Wegener prostatitis presenting with acute urinary retention

Prostatitis and acute urinary retention as first manifestations of Wegnener's granulomatosis

OBJECTIVES

We present a case of prostatitis with acute urinary retention as a rare initial manifestation of Wegener' Granulomatosis.

METHODS

The case was a 48-year-old male with symptoms of prostatitis over ten days. The patient presented urinary retention, with partial response to antibiotic treatment. High levels of cytoplasmic antineutrophil cytoplasmic antibody and a prostatic biopsy were compatible with Wegener' Granulomatosis.

RESULTS

After starting treatment with glucocorticoids and cyclophosphamide, a significant improvement to the point of disappearance of symptoms was observed. At 3 months pulmonary and upper airway symptoms began, requiring higher doses of cyclophosphamide to control symptoms.

CONCLUSIONS

Wegener's Granulomatosis is a multisystem entity whose presentation as prostatitis with urinary retention is rare.

Uncommon presentations of primary systemic necrotizing vasculitides: the Great Masquerades

INTRODUCTION

Systemic vasculitides are great masqueraders and at times their presenting manifestations can be very different from the usual recognized patterns. Such uncommon presentations of granulomatosis with polyangiitis (Wegener's granulomatosis), classical polyarteritis nodosa and unclassifiable vasculitides are described here with the relevant review of literature.

METHODS

All patients diagnosed as having systemic vasculitides and classified as having granulomatosis with polyangiitis (Wegener's granulomatosis), classic polyarteritis nodosa, microscopic polyangiitis and unclassifiable vasculitis according to EMEA consensus methodology and followed up prospectively from June 2007 to December, 2011 were included. Details of uncommon presentations of these disorders were identified.

RESULTS

Seventy-nine patients with systemic vasculitides were seen under our rheumatology services during this period. These included 45 patients with granulomatosis with polyangiitis (Wegener's granulomatosis), 18 with classic polyarteritis nodosa, five with microscopic polyangiitis, four with Churg-Strauss syndrome and seven with unclassifiable vasculitis. The uncommon presentations of granulomatosis with polyangiitis were a tumefactive subcutaneous mass in the thigh; prostatomegaly with obstructive uropathy and advanced renal failure; and predominant gastrointestinal (GI) vasculitis with thrombocytopenia and coagulopathy at presentation. The uncommon manifestations of classic polyarteritis nodosa were secondary antiphospholipid antibody syndrome and Budd-Chiari syndrome. One patient with massive lower GI bleeding required surgical resection of the large bowel which showed isolated necrotizing granulomatous GI vasculitis. Single organ vasculitis of the GI tract was diagnosed.

CONCLUSIONS

Systemic necrotizing vasculitides may present with uncommon manifestations and a high index of suspicion is required for early diagnosis and prompt treatment to prevent adverse outcomes.

Anti-MPO small-vessel vasculitis causing prostatis and nephritis

Microscopic polyangiitis is a necrotizing angiitis involving capillaries, venules, and arterioles. The vascular beds of various organs may be involved, causing varying presentations. To our knowledge, this is the first case of anti-myeloperoxidase (anti-MPO) antibody small-vessel vasculitis causing prostatic vasculitis. A 79 year-old nonsmoker American man presented with symptoms of fevers, malaise, weight loss, and cough. Urine analysis revealed hematuria. Blood tests were remarkable for an elevated prostate-specific antigen (PSA) and a serum creatinine of 3.1 mg/dl (baseline, 1.2 mg/dl). Computed tomography (CT) scan of the thorax revealed a 4.7-cm mass in the left lower lobe of the lung. Metastatic prostate cancer was suspected. Therefore, prostatic biopsy was performed. The biopsy revealed fibrinoid degeneration with vasculitic changes involving the arterioles. When evaluated by nephrology, his serum creatinine was 9.9 mg/dl. A renal biopsy was performed, which revealed focal segmental necrotizing glomerulopathy with microscopic vasculitis. All the serologies were normal, with the exception of low C4, and positive perinuclear antineutrophil cytoplasmic antibodies (ANCA) associated with anti-MPO. The patient was started on intermittent hemodialysis, steroids, and oral cytoxan. Despite treatment, with improvement of the respiratory and constitutional symptoms, the patient remained dialysis-dependent. He later decided to discontinue dialysis and subsequently expired. Vasculitic involvement of the prostate is an uncommon manifestation of microscopic polyangiitis. This bedazzling entity is challenging to diagnose and thus makes it difficult to treat in a timely manner.