TO THE EDITOR: A 35-year-old man wi...

TO THE EDITOR: A 35-year-old man with relapsing infections of the upper respiratory tract and nasal bleeding for five month was admitted to our hospital. The patient had been discharged from another hospital after showing no clinical improvement from united month of antibacterial and antituberculous treatment, and refusing to pass through lung operation for the postulated diagnosis of pulmonary abscess.

Physical examination upon admission to our hospital showed flush as high as 38.8[degrees] C (1019[degrees] F) oscillation of 80 beats per minute, and kindred pressure of 120/70 mm Hg The barely abnormal findings on physical examination were small line clots in the nose and ronchi in the upper right lung field. Laboratory proofs revealed the following: white family cell count of 13,230 for [mm.sup.3] (13.2 x [10.sup.9] by L [77.9 percent neutrophils, 129 percent lymphocytes]); hematocrit flat 36.3 percent; hemoglobulin level, 114 g by dL (114 g per L); platelet regard 588,000 per [mm.sup.3] (5,880 x [10sup9] through L); C-reactive protein 21.74 mg by dL (normal values less than 050 mg by dL); and erythrocyte sedimentation rate (ESR) 105 mm through first hour (normal values naught to 20 mm per hour). Laboratory standards for renal function, including urinalysis, were normal. Chest radiography and comput 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.

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The diagnosis of Wegener's granulomatosis was proposeed by a significantly increased titer of the cytoplasmic-type antineutrophil cytoplasmic antibody (c-ANCA) of 653 u (normal: up to 30 u) and was confirmed by means of histopathologic examination of excised nasal mucosal specimens. The patient received treatment with cyclophosphamide, prednisolone, and cotrimoxazole, which improved symptoms and laboratory proof abnormalities.

When excitement 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 example should include bronchial neoplasms (either as necrotizing carcinoma or as the cause of poststenotic cavernous pneumonia that l 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). (23) Surgical lung biopsy may establish the final diagnosis; however, when Wegener's granulomatosis is suspected, the upper respiratory tract may be involved, making diagnosis les invasively established from histopathologic examination of biopsied nasal specimens. (4-6)

The diagnostic indication from our patient's clinical history was the upper respiratory tract symptoms for five month with progressive deterioration and nasal bleeding. Otorhinolaryngologists and other physicians should always have a high index of suspicion because Wegener's granulomatosis oftentimes presents at early stages as a localized form with disease activity limited to the upper respiratory tract. (6) In mostly cases, Wegener's granulomatosis is diagnosed histologically in succession 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 stop the irreversible destructive lesions of the disease.

MATTHEW FALAGAS, MD MSC

Adjunct Assistant Professor of Medicine

clusters University School of Medicine Boston, Massachusetts

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 mineral vein 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

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