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Granulomatosis with Polyangiitis

(Previously known as Wegener’s Granulomatosis)

By

Alexandra Villa-Forte

, MD, MPH, Cleveland Clinic

Last full review/revision Sep 2020| Content last modified Sep 2020
CLICK HERE FOR THE PROFESSONAL VERSION
Topic Resources

Granulomatosis with polyangiitis often begins with inflammation of small- and medium-sized blood vessels and tissues in the nose, sinuses, throat, lungs, or kidneys.

  • The cause is unknown.

  • The disorder usually begins with nosebleeds, nasal congestion with crusting, sinusitis, hoarseness, ear pain, fluid in the middle ear, eye redness and pain, wheezing, and coughing.

  • Other organs may be affected, sometimes with serious complications, such as kidney failure.

  • Symptoms and other findings suggest the diagnosis, but a biopsy is usually needed to confirm it.

  • A corticosteroid and a second drug that suppresses the immune system are needed to control inflammation and induce remission.

Granulomatosis with polyangiitis is most common among whites but can occur in all ethnic groups and at any age. Most people are affected at about age 40. Its cause is unknown. It resembles an infection, but no infecting organism has been identified. Collections of immune cells that cause inflammation (called granulomas) form nodules and ultimately destroy normal tissue. Granulomatosis with polyangiitis is often life threatening.

Symptoms of Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis may begin suddenly or gradually. Usually, the first symptoms involve the upper respiratory tract—the nose, sinuses, ears, and windpipe (trachea). They may include the following:

Sometimes only the upper respiratory tract is affected for many years. People may also have a fever, feel generally unwell, and lose their appetite. Inflammation can affect the eyes, which may become swollen, red, and painful.

The disorder may progress to affect other areas of the body or may affect several organs from the beginning:

Diagnosis of Granulomatosis with Polyangiitis

  • A doctor's evaluation

  • Imaging tests

  • Blood and urine tests

  • Biopsy

Granulomatosis with polyangiitis must be diagnosed and treated early to prevent complications, including kidney disorders, lung disorders, and heart attacks.

Doctors usually suspect the diagnosis of granulomatosis with polyangiitis based on the distinctive pattern of symptoms. For example, doctors suspect the diagnosis when people have unexplained respiratory symptoms (including otitis media in adults, which is otherwise unusual) particularly if problems in other organs, especially the kidneys, exist. Doctors also suspect the diagnosis in people who have a long history of sinus problems that have not been cured by or only partially cured by antibiotics.

A chest x-ray is done because the lungs are usually affected. However, symptoms and chest x-rays can resemble those of several lung disorders, making the diagnosis difficult. So doctors also do a computed tomography (CT) scan of the chest to look for things the chest x-ray might miss, such as cavities or areas of inflammation in the lungs that may mimic cancer or infection.

Although blood test results cannot specifically identify granulomatosis with polyangiitis, they can strongly support the diagnosis. One such test can detect antineutrophil cytoplasmic antibodies (c-ANCA) in the blood. These antibodies occur in several types of vasculitis and trigger certain white blood cells to attack normal organs. Other specific antibodies are identified with further testing. People with this disorder may have blood and protein in their urine due to kidney inflammation. Because kidney inflammation can cause damage without causing symptoms, doctors always do a urine test to detect this inflammation.

Doctors can confirm the diagnosis by examining a small piece of tissue under a microscope (biopsy). The tissue sample may be taken from an affected area, such as the nasal passages, airways, or lungs. Skin and kidney biopsies may occasionally be helpful.

Prognosis of Granulomatosis with Polyangiitis

The prognosis depends on how severe and widespread the granulomatosis with polyangiitis is, how much organ damage has occurred, and how quickly people receive treatment.

For people with severe disease, prognosis has been greatly improved by using drugs that suppress the immune system Overview of the Immune System The immune system is designed to defend the body against foreign or dangerous invaders. Such invaders include Microorganisms (commonly called germs, such as bacteria, viruses, and fungi) Parasites... read more (immunosuppressants). With treatment, symptoms completely disappear (called remission) for about 80% of people. However, in about half of treated people, symptoms return (called a relapse). Relapses may occur when treatment is stopped or many years later. Resuming or increasing treatment can usually control the disorder.

Treatment of Granulomatosis with Polyangiitis

  • Corticosteroids

  • Other immunosuppressants

Corticosteroids (such as prednisone) are almost always used to suppress inflammation in people with granulomatosis with polyangiitis. Most people also need immunosuppressants, such as cyclophosphamide, methotrexate, rituximab, or azathioprine. If the disorder is not severe, doctors give a corticosteroid and methotrexate. Rituximab may be given instead of methotrexate. If the disorder is severe, people are hospitalized and are given high doses of a corticosteroid and cyclophosphamide or rituximab. Most people feel better within days to weeks. But for some, improvement may take months.

During remission, the dose of the drugs is gradually reduced. Treatment of granulomatosis with polyangiitis is usually continued for at least a year or often for many years after the symptoms disappear. The dose of a corticosteroid can usually be gradually decreased and eventually stopped. Doses may need to be adjusted throughout the course of treatment. If symptoms worsen or return, the dose is increased, or if drugs have been stopped, they are started again.

Because immunosuppressants weaken the immune system, the risk of developing serious infections is increased. Taking prednisone for a long time can result in weight gain, cataracts, high blood pressure, decreased bone density, diabetes, changes in mood, and difficulty sleeping. Cyclophosphamide can cause bladder irritation and, if taken repeatedly, sometimes bladder cancer. When cyclophosphamide is given by vein (intravenously), mesna, which chemically counteracts some toxic effects of cyclophosphamide on the bladder, is also given.

People with granulomatosis with polyangiitis need to be closely monitored by their doctor to check whether the dose of the drugs is appropriate, whether they are having side effects from the drugs, whether they could have an infection, and, during remission, whether there is any indication of a relapse. A complete blood count Complete blood count Doctors select tests to help diagnose blood disorders based on the person's symptoms and the results of the physical examination. Sometimes a blood disorder causes no symptoms but is discovered... read more is done frequently, sometimes as often as once a week, for people who take potent immunosuppressants. Immunosuppressants may cause the number of blood cells to decrease.

People should also learn as much as they can about the disorder. Thus, they can recognize signs of a relapse early. People can also learn to test their urine for blood and protein so that they can notify their doctor at the first sign of any new abnormality.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • Vasculitis Foundation: Provides information for patients about vasculitis, including how to find a doctor, learn about research studies, and join patient advocacy groups

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