ABSTRACT
We present a patient with Wegener's granulomatosis (WG) with involvement of the abdominal aorta, testis, peripheral nerve system, and skin. A 51-year-old man presented at our outpatient clinic with lower back pain. He had a history of smoking, hypertension, and an embryonal carcinoma of the left testis, treated 13 years ago with orchidectomy and chemotherapy. One month earlier, he underwent a partial orchidectomy of the right testis due to testicular swelling. Abdominal computed tomography showed a 3.8 cm wide aneurysm of the distal part of the aorta with inflammation. One week later he was admitted to the hospital with numbness of his hands and feet. Physical examination showed signs of peripheral microemboli. Serological laboratory tests revealed elevated antineutrophil cytoplasmic antibody titers with positive reactions against proteinase-3, indicating Wegener's disease. The chest X-ray was normal. Pathological examination of the right testis showed necrotizing vasculitis of a small artery. He was treated with cyclophosphamide and prednisolone. WG with extrapulmonary involvement occurs infrequently, and reports of manifestations of WG in aorta, testis, the peripheral nerve system, and skin are even more uncommon. Small- and medium-vessel vasculitis can precede large-vessel vasculitis or occur in the absence of small-vessel involvement. Therefore, WG should be included in the work-up of large-vessel vasculitis, which can give rise to periaortic inflammation.
Subject(s)
Aortic Aneurysm, Abdominal/etiology , Granulomatosis with Polyangiitis/diagnosis , Orchitis/etiology , Adult , Aged , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/drug therapy , Aortography/methods , Cyclophosphamide/administration & dosage , Drug Therapy, Combination , Female , Granulomatosis with Polyangiitis/complications , Granulomatosis with Polyangiitis/drug therapy , Humans , Hypesthesia/etiology , Immunosuppressive Agents/administration & dosage , In Vitro Techniques , Male , Middle Aged , Orchitis/drug therapy , Orchitis/pathology , Prednisolone/administration & dosage , Pulse Therapy, Drug , Testis/pathology , Tomography, X-Ray Computed , Treatment Outcome , Young AdultABSTRACT
OBJECTIVES: To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg. DESIGN: Randomised controlled diagnostic trial. MATERIALS AND METHODS: Patients were randomly allocated to MRA (n=97) or DSA (n=100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs. RESULTS: A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p=0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p=0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were euro4768,- in the MRA group compared to euro4697,- in the DSA group (95% CI of difference -1331;1472). CONCLUSIONS: In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable.