis with polyangiitis: a case report

Background

Granulomatosis with polyangiitis is a granulomatous, necrotizing small-vessel vasculitis affecting both children and adults. However, subglottic tracheal stenosis appears more frequently in the pediatric cohort. To date, granulomatosis with polyangiitis is often treated with steroids, cyclophosphamide, azathioprine, or rituximab, but tumor-necrosis-factor-α-antagonistic drugs are increasingly gaining significance in treatment of refractory cases.

Case presentation

We report the case of a 15-year-old Caucasian male diagnosed with proteinase-3-positive granulomatosis with polyangiitis with acute shortness of breath. X-ray and magnet resonance imaging showed extensive subglottic narrowing. Forced expiratory volume in 1 s was reduced to 50% of age norm, with massively increased effective airway resistance. The patient initially responded very well to high-dose steroids and maintenance therapy with azathioprine. He was subsequently treated with four doses of rituximab, and levels of proteinase 3 antibodies normalized. After 6 months of clinical remission, the patient presented again with acute respiratory symptoms. Again, he was treated with high-dose steroids, but showed poor clinical response this time. Therefore, we decided to commence a tumor-necrosis-factor-α-antagonistic treatment with infliximab, under which our patient achieved clinical remission and normalization of lung function parameters.

Conclusions

The use of tumor-necrosis-factor-α-antagonistic agents might be a promising alternative for the treatment of refractory tracheal stenosis in pediatric patients with granulomatosis with polyangiitis.

Persistent pain after successful endodontic treatment in a patient with Wegener’s granulomatosis: a case report

Wegener’s granulomatosis (WG) is a condition with immune-mediated pathogenesis that can present oral manifestations. This report describes the case of a patient diagnosed with WG 14 years previously, who was affected by persistent pain of non-odontogenic origin after successful endodontic treatment. A 39-year-old woman with WG was diagnosed with pulp necrosis and apical periodontitis of teeth #31, #32, and #41, after evaluation through a clinical examination and cone-beam computed tomography (CBCT). At the first appointment, these teeth were subjected to conventional endodontic treatment. At 6- and 12-month follow-up visits, the patient complained of persistent pain associated with the endodontically treated teeth (mainly in tooth #31), despite complete remission of the periapical lesions shown by radiographic and CBCT exams proving the effectiveness of the endodontic treatments, thus indicating a probable diagnostic of persistent pain of non-odontogenic nature. After the surgical procedure was performed to curette the lesion and section 3 mm of the apical third of tooth #31, the histopathological analysis suggested that the painful condition was likely associated with the patient's systemic condition. Based on clinical, radiographic, and histopathological findings, this unusual case report suggests that WG may be related to non-odontogenic persistent pain after successful endodontic treatments.

[Granulomatosis with polyangiitis - manifestations in the head and neck area]

Granulomatosis with polyangiitis is a rare chronic rheumatologic systemic disease with a vasculitis of small- and medium-size vessels. Mostly the upper airways, lung and kidneys are affected. Symptoms are unspecific. Patients complain about stuffy nose, crustiness of nasal secretions, ulcera of the oral mucosa or epistaxis. The otorhinolaryngologist may be the first one to evaluate the patient's health condition. Long term complications may be cardial, renal or pulmonal failure. To this day the aetiology is still unknown. Severe disease is treated with a combination of immunosuppressive medications. Clinic examinations and laboratory tests should be carried out for life-time.

A Rare Case of Granulomatosis With Polyangiitis Presenting as Retroperitoneal Fibrosis in the Peri-Iliac Region Causing Hydronephrosis

Wegener's granulomatosis, now more commonly referred to as granulomatosis with polyangiitis (GPA), is a rare, idiopathic, systemic inflammatory disease, most commonly involving the respiratory tract, kidneys, and sinonasal region. The condition affects small and medium-sized blood vessels, such as arteries, arterioles, venules, and capillaries. Some cases of the disease presenting as retroperitoneal fibrosis and/or affecting the aorta have been reported. Although advances in the treatment of GPA have contributed to a decline in mortality, early diagnosis is still of vital importance due to the possible complications of the disease. Here, we present the case of a 69-year-old man with acute-onset abdominal pain. Ultrasound of the abdomen showed left-sided hydronephrosis. Computed tomography detected cavitating pulmonary lesions and peri-iliac alterations caused by retroperitoneal fibrosis with involvement of the crossing ureter. Laboratory results revealed high antineutrophil cytoplasmic antibody levels and high inflammatory markers. A lung biopsy performed via bronchoscopy revealed necrotizing granulomas and solidified the diagnosis of GPA both in the lung and the peri-iliac region. Treatment with immunosuppressive agents and glucocorticoids was initiated. A follow-up after two months showed regression of the pulmonary lesions and partial resolution of the hydronephrosis as well as reduced inflammatory markers in the blood tests.

ECMO Rescues Patients With Acute Respiratory Failure Related to GPA

Granulomatosis with polyangiitis (GPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis with a wide range of clinical symptoms related to the systemic involvement of small blood vessels. The respiratory system is one of the most frequently involved, and life-threatening acute respiratory failure could occur due to diffusive alveolar hemorrhage and tracheal stenosis. When maximum mechanical ventilation is unable to maintain oxygenation, extracorporeal membrane oxygenation (ECMO) should be considered as the final respiratory supportive method, if available. Here we present a 32-year-old male patient with acute respiratory failure (ARF) related to GPA, who was rescued by winning time for accurate diagnosis and appropriate treatment. Additionally, we reviewed more than 60 GPA-related ARF cases on multiple online databases, summarized the clinical manifestations of these patients, and concluded that ECMO plays an important role in further respiratory support for ARF patients with GPA and assists in accurate and timely diagnosis and appropriate treatment, thus helping them recuperate.

Granulomatosis with polyangiitis presenting as high fever with diffuse alveolar hemorrhage and otitis media: A case report

BACKGROUND

Granulomatosis with polyangiitis is a necrotizing inflammation of small and medium-sized vessels accompanied by formation of granuloma, involvement of primary granulomatous upper and lower respiratory tracts, glomerulonephritis, and vasculitis of small vessels.

CASE SUMMARY

Herein, we described a case of a 52-year-old man admitted with pulmonary nodules and high fever. Autoantibody workup revealed that the patient was positive for c-anti-neutrophil cytoplasmic antibodies and proteinase-3 anti-neutrophil cytoplasmic antibodies. Pulmonary biopsies revealed a local granulomatous structure. The patient received therapy with methylprednisolone and intravenous immunoglobulin, and his clinical symptoms improved.

CONCLUSION

Intravenous immunoglobulin may act on granulomatosis with polyangiitis similar to immunosuppressants.

Saprochaete clavata Infection in Immunosuppressed Patients: Systematic Review of Cases and Report of the First Oral Manifestation, Focusing on Differential Diagnosis

Background: Saprochaete clavata infection is an emerging issue in immunosuppressed patients, causing fulminant fungaemia. The purpose of this systematic review of cases is to retrieve all cases of S. clavata infection and describe oral lesions as the first manifestation of S. clavata infection. Methods: We report the first case of intraoral S. clavata infection in Acute Myeloid Leukemia (AML) affected subject, presenting as multiple grayish rapidly growing ulcerated swellings, and provide a review of all published cases of infection caused by S. clavata, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, conducted by searching SCOPUS, Medline, and CENTRAL databases. Only articles in English were considered. Individual patient data were analyzed to identify risk factors for S. clavata infection. Results: Seventeen of 68 retrieved articles were included in the review reporting data on 96 patients (mean age 51.8 years, 57 males and 38 females). Most cases were disseminated (86) with a 60.2% mortality rate. Ninety-five were hematological patients, with AML being the most common (57 cases). Conclusions:S. clavata infection in immunosuppressed patients has a poor prognosis: middle-age patients, male gender and Acute Myeloid Leukemia should be considered risk factors. In immunosuppressed patients, the clinical presentation can be particularly unusual, imposing difficult differential diagnosis, as in the reported case.

Systemic diseases and the cornea

There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.

Radiological approach to cavitary lung lesions

Cavitary lesions in the lung are not an uncommon imaging encounter and carry a broad differential diagnosis that includes a wide range of pathological conditions from cancers, infections/inflammatory processes to traumatic and congenital lung abnormalities. In this review article, we describe a comprehensive approach for evaluation of cavitary lung lesions and discuss the differential diagnosis in the light of radiological findings.

Tuberculous vasculitic lung mass: Unique presentation of a common disease

Tuberculosis is a common disease but it keeps on surprising with its unique presentations. It has been reported as lung mass but here we are reporting a case of Tuberculosis presented as vasculitic lung mass. A 61 years old female, known case of hypertension and secondary Sjogren syndrome, on treatment, presented with history of mild dyspnea and generalised weakness with incidental finding of Right hilar mass on chest X-ray undergoes a CECT thorax and CT guided biopsy. Histopathology contrary to expectations revealed granulomatous vasculitis with no microbiological evidence of TB, responded to antitubercular treatment and there was almost complete regression of the lesion after 6 weeks of ATT.

Main tract stenosis complicated by granulomatous with polyangiitis: A case report

Granulomatosis with polyangiitis (GPA) is a rheumatic auto-immune disease involved in vasculitis. It is rarely reported that anti-neutrophil cytoplasmic antibodies (ANCAs) associated with GPA would cause main tract stenosis. The current report documents a 54-year-old woman, with a history of severe cough, presented with wheezing and shortness of breath. Although she was treated with cephalosporin antibiotics for half a month, the symptoms were not alleviated. Accordingly, laboratory testing, radiology and pathology was performed at the Department of Respiratory and Critical Care Medicine, Huashan Hospital. Blood samples were tested negative for ANCAs. Chest CT revealed stenosis of the main trachea and uneven thickening of the tracheal wall. Nasal sinuses CT scanning indicated thickening of the nasal mucosa. Pathological analysis demonstrated chronic granulomatous inflammation with focal lesions. According to the classification criteria of ACR/EULAR provisional 2017, the patient was diagnosed with the ANCAs-negative GPA. Following treatment with oral prednisone only for 6 months, obstruction of main tract was significantly improved. This case study is of interest for the promotion a potentially novel therapeutic intervention for GPA associated with the absence ANCA of in clinic.

Gingival Swelling as the Initial Manifestation of Granulomatosis with Polyangiitis

We describe a case of granulomatosis with polyangiitis (GPA; formerly named Wegener granulomatosis) that presented initially as florid areas of gingival swelling. The patient also had upper respiratory symptoms that included sinus congestion and cough of recent onset. Clinical-pathologic correlation aided the interpretation of non-specific biopsy findings and immediate referral to an appropriate medical specialist. Treatment was rendered at an early stage of disease with a good response to date. Review of the literature indicates that gingival swelling, often with the characteristic appearance of "strawberry gingivitis" may represent the initial sign of disease in 2% of patients with GPA. Biopsy of gingival lesions often shows a non-specific histologic appearance that should be interpreted in the context of the clinical appearance and pertinent medical history. The clinical investigations that lead to definitive diagnosis and treatment are presented to facilitate the management of this uncommon but potentially fatal condition.

Hypercalcemia, an Important Puzzle Piece in Uncommon Onset Pediatric Sarcoidosis-A Case Report and a Review of the Literature

Sarcoidosis (SD) is a systemic granulomatous condition that is especially encountered in young adults and rarely in children, affecting predominantly the lungs and lymph nodes. We report the case of a 14-year-old teenage boy admitted to our clinic for nausea, vomiting, and weight loss. Clinical examination at the time of admission revealed malaise, pallor, and abdominal tenderness in the epigastric area at palpation. Laboratory tests revealed an elevated level of hemoglobin, mild thrombocytosis, increased erythrocyte sedimentation rate, and a mild increase in creatinine and urea levels along with hypercalcemia. An abdominal ultrasound revealed a right ectopic kidney, whereas the upper digestive endoscopy showed intense hyperemia and edema of the gastric mucosa. Thoracic computed tomography scan revealed giant hilar and mediastinal lymphadenopathy, along with multiple micronodules within the lung parenchyma and ground-glass aspect. The level of angiotensin-converting enzyme was high, parathormone was normal, and vitamin D level was low. Pathological examination of the bronchial, mediastinal, and lung biopsies established the diagnosis of SD. We administered oral corticosteroids for 2 months with outstandingly favorable outcome and no signs of recurrence 6 months after the cessation of the therapy.

Oral manifestations of granulomatosis with polyangiitis - Clinical and radiological assessment

Background/purpose

Granulomatosis with polyangiitis (GPA) is a type of primary systemic vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). GPA mainly affects medium and small vessels and may manifest in different organs, most commonly upper respiratory tract. Oral lesions occur in 6–13% of GPA patients and might be the first symptom observed by the patient. This study presents the evaluation of orofacial manifestations of patients with GPA.

Materials and methods

Prospective study was conducted between June 2014 and November 2017 in Department of Allergy and Immunology at University Hospital in Krakow. Patients diagnosed with GPA, after medical assessment, were examined including precise dental inspection, bacterial and fungal flora of oral cavity evaluation and Cone Beam Computed Tomography (CBCT) imaging.

Results

Nine patients were enrolled in the study. Characteristic for GPA strawberry gingivitis was observed in one patient. Bone destruction and inflammatory lesions in paranasal sinuses was confirmed by CBCT in 55.6% of patients. Fungal infection was revealed in 66.7% of patients.

Conclusion

These findings oblige dentists to consult patient with laryngologist or internal medicine physician to establish further diagnostic approach, because early diagnosis of GPA is crucial for implementing appropriate treatment and preventing chronic organ damage.

Clinical manifestations of granulomatosis with polyangiitis: key considerations and major features

BACKGROUND

Granulomatosis with polyangiitis (GPA) presents a wide spectrum of manifestations from the common respiratory symptoms to infrequent neurological and cardiac complications. The challenge in diagnosis and management makes the rapidly progressive disorder one of the most challenging dilemmas in clinical medicine.

METHOD

An extensive electronic literature search was done using multiple databases (e.g. PubMed) from January 2007 to August 2017 to gather information on the etiopathogenesis, clinical presentation, and current treatment management plan of GPA. The language used was English. Search items included 'Granulomatosis with Polyangiitis symptoms,' 'Wegener's Granulomatosis,' and 'Treatment of Granulomatosis with Polyangiitis' for the databases. Inclusion criteria consisted of published articles in the English language which reported on the clinical manifestations of GPA, as well as on the treatment of the disease. Exclusion criteria included articles that: (1) did not specifically report on GPA vasculitis but also focused on discussion of other vasculitis such as MPA or Churg-Strauss; (2) reported on treatment/symptoms of GPA prior to 2007.

RESULT

This review provides an overview of work undertaken in key areas of GPA research, including its complex multifactorial etiology, clinical manifestations, treatment strategies, and treatment-related adverse effects.

CONCLUSION

Major advances in the understanding and treatment of GPA over recent decades have contributed to the notable decline in morbidity and mortality of patients. The ultimate goal is an improved prognosis through outcome measures which assesses the disease control with minimal adverse effects of intensive immunosuppressive regimens, an integral part of the clinical approach to improve the quality of life of GPA patients.

Levamisole-induced vasculopathy: A systematic review

OBJECTIVE

To characterize levamisole-induced vasculopathy.

METHODS

We performed a systematic review searching MEDLINE for articles published from 1972 to 2016.

RESULTS

We retrieved 357 references and abstracts and selected 111 articles. Levamisole-induced vasculopathy was reported in 192 patients, with a female predominance (n = 122, 63.5%). Median [interquartile range] age was 44 [38-50]. Skin was the most frequently involved organ (n = 182, 94.8%). Cutaneous lesions were mostly on the face (n = 136, 70.8%), especially the ears. Purpura (n = 131, 68.2%) was the most reported cutaneous lesion. Organ involvement included acute renal failure (n = 24, 12.5%), and pulmonary involvement (n = 20, 10.4%). Anti-neutrophil cytoplasmic antibodies (ANCAs) were found in 167/178 patients (93.8%), with both anti-myeloperoxydase and anti-proteinase 3 specificity reported in 51/118 patients (43.2%). Anti-phospholipid (APL) antibodies were found in 93/137 patients (67.9%). Leukopenia was detected in 69/138 patients (50%). Skin biopsies identified vasculitis and thrombotic vasculopathy in 73/148 (49.3%) and 62/148 (41.9%) patients, respectively. The outcome was favourable in 116/134 patients (86.6%), but relapses were reported in 33 (28.4%), mainly on levamisole re-exposure.

CONCLUSION

Levamisole-induced vasculopathy is characterized by a female predominance, skin involvement, ANCA and/or APL antibody positivity, leukopenia, vasculitis or vascular thrombotic histological lesions, and despite possible systemic involvement, a favourable outcome with levamisole interruption.

Seronegative granulomatosis with polyangiitis presenting with multiple cranial nerve palsies

Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare systemic disease characterized by necrotizing granulomas and vasculitis that usually presents in the respiratory tract and renal system. Here, we report a case of anti-neutrophil cytoplasmic antibody (ANCA)-negative GPA with diagnostic difficulties. Neurologic involvement in GPA is not uncommon, with up to 50% of patients manifesting with neurologic defects; however, it is usually a late event. This patient was a 50-year-old man whose first manifestation was multiple neurologic defects without respiratory or renal symptoms. Since multiple neurologic deficits were the first manifestation and there were no pulmonary or renal symptoms, our patient was treated for 1 year for suspected infectious or inflammatory diseases such as non-tuberculous mycobacterial infection or immunoglobulin G4 (IgG4)-related disease with brain involvement; however, his symptoms would wax and wane. Reanalysis of the laboratory findings including biopsies, finally revealed this case to be compatible with GPA. Here, we report a case of GPA, focusing on the diagnostic pitfalls.

Spectrum of orocutaneous disease associations: Immune-mediated conditions

There are a number of diseases that manifest both on the skin and the oral mucosa, and therefore the importance for dermatologists in clinical practice to be aware of these associations is paramount. In the following continuing medical education series, we outline orocutaneous disease associations with both immunologic and inflammatory etiologies.

CT Features of Vasculitides Based on the 2012 International Chapel Hill Consensus Conference Revised Classification

Vasculitis, characterized by inflammation of vessel walls, is comprised of heterogeneous clinicopathological entities, and thus poses a diagnostic challenge. The most widely used approach for classifying vasculitides is based on the International Chapel Hill Consensus Conference (CHCC) nomenclature system. Based on the recently revised CHCC 2012, we propose computed tomography (CT) features of vasculitides and a differential diagnosis based on location and morphological characteristics. Finally, vasculitis mimics should be differentiated, because erroneous application of immunosuppressive drugs on vasculitis mimics may be ineffective, even deteriorating. This article presents the utility of CT in the diagnosis and differential diagnosis of vasculitides.

Gingival granulomatosis with polyangiitis (Wegener's granulomatosis) as a primary manifestation of the disease

Granulomatosis with polyangiitis (GPA) is a potentially lethal disease characterized by systemic necrotizing vasculitis, which affects small- and medium-sized blood vessels and is often associated with serum cytoplasmic antineutrophil cytoplasmic antibody. The upper and lower respiratory tract and kidney are the most involved sites, but oral lesions can be identified in 6-13% of the cases, whereas in only 2% of the cases, oral manifestations represent the first signal of the disease usually as gingival swellings or unspecific ulcerations. Without treatment, the mainstay of which is the combination of immunosuppressants and systemic corticosteroids, GPA may run a fatal course. In this report we describe an original case of GPA affecting a 75-year-old female patient referred to our service due to a gingival swelling with 3-month duration. Although the patient was correctly diagnosed and promptly treated, she died 3 months after the initial diagnosis.

Orbital inflammation: Corticosteroids first

Orbital inflammation is common, and may affect all ages and both genders. By combining a thorough history and physical examination, targeted ancillary laboratory testing and imaging, a presumptive diagnosis can often be made. Nearly all orbital inflammatory pathology can be empirically treated with corticosteroids, thus obviating the need for histopathologic diagnosis prior to initiation of therapy. In addition, corticosteroids may be effective in treating concurrent systemic disease. Unless orbital inflammation responds atypically or incompletely, patients can be spared biopsy.

Non-infectious Inflammatory Lesions of the Sinonasal Tract

This review covers the histopathology and pathogenesis of non-infectious inflammatory diseases of the sinonasal tract, in particular, sarcoidosis, granulomatous vasculitides Wegener, Churg-Strauss), relapsing polychondritis, eosinophilic angiocentric fibrosis, chronic rhinosinusitis and nasal perforations. Molecular associations and mechanisms are emphasised to assist pathologists to put their observations into the context of clinical, genetic and environmental influences on patients' diseases.

Role of gingival manifestation in diagnosis of granulomatosis with polyangiitis (Wegener's granulomatosis)

Purpose

This report describes a case of granulomatosis with polyangiitis (GPA) in which the gingival manifestation was crucial in both making an early diagnosis and possibly in deciding the approach to treatment.

Methods

A 57-year-old sailor presented to the Department of Dentistry at Ulsan University Hospital complaining of gingival swelling since approximately 2 months. He had orofacial granulomatous lesions and the specific gingival manifestation of strawberry gingivitis.

Results

The diagnosis of GPA was made on the basis of clinical symptoms and signs, and confirmed by the presence of the anti-neutrophil cytoplasmic antibody and a positive biopsy. The patient was admitted to the hospital and subsequently placed on a disease-modifying therapy regimen that included methotrexate and prednisone.

Conclusions

Identification of the gingival manifestation of the disease permitted an early diagnosis and prompt therapy in a disease in which time is a crucial factor. Because of its rapid progression and potentially fatal outcome, an early diagnosis of GPA is important. Therefore, dentists should be aware of the oral signs and symptoms of such systemic diseases.

Orofacial granulomatosis: clinical signs of different pathologies

Orofacial granulomatosis (OFG) is an uncommon disease characterized by persistent or recurrent soft tissue enlargement, oral ulceration and a variety of other orofacial features. It could be an oral manifestation of a systemic disease. For a correct differential diagnosis, local and systemic conditions characterized by granulomatous inflammation should be excluded using appropriate clinical and laboratory investigations. In fact, the diagnosis of OFG may be confirmed only by histopathological identification of noncaseating granulomas. The literature from 1943 to 2014 was reviewed with emphasis on the etiology of OFG and on clinical manifestations of systemic pathologies associated with OFG. The precise cause of OFG is still unknown, although several theories have been suggested, such as infection, hereditary factors and allergy. OFG is a disease that has a wide spectrum of presentation, which may include the oral manifestation of a systemic condition such as Crohn's disease, sarcoidosis, granulomatosis with polyangiitis and Melkersson-Rosenthal syndrome.