Letters to the Editor
Case Report: Wegener's Granulomatosis Presents as Pulmonary Infection
to the editor: A 35-year-old man with relapsing infections of the upper respiratory tract and nasal bleeding for five months was admitted to our hospital. The patient had been discharged from another hospital after showing no clinical improvement from one month of antibacterial and antituberculous treatment, and refusing to undergo lung operation for the postulated diagnosis of pulmonary abscess.
 Figure. Chest radiography showing a large infiltrate with a central cavitation in the right upper pulmonary field. |
Physical examination on admission to our hospital showed fever as high as 38.8° C (101.9° F), pulse of 80 beats per minute, and blood pressure of 120/70 mm Hg. The only abnormal findings on physical examination were small blood clots in the nose and ronchi in the upper right lung field. Laboratory tests revealed the following: white blood cell count of 13,230 per mm3 (13.2 3 109 per L [77.9 percent neutrophils, 12.9 percent lymphocytes]); hematocrit level, 36.3 percent; hemoglobulin level, 11.4 g per dL (114 g per L); platelet count, 588,000 per mm3 (5,880 3 109 per L); C-reactive protein 21.74 mg per dL (normal values less than 0.50 mg per dL); and erythrocyte sedimentation rate (ESR), 105 mm per first hour (normal values zero to 20 mm per hour). Laboratory tests for renal function, including urinalysis, were normal. Chest radiography and computed tomography (CT) of the thorax showed a large infiltrate with a central cavitation in the right upper pulmonary field (see accompanying figure). Craniofacial CT revealed ethmoid sinusitis.
The diagnosis of Wegener's granulomatosis was suggested by a significantly increased titer of the cytoplasmic-type antineutrophil cytoplasmic antibody (c-ANCA) of 65.3 u (normal: up to 30 u), and was confirmed by histopathologic examination of excised nasal mucosal specimens. The patient received treatment with cyclophosphamide, prednisolone, and co-trimoxazole, which improved symptoms and laboratory test abnormalities.
When fever persists in a patient with a significantly high ESR value, and radiographic and CT findings reveal sinusitis or a large pulmonary infiltrate with a central cavitation, Wegener's granulomatosis must be considered.1 Differential diagnosis of a pulmonary abscess-like lesion in an imaging test should include bronchial neoplasms (either as necrotizing carcinoma or as the cause of poststenotic cavernous pneumonia that led to an abscess), infectious diseases (like tuberculosis, aspergillosis and other fungal infections, Pneumonocystis carinii pneumonia, and actinomycosis), pulmonary embolism, or vasculitis (primarily Wegener's granulomatosis).2,3 Surgical lung biopsy may establish the final diagnosis; however, when Wegener's granulomatosis is suspected, the upper respiratory tract may be involved, making diagnosis less invasively established from histopathologic examination of biopsied nasal specimens.4-6
The diagnostic clue from our patient's clinical history was the upper respiratory tract symptoms for five months with progressive deterioration and nasal bleeding. Otorhinolaryngologists and other physicians should always have a high index of suspicion because Wegener's granulomatosis often presents at early stages as a localized form with disease activity limited to the upper respiratory tract.6 In most cases, Wegener's granulomatosis is diagnosed histologically on biopsy specimens taken from the ear, nose, and throat region. Initially, the disease acute-phase proteins and c-ANCA have a normal value.5 Early diagnosis can lead to early institution of the appropriate treatment and can prevent the irreversible destructive lesions of the disease.
Alfa HealthCare
Infectious Diseases Clinic
"Henry
Dunant" Hospital
9 Neapoleos St.
Marousi, Athens, Greece 15132
REFERENCES
1. Kariv R, Sidi Y, Gur H. Systemic vasculitis presenting as a tumorlike lesion. Four case reports and an analysis of 79 reported cases. Medicine 2000;79:349-59.
2. Allewelt M, Lode H. Diagnosis and therapy of abscess forming pneumonia [in German]. Ther Umsch 2001;58:599-603.
3. Sando Y, Sugita Y, Kaneko K, Ubukata M, Motegi M, Takayanagi N. Three cases of pulmonary actinomycosis [in Japanese]. Nihon Kyobu Shikkan Gakkai Zasshi 1992;30:1869-73.
4. Dechambre S, Driesschaert P, Goncette L, Pringot J. Unilateral peripheral pulmonary nodules: initial symptoms of a limited form of Wegener's disease [in French]. J Belge Radiol 1996;79:162-4.
5. Paulsen JI, Rudert H. Manifestations of primary vasculitis in the ENT region [in German]. Z Rheumatol 2001;60:219-25.
6. Rasmussen N. Management of the ear, nose, and throat manifestations of Wegener granulomatosis: an otorhinolaryngologist's perspective. Curr Opin Rheumatol 2001;13:3-11.
Diagnosis and Treatment of Group A Pharyngitis Strep
to the editor: The article1 on pharyngitis by Vincent and colleagues raises several questions about their approach to diagnosis and treatment of group A beta-hemolytic streptococcal pharyngitis.
They report the sensitivity and specificity of throat culture as 97 and 99 percent, respectively, for diagnosing group A beta-hemolytic streptococci, citing McIsaac's article,2 which seems to be higher than reported in the literature. McIsaac and colleagues2 compared the sensitivity and specificity of a score-based approach to the diagnosis of sore throat in their population as compared to throat culture, but did not provide the sensitivity and specificity of throat culture in their article. Perhaps a more accurate estimate comes from the study by Gerber and colleagues.3 The sensitivity and specificity of culture is reported as 78 and 99 percent, respectively. Similarly, in an article published in American Family Physician, Hayes and colleagues4 state that under ideal conditions, the sensitivity of throat culture for group A beta-hemolytic streptococci is only 90 percent; in office settings, the sensitivity ranges from 29 to 90 percent.4 The specificity of throat culture is 99 percent under ideal conditions and can be anywhere from 76 to 99 percent in office settings.4
The authors also recommend obtaining cultures if symptoms do not improve, citing the article by Attia.5 Attia and colleagues sought to determine the performance of a predictive model for group A beta-hemolytic streptococcal pharyngitis and did not recommend follow-up cultures if symptoms do not improve.5 We fail to understand the reasons for obtaining cultures in these patients as shown in Figure 1 of the article1 by Vincent and colleagues because some of these patients have already been treated based on rapid strep test results. It is unclear whether they intend to identify bacteriologic failures, relapse, or reinfection.
SONAL SINGH, M.D.
JAMES DOLAN,
M.D.
Department of Internal Medicine
Unity Health System
1555 Long Pond Rd.
Rochester, NY 14626
REFERENCES
1. Vincent MT, Celestin N, Hussain AN. Pharyngitis. Am Fam Physician 2004;69:1465-70.
2. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163:811-5.
3. Gerber MA, Tanz RR, Kabat W, Dennis E, Bell GL, Kaplan EL, et al. Optical immunoassay test for group A beta-hemolytic streptococcal pharyngitis. An office-based, multicenter investigation. JAMA 1997;277:899-903.
4. Hayes CS, Williamson H Jr. Management of Group A beta-hemolytic streptococcal pharyngitis [published correction appears in Am Fam Physician 2002;65:1282]. Am Fam Physician 2001;63:1557-64.
5. Attia MW, Zaoutis T, Klein JD, Meier FA. Performance of a predictive model for streptococcal pharyngitis in children [published correction appears in Arch Pediatr Adolesc Med 2001;155:1179]. Arch Pediatr Adolesc Med 2001;155:687-91.
in reply: Drs. Singh and Dolan raise the question of the sensitivity of throat culture to diagnose streptococcal pharyngitis and reinforce the importance of obtaining the specimen under "ideal conditions." In our article,1 we recognized the significance and described the proper technique for obtaining a throat culture under the subsection "Laboratory Evaluation" and state in Table 1 a sensitivity of "97 percent results dependent on the technique, medium, and incubation."2 Several of the references that support a sensitivity greater than 90 percent of throat culture for the diagnosis of group A beta-hemolytic streptococcus report a sensitivity of 90 to 97 percent when performed properly.2-5 A question also is raised about the necessity of obtaining a throat culture in the subset of patients who do not improve following treatment. Bisno and colleagues2 state that these patients require reculture to identify treatment failures, reinfection, or relapse.
REFERENCES
1. Vincent MT, Celestin N, Hussain AN. Pharyngitis. Am Fam Physician 2004;69:1465-70.
2. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35:113-25.
3. Gerber MA. Diagnosis of group A streptococcal pharyngitis. Pediatr Ann 1998;27:269-73.
4. Bisno AL. Acute pharyngitis.
N Engl J Med 2001;344:
205-11.
5. Pitetti RD, Wald ER. Strep throat: considering the diagnostic options. Patient Care 1999;33:119-45.
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