Sinusitis—not Always of Infectious Origin

1University of Illinois at Urbana‐Champaign, Urbana, IL
2Carle Foundation Hospital, Urbana, IL

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 296

Case Presentation:

Sinonasal symptoms are very common in the general community, and most cases are successfully treated with empirical antibiotics, unlike our patient. The patient is a 47‐year‐old white man with a medical history of diabetes mellitus and hypertension who had presented to his primary care physician with complaints of increasing sinus congestion and drainage, significant headache, subjective fever and hearing impairment. For presumed bacterial sinusitis, he was treated with multiple courses of empiric antibiotics over 3 months, with only partial relief. CT of the sinuses revealed bilateral maxillary and left anterior ethmoid obstructive sinusitis. MRI of the brain was done, which suggested bilateral mastoiditis. He was scheduled to undergo functional endoscopic sinus surgery for his persistent complaints. A chest radiograph done as a part of preo‐perative evaluation showed bilateral lung masses. CT chest showed multiple cavitary lesions—a 5.6‐cm right perihilar mass, a 4.9‐cm right upper lobe mass, and several nodules measuring up to 2 cm. He was admitted to the hospital for further evaluation and management in view of the radio‐graphic findings, persistent symptoms of fever, cough, hemoptysis, and weight loss of 40 pounds over 4 months. Bronchial wash cultures were obtained, which were negative for bacteria, fungi, and acid‐fast‐bacilli. Transbronchial biopsies of the right lung lesions were positive for necrotizing granulomatous inflammation with evidence of vasculitis.

Serologic testing was positive for c‐ANCA (1:320) and elevated proteinase‐3 antibodies. With the patient meeting the diagnostic criteria for Wegener's granulomatosis, he was started on treatment with steroids and cyclophosphamide. The patient showed clinical and radiological improvement on follow‐up.

Discussion:

Wegener's granulomatosis is a rare autoimmune disease characterized by granulomatous inflammation and ANCA‐associated small‐vessel vasculitis. It has a broad clinical presentation that ranges from manifestations restricted to the respiratory system to life‐threatening necrotizing vasculitis affecting many organs, mainly the lungs and kidneys. Upper respiratory tract involvement affecting the nasal and oral cavity, sinuses, trachea, and bronchi is reported to occur in 75%–93% of patients at diagnosis. Pulmonary involvement is reported in 60%–85%. Glomerulonephritis is reported in 38%–70% of patients and is the hallmark of generalized disease. Our patient had typical upper and lower respiratory tract involvement and, significantly, no renal impairment.

Conclusions:

For patients presenting with chronic rhinosinusitis, a high index of suspicion and early diagnostic intervention can prevent a delay in diagnosis and treatment of Wegener's granulomatosis, and thus prevent significant morbidity and mortality.

Disclosures:

S. Hublikar ‐ University of Illinois at Urbana‐Champaign, employment; J. Cho ‐University of Illinois at Urbana‐Champaign, employment; M. Ahmed ‐ Carle Foundation Hospital, employment.

To cite this abstract:

Hublikar S, Cho J, Ahmed M. Sinusitis—not Always of Infectious Origin. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 296. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/sinusitisnot-always-of-infectious-origin/. Accessed May 24, 2019.

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