Cutaneous Wegener's granulomatosis. Report of a case and review of the literature

Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II)

The accurate diagnosis of inflammatory conditions in dermatopathology requires integrating the histopathologic findings with the clinical features. This second part of a 2-part review of inflammatory cutaneous conditions presents a pattern-based approach to the diagnosis of dermatologic disorders and reviews the salient clinical and histologic features.

Cutaneous manifestations of Wegener?s granulomatosis: a clinicopathologic study of 17 patients and correlation to antineutrophil cytoplasmic antibody status

BACKGROUND

Wegener's granulomatosis (WG), a systemic vasculitis, can be associated with cutaneous signs and symptoms before, during or after the diagnosis of systemic disease.

METHODS

We reviewed clinical and histologic features of cutaneous lesions from 17 patients with WG. The temporal relationship between development of cutaneous symptoms and onset of systemic disease was determined, and antineutrophil cytoplasmic antibody (ANCA) status of the patients was also established.

RESULTS

In six patients, systemic and cutaneous disease developed concurrently. In eight patients, cutaneous disease developed after patients received the diagnosis of systemic disease. In three patients, cutaneous disease preceded systemic disease. Cytoplasmic ANCA or proteinase-3-ANCA [c-ANCA/proteinase 3 (PR3)-ANCA] serologic test results were negative for one patient when cutaneous disease developed, and one patient had c-ANCA/PR3-ANCA seroconversion a year before systemic disease developed. Histopathologic features of cutaneous WG were not limited to leukocytoclastic vasculitis; they also included acneiform perifollicular and dermal granulomatous inflammation and palisaded neutrophilic and granulomatous inflammation.

CONCLUSIONS

Patients with WG can present initially with cutaneous symptoms. Histopathologic patterns vary, but leukocytoclastic vasculitis is most commonly noted. Patients with WG and skin lesions are likely to have positive c-ANCA/PR3-ANCA serologic test results.

Protracted superficial Wegener's granulomatosis

We describe a patient with protracted superficial Wegener's granulomatosis. On the basis of nasal mucosa and conjunctival biopsy specimens, a diagnosis of sarcoidosis was originally made. However, later biopsy specimens and the clinical condition indicated a rare variant of Wegener's granulomatosis, one with a protracted course of granulomatous ulcers localized to the skin and mucosa.

Wegener's granulomatosis: cutaneous and oral mucosal disease

BACKGROUND

Wegener's granulomatosis is a complex disease that can be difficult to diagnose, especially if the classic triad of necrotizing granulomas of the respiratory tract, generalized vasculitis, and glomerulitis are not present. A delay in diagnosis may result in irreversible kidney damage and ultimately death.

OBJECTIVE

This study was done to identify clinical and histologic findings of the skin and oral mucosa that may aid in the diagnosis of this disease.

METHODS

The records of 40 patients with Wegener's granulomatosis were reviewed.

RESULTS

Of these patients 12 had cutaneous lesions, 2 had oral mucosal lesions, and 2 had both cutaneous and oral mucosal lesions. Cutaneous and oral mucosal lesions were a presenting sign in 10% and 5% of patients, respectively. Overall, 25% demonstrated at least one of the specific cutaneous histopathologic findings described for Wegener's granulomatosis, that is, necrotizing vasculitis, granulomatous vasculitis, and palisading granuloma. One patient had gingival hyperplasia with petechiae, considered to be pathognomonic for Wegener's granulomatosis.

CONCLUSION

This study demonstrates that cutaneous or oral mucosal findings may serve as valuable diagnostic aids when evaluating a patient suspected of having Wegener's granulomatosis.

Classification of vasculitis

A working classification of necrotizing vasculitis based on size of the affected vessel is proposed. The classification proposed by Gilliam and Fink in 1976 is a basis for the current proposal. A revised working classification of vasculitis is presented. Small vessel necrotizing vasculitis and larger vessel necrotizing vasculitis categories are further subdivided. Improved understanding of the basic science aspects of vasculitis will hopefully give rise to a better consensus on the classification of vasculitis.