Wegener's granulomatosis presenting with colonic ulcerations.

c r t e r A otherwise healthy woman presented with a 3-day history of explosive diarrhea, abdominal cramping, and right red blood per rectum. Rectal examination was notable only or trace bright red blood on the examining glove. Initial laboraory findings included hemoglobin of 10.0 g/dL and a total white lood cell count of 11.4 109/L. Stool studies were negative for Clostridium difficile and enteric pathogens. She underwent further evaluation with colonoscopy (Figure A), which revealed scattered ulcers ranging in size from 5 mm to 2 cm. In total, there were more than 20 ulcers scattered throughout the colon, except for cecal sparing. Ulcer borders were erythematous and edematous with white exudative bases, but without signs of active bleeding. The intervening mucosa between ulceration was normal. Cytomegalovirus immunostain was negative. Biopsies of the lesions showed foci of ulceration and hemorrhage within the lamina propria and scattered foci of cryptitis and crypt abscesses. Three days into her hospital course she developed new hypoxia and had apparently aspirated. A chest x-ray showed extensive infiltrates and consolidation in the left upper lobe, which was new compared with a film taken 10 days prior. She was treated for aspiration pneumonia. She was discharged to home with oxygen and instructions to complete a 10-day course of oral levofloxacin. She was readmitted 6 days later with worsened shortness of breath, intermittent hemoptysis, and acute renal failure (creatinine, 2.0 mg/dL). Unenhanced computed tomography of the chest showed extensive bilateral infiltrates in the upper lobes consistent with diffuse alveolar hemorrhage (Figure B). The patient was found to have a C-reactive protein of 253.9 mg/L and was positive for cytoplasmic anti-neutrophilic cytoplasmic antibody and equivocal for PR3. A renal biopsy demonstrated pauciimmune necrotizing and crescentic glomerulonephritis. A diagnosis of Wegener’s granulomatosis (WG) was made. Our patient underwent treatment with cyclophosphamide and systemic steroids as well as plasma exchange for 14 days. Her respiratory status and renal function improved dramatically. She had no recurrence of gastrointestinal bleeding and was eventually discharged to home. Discrete colonic ulcerations can be seen in Crohn’s disease, nonsteroidal anti-inflammatory drug ingestion, ischemia, or infectious processes (eg, amebiasis, Campylobacter or Yersinia infection.). However, in the context of new pulmonary infiltrates and renal failure, gastrointestinal involvement by vasculitis should be considered. WG, a disseminated, small-vessel necrotizing vasculitis, typically affects the kidneys and respiratory tract. In this rare case, WG initially presented with colonic ulcerations. Colonic ulcerations, typically presenting with lower gastrointestinal bleeding and diarrhea, are unusual manifestations of systemic vasculitides, but they have been described in WG.1,2 At olonoscopy, multiple ulcerations with sharp borders, no surounding inflammation, and in a nonspecific anatomic distribuion are seen.1 Characteristic histologic changes include the presnce of granulomas and vasculitis; however, these are rarely eported in mucosal biopsy material.3 In this case, biopsies of the colonic mucosa were largely nonspecific. This case illustrates that the differential for colonic ulcerations in patients with multisystemic disease should include vasculitis, specifically WG.