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Rheumatology 2006 45(12):1554; doi:10.1093/rheumatology/kel219
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Wegener's granulomatosis presenting as a disappearing renal mass

A. Negi1, J. P. Camilleri1, P. N. Matthews2 and M. D. Crane3

1Department of Rheumatology, 2Department of Urology and 3Department of Radiology, University Hospital of Wales, Cardiff, UK

Correspondence to: Dr A. Negi, Specialist Registrar, Department of Rheumatology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK. E-mail: anuragnegi69{at}hotmail.com

A 40-yr-old man presented with fever, flank pain, epistaxis, haemoglobin 12.8 g/dl, WCC 12.9x 103 /mm3, C-reactive protein (CRP) 142 mg/l and erythrocyte sedimentation rate (ESR) 101 mm. Computed tomography (CT) of abdomen showed a left renal mass, suggesting renal cell carcinoma (RCC) (Fig. 1A) and possible metastases (Fig. 1B) on CT thorax. Following discussions, it was agreed that the radiological features were atypical for RCC, and renal abscess was more likely. Patient remained unwell after 6 weeks of antibiotics. CRP was 320 mg/l and ESR 124 mm. No organisms grew on blood/urine culture. cytoplasmic-Anti-neutrophil cytoplasmic antibody was 1:320 with strongly positive anti-PR3, suggesting Wegener's granulomatosis (WG). Biopsy of the renal mass was planned.


Figure 1
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  		FIG. 1. Initial CT showing the renal mass and pulmonary nodule (marked with arrows).

 
Pre-biopsy CT abdomen confirmed considerable reduction in the size of the mass and new lesions in both the kidneys (Fig. 2A) compatible with vasculitis. Repeat CT thorax showed new peribronchial shadowing (Fig. 2B). Renal function deteriorated acutely and decision was made to treat for WG. Dramatic improvement was noted. He remains well. Full blood count, renal function and CRP are normal.


Figure 2
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  		FIG. 2. Repeat CT with marked reduction in the renal mass and new renal and pulmonary lesions (marked with arrows).

 
Maguire et al. [1] reported atypical radiological findings in 31 WG patients; only one had a renal mass. Spontaneous resolution of the mass makes our case unique. We believe that the mass represented oedema surrounding the underlying vasculitis. Renal biopsy, while important, should not delay treatment if the overall picture is suggestive of WG.

The authors have declared no conflicts of interest.

References

  1. Maguire R, Fauci AS, Doppman JL, Wolff SM. (1978) Unusual radiographic features of Wegener's granulomatosis. Am J Roentgenol 130:233–8.[Abstract]
Accepted 19 May 2006


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