Wegener's granulomatosis

In medicine (rheumatology), Wegener's granulomatosis is a form of vasculitis that affects the lungs, kidneys and other organs. Due to its end-organ damage, it can be a serious disease that requires long-term immune suppression. more...

It is part of a larger group of vasculitic syndromes that all feature positivity for ANCAs (antineutrophil cytoplasmic antibodies) and affect small and medium-sized blood vessels. Apart from Wegener's, it includes Churg-Strauss syndrome and microscopic polyangiitis.

Signs and symptoms

Initial signs are protean, and diagnosis can be severely delayed due to the non-specific nature of the symptoms. The rhinitis is generally the first sign in most patients.

• Upper airway, eye and ear disease:
  • Nose: pain, stuffiness, nosebleeds, rhinitis, crusting, saddle-nose deformity
  • Ears: conductive hearing loss due to Eustachian tube dysfunction, sensorineural hearing loss (unclear mechanism)
  • Eyes: pseudotumours, scleritis, conjunctivitis, uveitis, episcleritis
• Airways:
  • Trachea: subglottal stenosis
  • Lungs: pulmonary nodules, infiltrates (often interpreted as pneumonia), cavitary lesions, pulmonary haemorrhage causing hemoptysis), and rarely bronchial stenosis.
• Kidney: rapidly progressive segmental necrotising glomerulonephritis (75%), leading to chronic renal failure
• Arthritis: Pain or swelling (60%), often initially diagnosed as rheumatoid arthritis
• Skin: nodules on the elbow, purpura, various others (see cutaneous vasculitis)
• Nervous system: occasionally sensory neuropathy (10%) and rarely mononeuritis multiplex
• Heart, gastrointestinal tract, brain other organs: rarely affected.

Diagnosis

Vasculitis such as Wegener's granulomatosis is usually only suspected when a patient has had unexplained symptoms for a longer period of time. Determination of ANCAs can aid in the diagnosis, but positivity is not conclusive, and neither are negative ANCAs enough to reject the diagnosis. Cytoplasmic staining ANCAs that react with proteinase 3 (cANCA) are associated with Wegener's.

If the patient has renal failure or cutaneous vasculitis, these are the most logical organs to obtain a biopsy from. Rarely, thoracoscopic lung biopsy is required. On histopathological examination, a biopsy will show leukocytoclastic vasculitis with necrotic changes and granulomatous inflammation. The latter is the main reason for the appellation of "Wegener's granulomatosis", although it is not an essential feature. Unfortunately, many biopsies can be aspecific and 50% provide too little information for the diagnosis of Wegener's.

Differential diagnosis can be extensive. ANCAs can be positive after the use of certain drugs, and other forms of vasculitis can present with very similar symptoms. The saddle-nose deformity is also seen in cocaine abuse.

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