Granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, is a multisystem systemic necrotising non-caseating granulomatous vasculitis affecting small to medium sized arteries, capillaries and veins, with a predilection for the respiratory system and kidneys 3.
This article discusses GPA in general. For organ specific radiographic features please refer to individual articles:
- granulomatosis with polyangiitis: pulmonary manifestations
- granulomatosis with polyangiitis: renal manifestations
- granulomatosis with polyangiitis: upper respiratory tract manifestations
- granulomatosis with polyangiitis: CNS manifestations
- granulomatosis with polyangiitis: orbital manifestations
There is a slight male predilection and onset is typically at approximately 50 years of age 8.
Presentation depends on which organ systems are involved, however upper respiratory tract symptoms are most common 8. Cough and haemoptysis, proteinuria and haematuria as well as systemic symptoms such as anorexia, malaise and fever are also common 9.
Symptoms related to other organ systems is less frequent, due to a corresponding infrequency of involvement (musculoskeletal symptoms, ocular symptoms, skin changes) 9.
Interstitial fibrosis at the bases is usually the first finding, but is usually asymptomatic. Multiple pulmonary nodules, cavitating in 50% cases is the most common and characteristic manifestation. Pleural effusions and mediastinal nodal enlargement are also encountered.
Focal lesions can give proteinuria and haematuria while diffuse lesions can give acute renal failure.
Upper respiratory tract and paranasal sinus involvement
Causes mucosal ulceration and granulomatous masses within the nasal cavities with adjacent bony and cartilaginous destruction.
Can result in splenic infarction 16,17,18
It results from an immune mediated vascular injury.
Histologically necrotising granulomas with an associated vasculitis is the dominant feature.
In 90% of cases cANCA (PR3) is positive and the levels correlate with disease activity 8.
The classic triad of organ involvement consists of:
- lungs: involved in 95% of cases
- upper respiratory tract / sinuses: 75-90%
- kidneys: 80%
In terms of extent granulomatosis with polyangiitis can be classified as:
- classical: full triad
- limited: not having the full triad
- usually respiratory tract involvement only
- renal only involvement has been described but is uncommon 7
- widespread: additional organ involvement 14
Treatment and prognosis
Treatment is typically with cyclophosphamide, methotrexate and / or steroids.
Without treatment granulomatosis with polyangiitis is rapidly progressive with death usually occurring within a year of diagnosis, with only 10% of patients surviving 2 years 7. Appropriate medical therapy has dramatically increased long term survival 7.
History and etymology
The former name "Wegener granulomatosis" comes from the German pathologist Friedrich Wegener who first described it in 1936 11. Wegener was a member of the Nazi party and it is speculated that he took part in experiments on concentration camp inmates. Following the discovery of his Nazi past the current name "granulomatosis with polyangiitis" has been proposed 15.
General imaging differential considerations include:
- 1. Kumar V, Abbas AK, Fausto N et-al. Robbins and Cotran pathologic basis of disease. W B Saunders Co. (2005) ISBN:0721601871. Read it at Google Books - Find it at Amazon
- 2. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2007) ISBN:0323040683. Read it at Google Books - Find it at Amazon
- 3. Mayberry JP, Primack SL, Müller NL. Thoracic manifestations of systemic autoimmune diseases: radiographic and high-resolution CT findings. Radiographics. 20 (6): 1623-35. Radiographics (full text) - Pubmed citation
- 4. Ha HK, Lee SH, Rha SE et-al. Radiologic features of vasculitis involving the gastrointestinal tract. Radiographics. 20 (3): 779-94. Radiographics (full text) - Pubmed citation
- 5. Ananthakrishnan L, Sharma N, Kanne JP. Wegener's granulomatosis in the chest: high-resolution CT findings. AJR Am J Roentgenol. 2009;192 (3): 676-82. doi:10.2214/AJR.08.1837 - Pubmed citation
- 6. Wadsworth DT, Siegel MJ, Day DL. Wegener's granulomatosis in children: chest radiographic manifestations. AJR Am J Roentgenol. 1994;163 (4): 901-4. AJR Am J Roentgenol (abstract) - Pubmed citation
- 7. Aberle DR, Gamsu G, Lynch D. Thoracic manifestations of Wegener granulomatosis: diagnosis and course. Radiology. 1990;174 (3): 703-9. Radiology (abstract) - Pubmed citation
- 8. Collins J, Stern EJ. Chest radiology, the essentials. Lippincott Williams & Wilkins. (2007) ISBN:0781763142. Read it at Google Books - Find it at Amazon
- 9. Maffessanti M, Polverosi R, Dalpiaz G et-al. Diffuse lung diseases, clinical features, pathology, HRCT. Springer Verlag. (2006) ISBN:8847004292. Read it at Google Books - Find it at Amazon
- 10. Allen SD, Harvey CJ. Imaging of Wegener's granulomatosis. Br J Radiol. 2007;80 (957): 757-65. Br J Radiol (full text) - doi:10.1259/bjr/34705892 - Pubmed citation
- 11. Ananthakrishnan L, Sharma N, Kanne JP. Wegener's granulomatosis in the chest: high-resolution CT findings. AJR Am J Roentgenol. 2009;192 (3): 676-82. doi:10.2214/AJR.08.1837 - Pubmed citation
- 12. Martinez F, Chung JH, Digumarthy SR et-al. Common and uncommon manifestations of Wegener granulomatosis at chest CT: radiologic-pathologic correlation. Radiographics. 2012;32 (1): 51-69. doi:10.1148/rg.321115060 - Pubmed citation
- 13. Lohrmann C, Uhl M, Kotter E et-al. Pulmonary manifestations of wegener granulomatosis: CT findings in 57 patients and a review of the literature. Eur J Radiol. 2005;53 (3): 471-7. doi:10.1016/j.ejrad.2004.04.016 - Pubmed citation
- 14. Oxford desk reference. Oxford University Press. ISBN:0199229562. Read it at Google Books - Find it at Amazon
- 15. Jennette JC. Nomenclature and classification of vasculitis: lessons learned from granulomatosis with polyangiitis (Wegener's granulomatosis). Clin. Exp. Immunol. 2011;164 Suppl 1: 7-10. doi:10.1111/j.1365-2249.2011.04357.x - Free text at pubmed - Pubmed citation
- 16. Gal AA, Masor JJ. Splenic involvement in Wegener's granulomatosis. Archives of pathology & laboratory medicine. 120 (10): 974-7. Pubmed
- 17. Martusewicz-Boros M, Baranska I, Wiatr E, Bestry I, Roszkowski-Sliz K. Asymptomatic appearance of splenic infarction in Wegener's granulomatosis. Polish journal of radiology. 76 (2): 43-5. Pubmed
- 18. Fonner BT, Nemcek AA, Boschman C. CT appearance of splenic infarction in Wegener's granulomatosis. AJR. American journal of roentgenology. 164 (2): 353-4. doi:10.2214/ajr.164.2.7839968 - Pubmed