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Opportunistic infection and antineutrophil cytoplasm antibodies in Wegener's granulomatosis
Respiratory Medicine (1989) 83, 421-424
Opportunistic infection and antineutrophil cytoplasm antibodies in Wegener's granulomatosis P. J. CARDER AND D. J. HARRISON
Department of Pathology, University Medical School, Teviot Place, Edinburgh, U.K.
Antineutrophil cytoplasmic antibodies (ANCA) are of established value in the diagnosis of Wegener's granulomatosis allowing early introduction of therapy. These patients are at risk of opportunistic infection, especially whilst receiving immunosuppressive drugs and this may mimic reactivation of disease. We present three cases of Wegener's granulomatosis complicated by opportunistic infection and assess the value of ANCA detection. Two presented with symptoms compatible with disease reactivation but ANCA were negative. One died With pulmonary infection due to Pneurnocystis carinii, Aspergillusfumigatus and Herpes simplex. Transbronchial biopsy in the second case revealed Pneumocystis carinii. A third case had strongly positive serum ANCA at diagnosis but in addition pulmonary infection with Legionella pneumophila. ANCA detection is of value in patients with Wegener's granulomatosis, but the result must be interpreted in the full clinical context.
Introduction Wegener's granulomatosis is a systemic, necrotizing vasculitis affecting predominantly the upper and lower respiratory tract and kidneys (1). Diagnosis relies upon typical histological findings of a necrotizing granulomatous vasculitis in nasal or lung biopsy and a focal segmental necrotizing glomerulonephritis within a characteristic clinical setting (I). Untreated, Wegener's granulomatosis progresses rapidly to renal failure and death (2), but the response to therapy with cytotoxic drugs is often dramatic. Accurate, rapid diagnosis is essential. The discovery of antibodies to neutrophil cytoplasmic antigens (ANCA), detectable by a simple indirect immunofluorescence assay (3), has led to hopes of a specific disease marker for both diagnosis (4) and monitoring disease activity (3,5). Patients in relapse show recrudescence of ANCA activity, even when on maintenance immunosuppressive therapy (unpublished observations), and so ANCA may be useful in monitoring disease activity especially when immunosuppressives are being reduced. Measurement of ANCA is now used routinely in many centres in the diagnosis and follow-up of Wegener's granuloma (6). The tissue damage and immune dysfunction predispose to opportunistic infection, but susceptibility is greatly increased whilst receiving immunosuppressives (7). Pulmonary infection may give a clinical illness indistinguishable from active disease. We report three Received 28 November 1988 and in revised form 19 April 1989.
0954-6111/89/050421+ 04 $03.00/0
cases complicated by opportunistic infection and assess the diagnostic value of ANCA detection in these patients. Material and Methods The method used to detect ANCA has been published previously (3). Briefly, neutrophils were separated from normal donor blood by dextran sedimentation and cytospin preparations were fixed in absolute alcohol for five minutes at 4°C. Patient serum was diluted 1:20 to h160 in phosphate buffered saline (PBS) and incubated at 37°C for 30 min on the cytospin. After washing, rabbit antihuman IgG conjugated to fluorescein isothiocyanate (SAPU, UK) was used, diluted 1:80 in PBS. Slides were viewed under ultraviolet light. The positive control serum gave a bright, coarsely granular, cytoplasmic fluorescence at dilutions of at least 1:80 (Plate I). Case Reports CASE I
A 55-year-old female presented in July 1986 with pleuritic chest pain, haemoptysis, arthralgia and microscopic haematuria. Transbronchial biopsies revealed acute florid inflammation of the bronchial mucosa with tissue necrosis, vasculitis and multinucleated giant cells consistent with Wegener's granulomatosis. Renal biopsy revealed a focal and segmental necrotizing glomerulonephritis with vasculitis in a single afferent arteriole. ANCA were strongly © 1989 Bailli~reTindall
422
P. J. Carder and D. J. Harrison necrotizing lesion and only trace ANCA activity. Immunosuppression was recommenced but seven weeks later he became unwell and developed diffuse infiltrates on his chest X-ray. The possibility of recrudescence of Wegener's granulomatosis was considered but transbronchial biopsy and bronchial washing revealed Pneumocystis carinii (Plate 2c). There was no evidence of vasculitis in the biopsy. ANCA remained negative. Despite ventilation and intensive therapy the patient died in respiratory failure. Autopsy was not performed.
Plate 1. Photomicrograph of neutrophil cytospin incubated with patient serumshowingcoarse granular cytoplasmic fluorescence for IgG. positive. Immunosuppressive therapy with cyclophosphamide and steroids was commenced and she remained well until December 1987 when she developed diffuse lung infiltrates on her chest X-ray. Reactivation of her disease was suspected but sputum culture revealed a pneumococcal infection and antibiotic therapy was commenced. ANCA were not detectable. Her condition failed to improve and antifungal therapy was initiated after repeat sputum culture grew Aspergillus fumigatus. She deteriorated and died 3 weeks later. At autopsy there was widespread consolidation of both lungs. Opportunistic infection with Aspergillus fumigatus, Pneumocystis carinii and Herpes simplex was confirmed histologically and microbiologically (Plate 2). There was no evidence of reactivation of Wegener's granuloma in either lungs or kidneys. CASE2
A 49-year-old man presented in 1983 with a bloody nasal discharge and pyoderma gangrenosum of his leg. Nasal antral biopsies revealed submucosal infiltration by acute and chronic inflammatory cells around small vessels and biopsies from the leg ulcer revealed a similar vasculitis with giant cells. Renal biopsy demonstrated a mild mesangial proliferative glomerulonephritis. Chest X-ray was normal: Retrospective analysis of serum revealed the bright coarse granular cytoplasmic ANCA fluorescence characteristic of Wegener's granulomatosis. Immunosuppressive therapy was commenced, but in April 1986 he developed shingles and therapy was stopped. Renal function deteriorated and a repeat biopsy 5 months later showed crescentic glomerulonephritis superimposed on a focal and segmental glomerulosclerosis. There was no active
CASE3 A 47-year-old man presented with pleuritic chest pain, dyspnoea, conjunctivitis and a nasal discharge. Chest radiograph revealed patchy consolidation and nasal antral biopsies demonstrated a small vessel necrotizing vasculitis with granuloma formation, consistent with Wegener's granulomatosis. ANCA were strongly positive and renal biopsy revealed a focal and segmental necrotizing glomerulonephritis with widespread crescent formation. Open lung biopsy showed no evidence of vasculitis but there was thickening of alveolar walls with type II pneumocyte proliferation, oedema, fibrin deposition and prominent infiltration of alveolar walls with polymorphonuclear leukocytes (Plate 3). These appearances suggested Legionella pneumophila infection which was subsequently confirmed bacteriologically. With appropriate antibiotic and immunosuppressive therapy he recovered and is currently well 18 months later. Discussion
Wegener's granulomatosis may present in many ways depending on the organ system involved (8). Treatment with cytotoxic immunosuppressives has dramatically improved the prognosis (1) although these drugs predispose to opportunistic infections. Wegener's granuiomatosis is thought to be the result of immune dysfunction, which itself may predispose to infection, and disease activity is associated with relatively specific serum auto-antibodies (3,5). It may be tempting to rely on detection of ANCA in monitoring patients rather than perform invasive procedures. Even transbronchial biopsy may not provide a firm diagnosis (10). In Cases 1 and 2 there was radiological evidence compatible with reactivation of disease. In both cases ANCA, which had been detectable at presentation, were not found, raising the possibility of another disease such as opportunistic infection. In Case 3 Wegener's granulomatosis was diagnosed on the basis of necrotizing glomerulonephritis, nasal vasculitis and
Wegener's granulomatosis
423
:-".:.':i:.~~:..~.~...',. Plate 2. Photomicrographs of post mortem lung from Case I (Grocott, x 700), (a) Fruiting head ofAspergillusfumigatus. (b) Cowdry type A nuclear inclusions of Herpes simplex. (c) Multiple cysts of Pneumocystis carinii within typical intra-alveolar exudate.
~.~,llw~.q"~ ~ " 7 . ~ •
. •
p~, ~...~.;~--,~ ,,."~ ~ , . ,~.~__~ ~ . . ~ ?',;: ~
.t
... --
~.¢ ~ ~
: _ .~ ._ ,,~ ca "~ ~
,,
positive A N C A . Fortunately, an open lung biopsy was performed in addition and this suggested infection which proved to be Legionnaire's disease, even though the patient had not received immunosuppressives. We conclude that A N C A are of value in the diagnosis and monitoring of patients with Wegener's granulomatosis. Whilst a positive result confirms disease activity, the absence of A N C A in a symptomatic patient may suggest an alternative diagnosis such as opportunistic infection. Serum A N C A activity however does not exclude other pathologies. The result must be interpreted in conjunction with full clinical, histological and microbiological findings.
Acknowledgements Plate 3. Photomicrograph of open lung biopsy from Case 3 showing intra-alveolar exudate with fibrin and polymorphonuclear leukocytes compatible with Legionella infection (H&E, x 320).
This work was supported by a grant from the British Medical Association to DJH. We would like to thank Dr M. Sudlow (Consultant Respiratory Physician) and Dr D. Lamb (Consultant Pathologist) for permission to report these cases.
424
P. J. C a r d e r a n d D. J. H a r r i s o n
References I. Cupps TR, Fauci AS. Wegener's Granulomatosis in The Vasculitides. Philadelphia: W.B. Saunders Company, 1981, pp. 72-87. 2. Walton EN. Giant cell granuloma of the respiratory tract (Wegener's Granulomatosis). Brit Med J 1958; ii: 265-270. 3. Van der Woude FJ, Lobatto S, Permin H, et aI. Autoantibodies against neutrophils and monocytes: Tool for diagnosis and marker of disease activity in Wegener's Granulomatosis. Lancet 1985; i: 425-429. 4. Lockwood CM, Bakes D, Jones S, Whitaker KB, Moss DW, Savage COS. Association of alkaline phosphatase with an autoantigen recognised by circulating antineutrophil antibodies in systemic vasculitis. Lancet 1987; ii: 716-720. 5. Ludemann G, Gross WL. Autoantibodies against cyto-
6. 7.
8. 9. 10.
plasmic structures of neutrophil granulocytes in Wegener's Granulomatosis. Clin Exp lmmunol 1987; 69: 350-357. Rasmussen N, Wiik A, Hoier-Madsen M, Borregaard N, Van der Woude F. Antineutrophil cytoplasm antibodies. Lancet 1988; i: 706-707. Dale DC, Fauci AS, Wolf SM. The effect of cyclophosphamide in leukocyte kinetics and susceptibility to infection in patients with Wegener's Granulomatosis. Arthritis Rheum 1973; 16: 657-664. De Remee RA, McDonald TJ, Weiland LH. Wegener's Granulomatosis: Experience with over 100 cases. New Sarcoidosis 1986; 3: 143-144. Douglas AC, Anderson TJ, Macdonald MK, Simpson JG. Midline and Wegener's Granulomatosis. Ann N Y AcadSci 1976; 278: 618-~25. Leavitt RY, Fauci AS. Pulmonary vasculitis. Am Rev o f Resp Disease 1986; 134: 149-166.
Opportunistic infection and antineutrophil cytoplasm antibodies in Wegener's granulomatosis P. J. CARDER AND D. J. HARRISON
Department of Pathology, University Medical School, Teviot Place, Edinburgh, U.K.
Antineutrophil cytoplasmic antibodies (ANCA) are of established value in the diagnosis of Wegener's granulomatosis allowing early introduction of therapy. These patients are at risk of opportunistic infection, especially whilst receiving immunosuppressive drugs and this may mimic reactivation of disease. We present three cases of Wegener's granulomatosis complicated by opportunistic infection and assess the value of ANCA detection. Two presented with symptoms compatible with disease reactivation but ANCA were negative. One died With pulmonary infection due to Pneurnocystis carinii, Aspergillusfumigatus and Herpes simplex. Transbronchial biopsy in the second case revealed Pneumocystis carinii. A third case had strongly positive serum ANCA at diagnosis but in addition pulmonary infection with Legionella pneumophila. ANCA detection is of value in patients with Wegener's granulomatosis, but the result must be interpreted in the full clinical context.
Introduction Wegener's granulomatosis is a systemic, necrotizing vasculitis affecting predominantly the upper and lower respiratory tract and kidneys (1). Diagnosis relies upon typical histological findings of a necrotizing granulomatous vasculitis in nasal or lung biopsy and a focal segmental necrotizing glomerulonephritis within a characteristic clinical setting (I). Untreated, Wegener's granulomatosis progresses rapidly to renal failure and death (2), but the response to therapy with cytotoxic drugs is often dramatic. Accurate, rapid diagnosis is essential. The discovery of antibodies to neutrophil cytoplasmic antigens (ANCA), detectable by a simple indirect immunofluorescence assay (3), has led to hopes of a specific disease marker for both diagnosis (4) and monitoring disease activity (3,5). Patients in relapse show recrudescence of ANCA activity, even when on maintenance immunosuppressive therapy (unpublished observations), and so ANCA may be useful in monitoring disease activity especially when immunosuppressives are being reduced. Measurement of ANCA is now used routinely in many centres in the diagnosis and follow-up of Wegener's granuloma (6). The tissue damage and immune dysfunction predispose to opportunistic infection, but susceptibility is greatly increased whilst receiving immunosuppressives (7). Pulmonary infection may give a clinical illness indistinguishable from active disease. We report three Received 28 November 1988 and in revised form 19 April 1989.
0954-6111/89/050421+ 04 $03.00/0
cases complicated by opportunistic infection and assess the diagnostic value of ANCA detection in these patients. Material and Methods The method used to detect ANCA has been published previously (3). Briefly, neutrophils were separated from normal donor blood by dextran sedimentation and cytospin preparations were fixed in absolute alcohol for five minutes at 4°C. Patient serum was diluted 1:20 to h160 in phosphate buffered saline (PBS) and incubated at 37°C for 30 min on the cytospin. After washing, rabbit antihuman IgG conjugated to fluorescein isothiocyanate (SAPU, UK) was used, diluted 1:80 in PBS. Slides were viewed under ultraviolet light. The positive control serum gave a bright, coarsely granular, cytoplasmic fluorescence at dilutions of at least 1:80 (Plate I). Case Reports CASE I
A 55-year-old female presented in July 1986 with pleuritic chest pain, haemoptysis, arthralgia and microscopic haematuria. Transbronchial biopsies revealed acute florid inflammation of the bronchial mucosa with tissue necrosis, vasculitis and multinucleated giant cells consistent with Wegener's granulomatosis. Renal biopsy revealed a focal and segmental necrotizing glomerulonephritis with vasculitis in a single afferent arteriole. ANCA were strongly © 1989 Bailli~reTindall
422
P. J. Carder and D. J. Harrison necrotizing lesion and only trace ANCA activity. Immunosuppression was recommenced but seven weeks later he became unwell and developed diffuse infiltrates on his chest X-ray. The possibility of recrudescence of Wegener's granulomatosis was considered but transbronchial biopsy and bronchial washing revealed Pneumocystis carinii (Plate 2c). There was no evidence of vasculitis in the biopsy. ANCA remained negative. Despite ventilation and intensive therapy the patient died in respiratory failure. Autopsy was not performed.
Plate 1. Photomicrograph of neutrophil cytospin incubated with patient serumshowingcoarse granular cytoplasmic fluorescence for IgG. positive. Immunosuppressive therapy with cyclophosphamide and steroids was commenced and she remained well until December 1987 when she developed diffuse lung infiltrates on her chest X-ray. Reactivation of her disease was suspected but sputum culture revealed a pneumococcal infection and antibiotic therapy was commenced. ANCA were not detectable. Her condition failed to improve and antifungal therapy was initiated after repeat sputum culture grew Aspergillus fumigatus. She deteriorated and died 3 weeks later. At autopsy there was widespread consolidation of both lungs. Opportunistic infection with Aspergillus fumigatus, Pneumocystis carinii and Herpes simplex was confirmed histologically and microbiologically (Plate 2). There was no evidence of reactivation of Wegener's granuloma in either lungs or kidneys. CASE2
A 49-year-old man presented in 1983 with a bloody nasal discharge and pyoderma gangrenosum of his leg. Nasal antral biopsies revealed submucosal infiltration by acute and chronic inflammatory cells around small vessels and biopsies from the leg ulcer revealed a similar vasculitis with giant cells. Renal biopsy demonstrated a mild mesangial proliferative glomerulonephritis. Chest X-ray was normal: Retrospective analysis of serum revealed the bright coarse granular cytoplasmic ANCA fluorescence characteristic of Wegener's granulomatosis. Immunosuppressive therapy was commenced, but in April 1986 he developed shingles and therapy was stopped. Renal function deteriorated and a repeat biopsy 5 months later showed crescentic glomerulonephritis superimposed on a focal and segmental glomerulosclerosis. There was no active
CASE3 A 47-year-old man presented with pleuritic chest pain, dyspnoea, conjunctivitis and a nasal discharge. Chest radiograph revealed patchy consolidation and nasal antral biopsies demonstrated a small vessel necrotizing vasculitis with granuloma formation, consistent with Wegener's granulomatosis. ANCA were strongly positive and renal biopsy revealed a focal and segmental necrotizing glomerulonephritis with widespread crescent formation. Open lung biopsy showed no evidence of vasculitis but there was thickening of alveolar walls with type II pneumocyte proliferation, oedema, fibrin deposition and prominent infiltration of alveolar walls with polymorphonuclear leukocytes (Plate 3). These appearances suggested Legionella pneumophila infection which was subsequently confirmed bacteriologically. With appropriate antibiotic and immunosuppressive therapy he recovered and is currently well 18 months later. Discussion
Wegener's granulomatosis may present in many ways depending on the organ system involved (8). Treatment with cytotoxic immunosuppressives has dramatically improved the prognosis (1) although these drugs predispose to opportunistic infections. Wegener's granuiomatosis is thought to be the result of immune dysfunction, which itself may predispose to infection, and disease activity is associated with relatively specific serum auto-antibodies (3,5). It may be tempting to rely on detection of ANCA in monitoring patients rather than perform invasive procedures. Even transbronchial biopsy may not provide a firm diagnosis (10). In Cases 1 and 2 there was radiological evidence compatible with reactivation of disease. In both cases ANCA, which had been detectable at presentation, were not found, raising the possibility of another disease such as opportunistic infection. In Case 3 Wegener's granulomatosis was diagnosed on the basis of necrotizing glomerulonephritis, nasal vasculitis and
Wegener's granulomatosis
423
:-".:.':i:.~~:..~.~...',. Plate 2. Photomicrographs of post mortem lung from Case I (Grocott, x 700), (a) Fruiting head ofAspergillusfumigatus. (b) Cowdry type A nuclear inclusions of Herpes simplex. (c) Multiple cysts of Pneumocystis carinii within typical intra-alveolar exudate.
~.~,llw~.q"~ ~ " 7 . ~ •
. •
p~, ~...~.;~--,~ ,,."~ ~ , . ,~.~__~ ~ . . ~ ?',;: ~
.t
... --
~.¢ ~ ~
: _ .~ ._ ,,~ ca "~ ~
,,
positive A N C A . Fortunately, an open lung biopsy was performed in addition and this suggested infection which proved to be Legionnaire's disease, even though the patient had not received immunosuppressives. We conclude that A N C A are of value in the diagnosis and monitoring of patients with Wegener's granulomatosis. Whilst a positive result confirms disease activity, the absence of A N C A in a symptomatic patient may suggest an alternative diagnosis such as opportunistic infection. Serum A N C A activity however does not exclude other pathologies. The result must be interpreted in conjunction with full clinical, histological and microbiological findings.
Acknowledgements Plate 3. Photomicrograph of open lung biopsy from Case 3 showing intra-alveolar exudate with fibrin and polymorphonuclear leukocytes compatible with Legionella infection (H&E, x 320).
This work was supported by a grant from the British Medical Association to DJH. We would like to thank Dr M. Sudlow (Consultant Respiratory Physician) and Dr D. Lamb (Consultant Pathologist) for permission to report these cases.
424
P. J. C a r d e r a n d D. J. H a r r i s o n
References I. Cupps TR, Fauci AS. Wegener's Granulomatosis in The Vasculitides. Philadelphia: W.B. Saunders Company, 1981, pp. 72-87. 2. Walton EN. Giant cell granuloma of the respiratory tract (Wegener's Granulomatosis). Brit Med J 1958; ii: 265-270. 3. Van der Woude FJ, Lobatto S, Permin H, et aI. Autoantibodies against neutrophils and monocytes: Tool for diagnosis and marker of disease activity in Wegener's Granulomatosis. Lancet 1985; i: 425-429. 4. Lockwood CM, Bakes D, Jones S, Whitaker KB, Moss DW, Savage COS. Association of alkaline phosphatase with an autoantigen recognised by circulating antineutrophil antibodies in systemic vasculitis. Lancet 1987; ii: 716-720. 5. Ludemann G, Gross WL. Autoantibodies against cyto-
6. 7.
8. 9. 10.
plasmic structures of neutrophil granulocytes in Wegener's Granulomatosis. Clin Exp lmmunol 1987; 69: 350-357. Rasmussen N, Wiik A, Hoier-Madsen M, Borregaard N, Van der Woude F. Antineutrophil cytoplasm antibodies. Lancet 1988; i: 706-707. Dale DC, Fauci AS, Wolf SM. The effect of cyclophosphamide in leukocyte kinetics and susceptibility to infection in patients with Wegener's Granulomatosis. Arthritis Rheum 1973; 16: 657-664. De Remee RA, McDonald TJ, Weiland LH. Wegener's Granulomatosis: Experience with over 100 cases. New Sarcoidosis 1986; 3: 143-144. Douglas AC, Anderson TJ, Macdonald MK, Simpson JG. Midline and Wegener's Granulomatosis. Ann N Y AcadSci 1976; 278: 618-~25. Leavitt RY, Fauci AS. Pulmonary vasculitis. Am Rev o f Resp Disease 1986; 134: 149-166.