Treatment of Wegener's granulomatosis with immune globulin: CNS involvement in an adolescent female

Epilepsy: an anticipatory presentation of pediatric Wegener's granulomatosis

Wegener's granulomatosis is a necrotizing, granulomatous vasculitis that primarily affects the respiratory tract and kidneys. It is rare in children. Few pediatric and adult case reports described seizures and central nervous system involvement at initial presentation, and none described central nervous system involvement in the absence of respiratory or renal disease. We describe a 17-year-old girl with secondarily generalized seizures and granulomatous lesions in her brain. Although a systemic inflammatory disorder was suspected, she lacked evidence of pulmonary or renal involvement, so her signs were initially labeled as postinfectious encephalitis or variant acute disseminated encephalomyelitis. After 1 year of immunosuppressive therapy, she developed additional signs, leading to histologic confirmation on lung biopsy of Wegener's granulomatosis. This case emphasizes the need for close follow-up to monitor the asynchronous development of diagnostic clues when a systemic vasculitis is suspected but cannot be confirmed.

Polyarteritis nodosa resistant to conventional treatment in a pediatric patient

OBJECTIVE

To report the case of a child diagnosed with polyarteritis nodosa (PAN) that was unresponsive to conventional treatment alone but improved with the addition of iloprost and bosentan to her drug regimen.

CASE SUMMARY

A 3-year-old girl who had been diagnosed with PAN was referred to our hospital from another region. With conventional treatment of high doses of a corticosteroid and cyclophosphamide, her condition resolved. Six months later, our patient had a relapse that required hospital admission. In this second hospital stay, some cutaneous lesions evolved into digital necrosis. Offlabel therapeutic alternatives, including a single dose (2 g/kg) of intravenous immunoglobulin (IVIG), intravenous iloprost 2 ng/kg/min over 6 h for 5 days and, approximately 4 wk later, oral bosentan 37.25 mg twice daily for 4 wk followed by 62.5 mg twice daily for 8 wk, were added to the conventional regimen to treat the serious cutaneous manifestations. Her fingers improved very slowly, and she was discharged on gradually tapered doses of oral corticosteroids, bosentan, and monthly pulsed injections of cyclophosphamide. The digital necrosis and other cutaneous lesions had resolved completely 6 months after the second discharge.

DISCUSSION

The dosages of IVIG and iloprost were based on those used for PAN, Raynaud's phenomenon, and digital necrosis in children. The use of bosentan for vasculitis had not been reported in children before the treatment of our patient, so its dosage was based on that used to produce vasodilation in children with pulmonary hypertension.

CONCLUSIONS

Digital necrosis and cutaneous manifestations not resolved with conventional PAN treatment improved within 5 days with iloprost and 12 weeks with bosentan.

Pharmacological therapy for Wegener's granulomatosis

Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This 'induction maintenance' approach to treatment has emerged as a central premise in planning therapy for patients with WG.A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.

Intravenous immunoglobulin treatment in vasculitis and connective tissue disorders

Vasculitis syndromes and connective tissue disorders are heterogeneous and mostly rare multisystem disorders with various autoimmune mechanisms driving tissue inflammation and remodeling, ischemic and hemorrhagic tissue damage. While the nervous system can be affected by most of these diseases, the pathogenesis for neural involvement is often ambiguous and elusive for the clinician. Intravenous immunoglobulins (IVIG) have been used for the treatment of most of these disorders. However, a thorough review of the literature indicates that the role for IVIG has to be discussed for individual entities, has often only anecdotal evidence, and is particularly hard to define with respect to neurological manifestations. This review gathers the available evidence on the efficacy of IVIG in neurologically relevant rheumatic diseases, leading to recommendations for their clinical use.

Wegener's granulomatosis presenting as pyoderma gangrenosum

A 59-year-old male patient developed a necrotizing ulceration on the right shin. Both clinical and histopathologic examinations suggested pyoderma gangrenosum. After temporary improvement of skin symptoms under peroral glucocorticoid treatment, a hemorrhagic-purulent discharge started from the nose, he began to have fever, malaise, cough, and a chest X-ray revealed inflammation in the lung. Cerebral CT and MRI disclosed midline bone loss within the nasal septum and granulomatosus tissue masses protruding into the right orbit. The c-ANCA test was positive, serum IgA was elevated, and he had microhaematuria and proteinuria. In this severe case of Wegener's granulomatosis prolonged methylprednisone and cyclophosphamide treatment was initiated. Both the skin symptoms and the granulomatosus infiltrations resolved.

Sarcoid polyneuropathy responsive to intravenous immunoglobulin

We describe a 38-year-old woman with a predominantly sensory axonal polyneuropathy in whom a nerve biopsy demonstrated sarcoid granulomas. The neuropathy did not respond to oral steroid therapy but there was a rapid and repeated response to intravenous immunoglobulin, which gradually diminished over subsequent treatments, but remained beneficial. The systemic sarcoidosis remained active.

Wegener granulomatosis manifesting as meningitis. Case report

The authors describe a unique presentation of Wegener granulomatosis (WG) manifesting predominantly as meningitis. Magnetic resonance imaging demonstrated diffuse meningeal enhancement, including the pia mater, in a 28-year-old man with meningitis. A diagnosis of atypical WG was based on the findings of a dural biopsy sample and an elevated cytoplasmic antineutrophil cytoplasmic antibody (cANCA) titer, although the patient did not have any of the lesions common to WG. Immunosuppressive therapy was quite effective. With treatment, the meningeal enhancement resolved and the cANCA titer normalized. Meningeal granulomatosis as the sole lesion in WG has never been reported in the literature. This atypical course of WG should be noted.

Intravenous immunoglobulin in neurological disease: a specialist review

Treatment of neurological disorders with intravenous immunoglobulin (IVIg) is an increasing feature of our practice for an expanding range of indications. For some there is evidence of benefit from randomised controlled trials, whereas for others evidence is anecdotal. The relative rarity of some of the disorders means that good randomised control trials will be difficult to deliver. Meanwhile, the treatment is costly and pressure to "do something" in often distressing disorders considerable. This review follows a 1 day meeting of the authors in November 2000 and examines current evidence for the use of IVIg in neurological conditions and comments on mechanisms of action, delivery, safety and tolerability, and health economic issues. Evidence of efficacy has been classified into levels for healthcare interventions (tables 1 and 2).

Vasculitides of the gastrointestinal tract

Systemic vasculitides, and especially their gastrointestinal manifestations, are a continuous challenge not only for gastroenterologists and rheumatologists but also for every practising physician. Owing to their chameleon-like appearance, overt clinical symptoms of vasculitides may be restricted to distinct parts of the human body including the intestine. In clinical practice, it is therefore essential to search for the systemic disease underlying the gastrointestinal symptoms such as abdominal pain, bleeding, ileus and necrosis in case vasculitis is suspected or likely as a cause for these sequelae. Classification of intestinal vasculitides is also difficult, since most of the criteria currently used have been established by rheumatologists and, in general, biopsies of the affected vessels cannot be obtained. However, there are increasing data that not only facilitate diagnosis but also allow adequate immunosuppressive and anti-inflammatory therapeutic approaches, which will be outlined in detail in this chapter.