Case 2

History
64-year-old man with chronic sinusitis and urinary tract infection.

PA chest radiograph shows cavitating masses with
fluid levels in both lungs of intermediate wall thickness.

Diagnosis?

Diagnosis
Wegener's Granulomatosis.

Findings
PA chest radiograph shows cavitating masses with fluid levels in both lungs of intermediate wall thickness.

Wegener's granulomatosis is characterized by necrotizing vasculitis and granulomatous inflammation which affects primarily the upper and lower respiratory tracts and kidneys. Etiology is unknown. Studies suggest a hypersensitivity reaction with immune complex deposition (vasculitis) and a cellular immune response (granulomatous reaction). The typical roentgenographic features are those of multiple pulmonary nodules that cavitate in one-third to one-half of patients. The cavities tend to be thick walled with irregular inner lining. There is no predilection for any lung zone. The cavities may resolve spontaneously or rapidly following immunosuppression. They may become thin walled cystic spaces.

Wegener's granulomatosis most commonly affects adults in their fifth decade without sex predominance. The majority of patients present with symptoms referable to the para-nasal sinuses or lungs. Ninety percent of patients manifest renal involvement, which is the major cause of morbidity and mortality. Rarely does renal disease precede the onset of pulmonary disease. The classic triad includes upper and lower respiratory disease with glomerulonephritis. The differential diagnosis includes metastatic lung disease, septic pulmonary emboli, rheumatoid nodules, and coccidiomycosis.