Wegener’s granulomatosis is not a contagious disease as many people believe. There is no evidence suggesting that it is hereditary either. About 500 new cases are diagnosed each year, with the disease occurring at any age. However, it mostly affects individuals in their 30s and 40s. It affects males and females equally, but 97% of all patients are Caucasian, 2% are Negroid and 1% are of another race. With Wegener’s granulomatosis it is extremely important to know more about diagnosis and its treatment once it is diagnosed.
What is Wegener’s granulomatosis?
Wegener’s granulomatosis is a rare disorder that causes blood vessels in the upper respiratory tract (nose, sinuses, and ears), followed by lungs, and kidneys, to become swollen and inflamed. The eyes, skin, and joints may also be affected with arthritis occurring in about half the cases. Wegener's granulomatosis is thought to be an autoimmune disorder. This uncommon disease usually begins as a localized granulomatous inflammation of upper or lower respiratory tract mucosa, and may progress into generalized necrotizing granulomatous vasculitis and glomerulonephritis. The cause of Wegener’s granulomatosis is unknown. Although the disease resembles an infectious process, no causative agent has been isolated yet. Because of the characteristic histological changes, hypersensitivity has been postulated as the basis of the disease.
Symptoms of Wegener’s granulomatosis
Frequent sinusitis is the most common symptom for Wegener’s granulomatosis.
Other early symptoms include persistent fever without an obvious cause, night sweats, fatigue, and malaise (an “ill feeling”). Chronic ear infections may preclude a diagnosis of Wegener’s granulomatosis.
Other upper respiratory symptoms include nose bleeds, pain, and sores around the opening of the patient’s nose. Loss of appetite and weight loss are common as well. Skin lesions typically occur, but there is no one typical lesion associated with this disease. Symptoms of kidney disease may be present, but this does not always happen. The urine may be bloody, and usually it first appears as red or smoky urine. Eye problems develop in a significant number of patients, which may range from mild conjunctivitis to severe swelling of the eye. Other symptoms include weakness, cough, or coughing up blood, as well as bloody sputum. The patient commonly complains about shortness of breath, wheezing, chest pain, rashes, and joint pains.
Diagnosis of Wegener’s granulomatosis
Wegener's granulomatosis is diagnosed by characteristic clinical, serologic, and pathologic findings. Wegener’s granulomatosis must be diagnosed and treated early to prevent complications. Common complications include kidney disease, lung disease, heart attacks, and brain damage. A doctor can usually recognize the distinctive pattern of symptoms, although blood test results cannot specifically identify Wegener’s granulomatosis. However, these blood tests can strongly support the diagnosis. A blood test can detect antineutrophil cytoplasmic antibodies in the blood, which suggest this disease. If the nose, throat, or skin is not affected, a diagnosis can be difficult. This is because the symptoms and x-rays can resemble those of several lung diseases. Chest x-ray may show cavities or dense areas in the lungs similar to cancer. To definitely diagnose Wegener’s granulomatosis a variety of tests may be performed, including a biopsy of abnormal tissue. The doctor could chose to have open lung biopsy, upper airway biopsy, nasal mucosal biopsy, bronchoscopy with transtracheal biopsy, or kidney biopsy. Urinalysis is helpful to look for signs of kidney disease such as protein and blood in the urine. In fact, the presence of kidney disease is necessary to make a definitive diagnosis of Wegener’s granulomatosis.
Treatment of Wegener’s granulomatosis
Corticosteroids may be used alone to treat the early symptoms. However, most people also need another immunosuppressive drug, such as cyclophosphamide to treat Wegener’s granulomatosis. Imuran is a common choice. This drug is able to control the disease by reducing the body’s inappropriate immune reaction, which improves the prognosis significantly. Without treatment, this form of the disorder is fatal. Treatment is usually continued for at least a year after the symptoms for Wegener’s granulomatosis disappear.
Corticosteroids, given at the same time to suppress inflammation, can usually be tapered off and discontinued during other treatment still last. For people receiving immunosuppressive drugs, a doctor treats any suspected infection as early as possible. This is because of the body’s decreased ability to fight infections during this therapy. Pneumonia is particularly common when the lungs are affected by Wegener’s. Moreover, antibiotic may be used to prevent infections in people who have been taking immunosuppressive drugs for years. Treatment with corticosteroids, cyclophosphamide, methotrexate, or azathioprine produces a long-term remission in over 90% of patients afflicted by Wegener’s granulomatosis.
With treatment, most people recover within months although some may develop chronic renal failure. Without treatment, patients can die within a few months, which is why complications usually result from lack of treatment. Possible complications include chronic kidney failure, hemoptysis (coughing up blood), respiratory failure, or inflammation of the eyes. Common complications are also nasal septum perforation and rash. Moreover, medications used to treat the disease can cause side effects. These side effects may also lead to complications.
It is important to know when to call the health care provider. Anyone who experiences chest pain, coughing up blood, blood in the urine, or other symptoms of this disorder should call their health care provider. The problem is that no preventive measures are currently known.
Prognosis of Wegener’s granulomatosis
With proper treatment, most people diagnosed with Wegener’s granulomatosis recover within months. However, some may develop chronic renal failure. The complete syndrome usually progresses rapidly to renal failure once the diffuse vascular phase begins due to Wegener’s granulomatosis.
Patients with limited disease may have nasal and pulmonary lesions, with little or no systemic involvement, where pulmonary manifestations may improve or worsen spontaneously. A previously fatal prognosis can be been dramatically improved by treatment with immunosuppressive cytotoxic drugs. Early diagnosis and treatment are crucial, because a high remission rate is now possible. In fact, critical renal complications can be avoided or reduced. Cyclophosphamide, 1 to 2 mg/kg/day with oral hydration, or by initial rapid IV infusion as a single dose q 2 to 3 weeks is the drug of choice for Wegener’s granulomatosis.
Corticosteroids, which reduce the vasculitic edema, are given concurrently. It could be prednisone 1 mg/kg/day. After 2 to 3 mo, prednisone is tapered until the patient is maintained solely on cyclophosphamide. This means long-term IV dosing appears to be less efficacious.
In Wegener’s granulomatosis treatment, Azathioprine is less effective. However, this drug may be an alternative or adjunct to cyclophosphamide for patients who cannot tolerate cyclophosphamide. Pulse treatment with methotrexate seems to be a better alternative. Long-term prophylactic trimethoprim-sulfamethoxazole seems to be highly effective for upper respiratory tract lesions and may suffice as the sole long-term treatment once all systemic features have been ablated by cyclophosphamide and corticosteroids. Occasionally, the associated anemia may be so profound that blood transfusions are required due to this therapy.
Long-term complete remission can be achieved with proper therapy, even in the case of advanced disease. Kidney transplantation has been successful in renal failure, although a report of one patient who received a cadaver kidney implant showed that typical renal lesions of Wegener's granulomatosis developed at the end. An increased incidence of solid tumors after many years may reflect high-dose cyclophosphamide use as a therapy of choice. The high incidence of bladder cancer many years after treatment is an alarming consequence of the hemorrhagic cystitis associated with excreted cyclophosphamide breakdown products. It is often unmitigated by high fluid output during initial therapy. Kidney lesions cause glomerulonephritis, which may result in blood in the urine and kidney failure at the end as serious consequences of Wegener’s granulomatosis.
Kidney disease can quickly worsen, and if left untreated, kidney failure and death occur in more than 90% of patients. Wegener's granulomatosis is most common in middle-aged adults and some doctors think that men are affected twice as often as women. It is rare in children, but the disease has been seen in infants as young as 3 months of age.