Wegener granulomatosis--an atypical case

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.

Chest CT findings in pediatric Wegener's granulomatosis

BACKGROUND

Although pulmonary involvement occurs in the majority of children and adolescents with Wegener's granulomatosis (WG), relatively little has been published regarding the CT imaging manifestations in this group of patients.

OBJECTIVE

To determine the frequency and types of chest CT abnormalities in active pediatric WG (pWG).

MATERIALS AND METHODS

The study was a retrospective examination of 29 chest CT examinations performed at diagnosis (n=14) and during disease flares (n=15) in 18 children.

RESULTS

The most common abnormalities were nodules (seen in 90% of examinations), ground-glass opacification (52%), and air-space opacification (45%). Of examinations with nodules, 73% demonstrated nodules >5 mm in diameter and 69% demonstrated more than five nodules; 17% had cavitary lesions. The only abnormality with a significant difference in prevalence between diagnosis and disease flares was air-space opacification, present in 71% and 20%, respectively (P < 0.01).

CONCLUSIONS

In accordance with the findings of published adult studies and at variance with those of prior pediatric studies, our findings indicate that chest CT abnormalities in active pWG are frequent, most commonly comprising nodules and ground-glass opacification, which may be difficult to detect on plain radiography. We therefore advocate the routine use of chest CT for all affected patients, both at the time of presentation and during disease flares.

Fatal neurologic involvement in pediatric Wegener's granulomatosis

Wegener's granulomatosis is a potentially life-threatening vasculitis with widely variable presentation. Only three pediatric cases with severe central nervous system involvement are reported in the literature. Early fatal outcome as described here is exceptional. This report describes a 13-year-old female with typical skin lesions, proteinuria, and renal failure initially misdiagnosed as a Schoenlein-Henoch purpura. A kidney biopsy revealed severe extracapillary proliferation in 70% of the analyzed glomeruli but no granuloma. In spite of methylprednisolone pulse therapy and oral high-dose prednisone, end-stage renal failure was reached 4 months later, necessitating peritoneal dialysis. Three months later she presented with pulmonary hemorrhage and positive antineutrophil cytoplasmic antibodies suggesting Wegener's granulomatosis. This episode was controlled by methylprednisolone pulses. Seven months later she presented generalized seizures and coma, suggesting central nervous system involvement confirmed by magnetic resonance imaging. Methylprednisolone pulses and intravenous immunoglobulins led to neurologic improvement. Oral methotrexate was then introduced for long-term disease control. Another severe relapse of central nervous system vasculitis did not respond to any applied therapies and led to death 16 months after initial symptoms. This case emphasizes the need for activity scores to identify patients at risk for progressive systemic vasculitis requiring early and long-term aggressive immunosuppressive therapy.

Successful renal transplantation in a child with ANCA-associated microscopic polyangiitis

Crescentic glomerulonephritis (CGN) is a clinicopathologic entity which is characterized by severe renal dysfunction of rapid onset with glomerular crescents. Type III CGN is associated with the absence of glomerular immune complex deposition (pauci-immune) and is associated with antineutrophil cytoplasmic antibody (ANCA). Microscopic polyangiitis and idiopathic pauci-immune necrotizing glomerulonephritis (NCGN) are strongly associated with ANCA directed against myeloperoxidase (anti-MPO). We describe here an unusual pediatric patient with MPO-ANCA-associated rapidly progressive glomerulonephritis (RPGN), emphasizing the management and outcome of the disease.

Neutrophil functions of patients with vasculitis related to myeloperoxidase-specific anti-neutrophil antibody

Neutrophils are hypothesized to cause tissue damage resulting in the development of vasculitis and glomerulonephritis, although they are known to primarily take part in host defense functions. The infiltration of inflammatory cells. notably neutrophils and macrophages, is observed in the progression of vasculitis. Neutrophils with activated status and anti-neutrophil cytoplasmic antibodies (ANCAs), especially myeloperoxidase-specific (MPO)-ANCA, have been implicated in the development of vasculitis. The target molecule of MPG-ANCA is a lysosomal enzyme MPO that usually acts to kill bacteria, viruses, and fungi and that causes damage to the tissue due to the toxicity of its product, hypochlorite (OCl-). To elucidate the role of MPO-ANCA in the progression of vasculitis, a set of MPO-peptide fragments has been developed, and the corresponding epitope site for the specific monoclonal and/or oligoclonal antibody resulting in vasculitis has been determined. Recently some mouse models have been used for analyzing the correlation between MPO and MPO-ANCA in relation to damage of blood vessels followed by the development of vasculitis. This review focuses on the role of activated neutrophils in the development of vasculitis associated with MPO-ANCA and the target molecules of ANCA. In addition, the reactivities of ANCA and inflammatory cytokines involving leukocyte-derived chemotaxin 2 (LECT2) are also discussed.