[Sinonasal and cerebral imaging findings in Wegener's granulomatosis]

Granulomatosis with polyangiitis presenting with unilateral exophthalmos: A case report

We report a case of a patient with no medical history, admitted for right exophthalmos. For whom imaging showed orbital masses without inflammatory signs pointing to a granulomatous origin. However, the histological and immunological workup revealed the diagnosis of Granulomatosis with polyangiitis.

[Ophthalmologic manifestation of granulomatosis with polyangiitis (Wegener's granulomatosis)]

Granulomatosis with polyangiitis (GPA), formerly earlier known as Wegener's granulomatosis, is primary system necrotizing vasculitis of small and medium-sized vessels, which is characterized by the formation of foci of granulomatous inflammation. One of the target organs in GPA is the organ of vision. Its affection may not only reduce quality of life, but also may lead to the severest complications even to fatal outcome. The affection varies in severity from slight inflammation of the ocular superficial structures to severe involvement of all orbital and ocular structures to develop complete blindness, including bilateral one. GPA can affect any portion of the organ of vision. The changes are low specific, which makes early diagnosis and timely adequate therapy difficult. Overall all ophthalmologic manifestations can be divide into 4 groups: 1) lesions of the orbit and appendages; 2) those of the conjunctiva and fibrous tunic of the eyeball: 3) those of the retina: 4) those of the optic nerve. Orbital affection is characterized by the development of granulomas, dacryoadenitis with marked inflammatory infiltration of the surrounding tissues, including oculomotor muscles, and destruction of orbital bony walls. Nonspecific conjunctivitis and episcleritis are commonly encountered. Affection of the fibrous tunic of the eyeball is characterized by the development of necrotizing scleritis, peripheral ulcerative or stromal keratitis. The retina is rarely involved and mainly described as sporadic cases in the literature. The optic nerve is most commonly damaged due to the compression of the orbit by inflamed tissue; the lesion is more infrequently ischemic.

Presentation and initial assessment of ENT problems in patients with granulomatosis with polyangiitis (Wegener's)

BACKGROUND

Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis) is a primary systemic vasculitis that affects medium to small sized vessels throughout the body. It often presents with symptoms and signs involving the ear, nose, and head and neck area.

OBJECTIVE

To highlight salient features of ENT-related issues in granulomatosis with polyangiitis, and raise awareness of the condition.

METHODS

A case report of a patient with limited disease and an insidious onset is presented, along with a review of the current literature. In addition, basic initial management is described.

RESULTS

Eighty-six publications were used to describe salient features of ENT-related issues in granulomatosis with polyangiitis.

CONCLUSION

The time to diagnosis has not reduced significantly in the last 10 years in the UK. A high index of suspicion is required for an earlier diagnosis of granulomatosis with polyangiitis.

Rapid progressive bilateral hearing loss due to granulomatous otitis media in Lyme disease

We report on a patient with Lyme disease who presented with chronic bilateral otitis media and cranial neuropathy with rapid progressive hearing loss. After ceftriaxone and high-dose intravenous immunoglobulins, the disease was controlled only with methylprednisolone and cyclophosphamide. The relationship between Lyme disease and granulomatous vasculitis is discussed. Lyme disease should be kept in mind in the differential diagnosis of various otolaryngological and neurological presentations.

[An ANCA negative limited form of granulomatosis with polyangiitis (Wegener's granulomatosis) affecting the cavernous sinus]

INTRODUCTION

Granulomatosis with polyangeitis (Wegener's granulomatosis) (GPA) is a granulomatous vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA). Affected organs usually include upper and lower respiratory tracts, and kidneys. Limited forms of GPA may affect the central nervous system (vasculitis, hypertrophic pachymeningitis, encephalitis), a location in which diagnosis is often uneasy.

CASE REPORT

We report a 74-year-old woman who presented with a limited form of GPA affecting the cavernous sinus. Diagnosis was considered in view of a retrospectively suggestive clinical presentation, compatible cerebral MRI and temporal artery biopsy, despite the absence of ANCA. It was supported by a favourable outcome with cyclophosphamide administration.

CONCLUSION

GPA presenting as a cavernous sinus syndrome is rare. Three co-existing pathogenic mechanisms may be involved in GPA affecting the central nervous system: contiguous invasion from nasal or orbitary granulomatous sites, vasculitis, or primary intra-cerebral granulomatous inflammation. Lack of biopsy evidence of affected tissues and ANCA negativity should not delay diagnosis and appropriate therapeutic management in central nervous system GPA.

[Stroke revealing granulomatosis]

INTRODUCTION

Central nervous system involvement is rare in Wegener granulomatosis. Stroke is the most common event suggestive of the disease.

COMMENT

A 35-year-old woman, who was followed for rhinitis and mild asthma, described gradual decline of visual acuity in the right eye over two months, persistent nasal obstruction and fronto-orbital headache since a few weeks. She presented left hemiparesis due to a stroke, associated with exophthalmos and deficits of the optic nerve and abducens of the right eye. The otolaryngological examination found signs of crusty rhinitis and right nasal stenosis. The diagnosis of Wegener's granulomatosis was established on the basis of the clinical findings, radiological aspects and the presence of ANCA. The patient was treated by antiplatelet agents and high-dose corticosteroids associated with immunosuppressive drugs including cyclophosphamide in a monthly bolus.

DISCUSSION

This case illustrates two of the three pathogenic mechanisms that may account for central nervous system involvement in Wegener granulomatosis: vasculitis, extension by contiguity of granulomatous tissue from the nasal cavity or sinuses, and in situ formation of a granuloma into the brain parenchyma or meninges.

[Central nervous system involvement in Wegener's granulomatosis]

INTRODUCTION

Wegener's granulomatosis (WG) is a systemic necrotizing vasculitis associated with c-ANCA antibodies. The involvement of the central nervous system in WG is uncommon and usually caused by in situ vasculitis, intracranial granuloma formation or contiguous invasion from extracranial sites.

CASE REPORT

Here, we report on a tumour-like expansion of a severe nasosinusal WG into the brain, which was confirmed by brain biopsy examination.

CONCLUSION

The positivity of positron emission tomography in our observation supports the potential role of such functional imaging in the staging, as well as in the follow-up of WG.