Tracheal involvement in Wegener's granulomatosis: evaluation using spiral CT

Differentiating tracheobronchial involvement in granulomatosis with polyangiitis and relapsing polychondritis on chest CT: a cohort study

Background

In patients with tracheobronchial involvement, the differential diagnosis between granulomatosis with polyangiitis (GPA) and relapsing polychondritis (RP) can be challenging. The aim of this study was to describe the characteristics of airway abnormalities on chest computed tomography (CT) in patients with GPA or RP and to determine whether specific imaging criteria could be used to differentiate them.

Methods

GPA and RP patients with tracheobronchial involvement referred to a national referral center from 2008 to 2020 were evaluated. Their chest CT images were reviewed by two radiologists who were blinded to the final diagnosis in order to analyze the characteristics of airway involvement. The association between imaging features and a diagnosis of GPA rather than RP was analyzed using a generalized linear regression model.

Results

Chest CTs from 26 GPA and 19 RP patients were analyzed. Involvement of the subglottic trachea (odds ratio for GPA=28.56 [95% CI: 3.17; 847.63]; P=0.001) and extensive airway involvement (odds ratio for GPA=0.02 [95% CI: 0.00; 0.43]; P=0.008) were the two independent CT features that differentiated GPA from RP in multivariate analysis. Tracheal thickening sparing the posterior membrane was significantly associated to RP (odds ratio for GPA=0.09 [95% CI: 0.02; 0.39]; P=0.003) but only in the univariate analysis and suffered from only moderate interobserver agreement (kappa=0.55). Tracheal calcifications were also associated with RP only in the univariate analysis (odds ratio for GPA=0.21 [95% CI: 0.05; 0.78]; P=0.045).

Conclusion

The presence of subglottic involvement and diffuse airway involvement are the two most relevant criteria in differentiating between GPA and RP on chest CT. Although generally considered to be a highly suggestive sign of RP, posterior tracheal membrane sparing is a nonspecific and an overly subjective sign.

• The presence of subglottic involvement is in favor of GPA.

• Extensive airway involvement is in favor of RP.

• Posterior tracheal membrane sparing is a nonspecific and an overly subjective sign.

Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature

Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.

CT findings of non-neoplastic central airways diseases

Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.

Central airway abnormalities - More than meets the eye

Central airway abnormalities are the most overlooked part of the respiratory system during high-resolution computed tomography thorax specifically when these are subtle and read by less experienced eyes. In this article, we have tried to emphasize the importance to include central airways in reporting checklist. Systematically, analysis of airways can give important clues and narrow down the differentials and clinch the diagnosis in some cases like in our index one.

A Wegener Granulomatosis Case Presented with Arthralgia

Granulomatosis with polyangitis (GPA/WG) (previously known as Wegener granulomatosis) is a multisystem systemic necrotizing non-caeseating granulomatous vasculitis affecting small to medium sized arteries, capillaries and veins, with a predilection for the respiratory system and kidneys. The average incidence of this disease is 40-55. 90% of the WG patients have pulmonary involvement. Wegener Granulomatosis is a disease with high mortality when its diagnosis and treatment is delayed. Although WG may have symptoms such as hemoptysis and hematuria, it should be noted that it may present with severe arthralgia and arthritis which may be in many connective tissue diseases and vasculitis. Male patient, 52 years old. Analgesic treatment was applied when he came to the center due to arthralgia two months ago, however, there was no change in his complaints and intra-articular injection treatment was applied on left knee and both shoulders. The symptoms did not regress and the patient lost 20 kg within the last two months. In urine analysis, 14-15 erythrocyte and 10-15 leucocyte detected in every field; 1 positive detected. The patient was hospitalized in order to make further examination upon the determination of CRP: 61mg/L and ESR: 82mm/hr in the next polyclinic control after three days. In the kidney biopsy report, “Pauci-immun glomerulonephritis” was primarily considered in the phenomenon. For the first three days 1 gr pulse and by the fourth day 1 mg/kg methylprednisolone and cyclophosphamide treatment was applied.

Accuracy of Magnetic Resonance Imaging for Grading of Subglottic Stenosis in Patients With Granulomatosis With Polyangiitis: Correlation With Pulmonary Function Tests and Laryngoscopy

OBJECTIVE

To compare magnetic resonance imaging (MRI)-based and laryngoscopy-based subglottic stenosis (SGS) grading with pulmonary function testing (PFT) in patients with granulomatosis with polyangiitis (GPA).

METHODS

In this retrospective study, we included 118 examinations of 44 patients with GPA and suspected SGS. All patients underwent MRI, laryngoscopy, and PFT. Stenosis was graded on a 4-point scale by endoscopy and MRI using the Meyer-Cotton (MC) score (score 1: ≤50%, 2: 51-70%, 3: 71-99%, and 4: 100%) and as percentage by MRI. Results were compared with peak expiratory flow (PEF) and maximum inspiratory flow (MIF) from PFT, serving as objective functional reference.

RESULTS

In MRI, 112 of 118 examinations (95%) were rated positive for SGS (grade 1 [n = 82], grade 2 [n = 26], and grade 3 [n = 4]), whereas in laryngoscopy 105 of 118 examinations (89%) were rated positive for SGS (grade 1 [n = 73], grade 2 [n = 24], and grade 3 [n = 8]). MRI and laryngoscopy agreed in 75 of 118 examinations (64%). MRI determined higher scores in 20 examinations (17%) and lower scores in 23 examinations (19%) compared to laryngoscopy. MC scores as determined by both MRI and laryngoscopy showed comparable correlations with PEF (r = -0.363, P = 0.016, and r = -0.376, P = 0.012, respectively) and MIF (r = -0.340, P = 0.024, and r = -0.320, P = 0.034, respectively). The highest correlation was found between MRI-based stenosis grading in percentage with PEF (r = -0.441, P = 0.003) and MIF (r = -0.413, P = 0.005).

CONCLUSION

MRI and laryngoscopy provide comparable results for grading of SGS in GPA and correlate well with PFT. MRI is an attractive noninvasive and radiation-free alternative for monitoring the severity of SGS in patients with GPA.

Imaging of the trachea

Numerous benign and malignant tracheal diseases may affect the trachea primarily and secondarily. While the posterior anterior (PA) and lateral chest radiograph is the conventional study for initial evaluation of the trachea and central airways, findings may not always be apparent on conventional radiographs, and further evaluation with cross sectional imaging is usually necessary. Computed tomography (CT) is the imaging modality of choice for imaging the trachea and bronchi. Familiarity with the imaging appearances of the normal and diseased trachea will enhance diagnostic evaluation.

The presentation and management of granulomatosis with polyangiitis (Wegener's Granulomatosis) in the pediatric airway

OBJECTIVE

Granulomatosis with polyangiitis (GPA) is a necrotizing inflammatory disease that can affect the airway. The purpose of this study was to present a case of pediatric laryngotracheal GPA and provide management recommendations based on a thorough review of the literature.

DATA SOURCES

Retrospective chart and literature review REVIEW METHODS: A pediatric patient with laryngotracheal and pulmonary manifestations of GPA who underwent chemotherapy and intralesional corticosteroid injection is described. An extensive literature review of pediatric GPA affecting the larynx/trachea was also performed.

RESULTS

A pediatric patient presented with acute respiratory distress. Flexible laryngoscopy revealed a laryngeal mass. Magnetic resonance imaging showed circumferential subglottic stenosis, and chest computed tomography demonstrated multiple pulmonary nodules. Laryngeal and tracheal biopsy revealed granulation tissue and primary vasculitis. Labs demonstrated positive cytoplasmic antineutrophil cytoplasmic antibody, consistent with GPA. Methylprednisone, rituximab, cyclophosphamide, and intralesional steroid injection resulted in remission after 12 weeks. Review of the literature revealed two pediatric cases series and 10 case reports of GPA affecting the larynx or trachea.

CONCLUSIONS

There is a higher prevalence of GPA of the airway in children when compared to adults. Biopsy of the airway lesion may not be necessary and has lower diagnostic yield compared to other GPA subsites. Medical management includes induction therapy followed by maintenance therapy once the disease is in remission. Most patients will require a surgical intervention to maintain the airway.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:233-240, 2017.

Tracheobronchial Stenoses in Granulomatosis With Polyangiitis (Wegener's): A Report on 26 Cases

Tracheobronchial stenoses (TBSs) are potentially severe manifestations of granulomatosis with polyangiitis (Wegener's) (GPA) that usually respond poorly to corticosteroids and immunosuppressive agents. We describe 26 GPA patients with ≥1 tracheal (mainly subglottic, SGS) and/or bronchial stenosis(ses) (BS(s)).Sixteen patients had solitary SGS and 10 had ≥1 BS(s). The male/female sex ratio was 9:17, and the median age at GPA diagnosis was 32 years (3:13 and 28 years, respectively, for SGS patients). Antineutrophil cytoplasm antibodies were proteinase 3-positive in 65.5% of the patients (50% of those with SGS).Despite conventional GPA therapy, 62% patients experienced ≥1 stenosis relapse(s) (81% of SGS patients, for a total of 1-8 relapses per patient). None of the several systemic or endoscopic treatments prevented future relapses. Cyclophosphamide induction therapy was effective in 4/6 patients with BS(s) and in 1 patient with SGS among the 7 treated. After many relapses, rituximab achieved remission in 3/4 SGS patients. Endoscopic treatments (dilation, laser, corticosteroid injection, etc.) had only transient efficacy. Other GPA manifestations relapsed independently of TBSs. One SGS patient died of acute respiratory distress syndrome.Our findings confirmed that TBSs are severe GPA manifestations that evolve independently of other organ involvements and do not respond to conventional systemic regimens. As previously described, our population was younger and comprised more females than usual GPA patients, especially those with SGS.The small number of patients and the wide variety of local and systemic treatments prevent us from drawing definitive conclusions about the contribution of each procedure. However, cyclophosphamide seemed to effectively treat BSs, but not SGS, and rituximab may be of interest for SGS management.

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.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

A case of granulomatosis with polyangiitis (Wegener's granulomatosis) presenting with marked inflamed tracheobronchial mucosa

A 70-year-old man was admitted to our hospital because of weight loss and persistent dry cough. Chest radiograph and CT showed multiple infiltrates in the bilateral upper lobes and the remarkably thickened bronchial walls. Bronchoscopy revealed diffuse erythema and edema of the tracheobronchial mucosa without any ulcerous legions. Serum MPO-ANCA was positive (155 EU). Transbronchial biopsy was performed and revealed necrotic granulomas with multinucleated giant cells in the bronchial/bronchiolar and parenchymal lesions. Thus, we diagnosed it as a localized form of granulomatosis with polyangiitis (GPA, Wegener's granulomatosis). After treatment with corticosteroid and cyclophosphamide, the bronchial findings were entirely resolved. We report here a rare case of GPA presenting with markedly inflamed tracheobronchial mucosa.

Modern imaging of the tracheo-bronchial tree

Recent state-of-the-art computed tomography and improved three-dimensional (3-D) postprocessing techniques have revolutionized the capability of visualizing airway pathology, offering physicians an advanced view of pathology and allowing for appropriate management planning. This article is a comprehensive review of trachea and main bronchi imaging, with emphasis on the dynamic airway anatomy, and a discussion of a wide variety of diseases including, but not limited to, congenital large airway abnormalities, tracheobronchial stenoses, benign and malignant neoplasms and tracheobronchomalacia. The importance of multiplanar reconstruction, 3-D reconstruction and incorporation of dynamic imaging for non-invasive evaluation of the large airways is stressed.

Surgical interventions and local therapy for Wegener's granulomatosis

PURPOSE OF REVIEW

This review discusses the use of interventional procedures to treat manifestations of Wegener's granulomatosis caused by tissue damage and scarring. These manifestations include nasal and paranasal sinus disease, middle ear inflammation, nasolacrimal duct obstruction, orbital inflammatory masses, subglottic stenosis, tracheobronchial disease, and end-stage renal disease.

RECENT FINDINGS

Tissue damage caused by inflammation or a cicatricial process represents one of the major sources of morbidity for patients with Wegener's granulomatosis. Some of these manifestations require special interventions used alone or in combination with conventional medical treatment. These interventional procedures may include surgical or endoscopic repair of altered tissue, replacement of damaged organs, or the delivery of topical or injectable medications directly to the site of disease. Distinguishing symptoms caused by active disease from symptoms caused by tissue scarring is challenging and may play a critical role regarding the use of systemic immunosuppressive medications in combination with interventional therapy.

SUMMARY

Interventional procedures are indicated in certain manifestations of Wegener's granulomatosis. Distinguishing active Wegener's granulomatosis from inactive Wegener's granulomatosis and recognizing disease manifestations that may be amenable to local interventions can greatly improve the quality of life of patients. However, the evidence supporting the use of many of these interventions is based on small case series or individual reports.

Vasculitis of the upper and lower airway

The pulmonary vasculitides are a heterogeneous group of rare disorders that result from an inflammatory process damaging the vessel wall and consequent impaired blood flow, ischaemia and tissue necrosis. The clinical manifestation of these vasculitides depends on the site, size, type and severity of the inflammatory process. Vasculitis involving the airways is a common feature of the anti-neutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) and can predate the diagnosis by years. Secondary causes of vasculitis associated with connective tissue disorders are also capable of presenting with pulmonary features. Recognition of involvement, investigation and treatment are important to ameliorate symptoms for patients. This article concentrates on the assessment and specific management of upper and lower airway problems of AASV.

Wegener's granulomatosis presenting as acute systemic vasculitis following 20 years of limited tracheobronchial disease

OBJECTIVE

We report a patient with a 20-year history of apparently idiopathic airways stenoses, who presented with an antineutrophil cytoplasmic antibody (ANCA) associated, acute, systemic vasculitis with necrotising glomerulonephritis, subsequently diagnosed as Wegener's granulomatosis.

METHODS

We present a case report and a review of the world literature on airway stenosis in Wegener's granulomatosis.

RESULTS

To our knowledge, this is the first report of Wegener's granulomatosis manifesting as local airway disease for such a prolonged period, before transforming into a systemic vasculitis.

CONCLUSIONS

This case highlights the need for physicians to be alert to the possibility of Wegener's granulomatosis as a cause of apparently idiopathic airway stenosis, and to be aware that systemic disease may occur in very long-standing, limited Wegener's granulomatosis.

Uncommon causes of tracheobronchial stenosis and wall thickening: MDCT imaging

Some uncommon diseases may involve the central airways focally or diffusely. These include Wegener's granulomatosis, relapsing polychondritis, tracheobronchopathia osteochondroplastica, amyloidosis, papillomatosis, rhinoscleroma, sarcoidosis and tuberculosis. Related computed tomography (CT) findings essentially include calcifications, luminal stenosis, wall thickening and nodules. The purpose of this paper is to help refine the differential diagnosis among these diseases through the use of multidetector CT (MDCT) imaging.

[Imaging procedures in rheumatology: imaging in vasculitis]

In small vessel vasculitides, imaging studies aid in determining disease extent and activity, localization for biopsy, and for disease monitoring. They do not directly delineate the vasculitic lesion. Imaging studies focus on the upper and lower respiratory tract. Cranial magnetic resonance imaging (MRI) shows upper respiratory and retrobulbar granuloma in Wegener's granulomatosis. Furthermore, MRI depicts both mastoiditis and mucosal inflammation of the ear, nose, and throat. It is sensitive but not specific for the detection of cerebral vasculitis. Computed tomography (CT) reliably detects osseous facial lesions. Chest radiography in two planes remains the standard method of investigation for the lower respiratory tract. High-resolution CT aids in detecting further interstitial pathologies. Medium-sized vasculitides frequently occur with aneurysms. The classification criteria for polyarteritis nodosa involve the angiographic detection of visceral aneurysms. Patients with Kawasaki disease may develop coronary aneurysms that may be described by echocardiography or angiography according to diagnostic criteria. In large-vessel vasculitides such as temporal arteritis (giant cell arteritis) and Takayasu arteritis, MRI, MR-angiography, CT, CT-angiography, and duplex sonography delineate characteristic homogenous wall thickening with or without stenoses in the aorta and other arteries. There is a high correlation with angiography and positron emission tomography. Duplex sonography of the temporal arteries has a high sensitivity and specificity for the diagnosis. Data on temporal artery MRI in giant cell arteritis have recently been published.

Sténoses endobronchiques au cours de la granulomatose de Wegener

INTRODUCTION

Endobronchial stenoses are rare in the course of Wegener's granulomatosis, and they occur even more rarely than subglottic stenoses.

EXEGESIS

We report seven cases of endobronchial stenoses in the setting of Wegener granulomatosis. Neither the pulmonary symptoms nor the systemic manifestations of vasculitis were specific. However 6/7 patients presented a wheezing or an hemoptysis. Bronchial endoscopy has permitted the diagnosis in all cases. Local evolution was cicatricial and symptomatic stenosis in 3 cases (42,8%).

CONCLUSION

Thus these lesions must be research in any case of pulmonary abnormality in the course of Wegener's granulomatosis, because they may lead to a pejorative prognosis. Moreover general and local treatment must be given early (at the inflammatory stage). After this stage, the local treatments are difficult and not efficient.

Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation

Nonneoplastic diseases of the central airways are uncommon but can be categorized as either focal or diffuse, although there is some overlap. Focal diseases include postintubation stenosis, postinfectious stenosis, posttransplantation stenosis, and various systemic diseases that may involve the airways and lead to focal stenosis (eg, Crohn disease, sarcoidosis, Behçet syndrome). Diffuse diseases of the central airways include Wegener granulomatosis, relapsing polychondritis, tracheobronchopathia osteochondroplastica, amyloidosis, papillomatosis, and rhinoscleroma. Conventional radiography is often the first step in the evaluation of suspected central airway disease and may be adequate in itself to identify the abnormality. However, computed tomography (CT) improves both the detection and characterization of central airway disease. Bronchoscopy remains the primary procedure for the diagnostic work-up of these disease entities. Nevertheless, a thorough radiologic evaluation with radiography and CT may demonstrate specific imaging findings (eg, calcification) that can help narrow the differential diagnosis and aid in the planning of bronchoscopy or therapeutic intervention.

CT of noninfectious granulomatous lung disease

Noninfectious granulomatous diseases of the lung consist of a diverse group of disorders that logically can be subdivided into those with and without associated vasculitis. This article reviews the epidemiologic, clinical, pathologic, and radiologic features of sarcoidosis, hypersensitivity pneumonitis, berylliosis, and the five entities traditionally classified as pulmonary angiitis and granulomatosis.

Helical CT with Multiplanar and Three-Dimensional Reconstruction of Nonneoplastic Abnormalities of the Trachea

Helical CT is being increasingly used for the evaluation of suspected tracheal diseases. Although nonneoplastic and noninfectious diseases of the trachea are rare, their appearance on CT images may be highly suggestive of the diagnosis. High quality multiplanar and 3D reconstructions including 3D surface-shaded display and virtual bronchoscopy are helpful to characterize tracheal abnormalities and to demonstrate the location and extent of the diseases.