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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 5-8

Prostate abscess with acute urinary retention as the initial presentation of granulomatosis with polyangitis


1 Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Rheumatology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission08-Mar-2020
Date of Decision15-May-2020
Date of Acceptance11-Aug-2020
Date of Web Publication19-Nov-2021

Correspondence Address:
K M Bhargav
Assistant Professor, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_16_20

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  Abstract 


A 50-year-old male presented with acute urinary retention. He also had a history of cough, haemoptysis, exertional dyspnoea, loss of appetite, generalised weakness and left-ear discharge of 1-month duration. Prior episode of acute urinary retention had occurred 2 months ago; diagnostic evaluation revealed prostate abscess, and he had received treatment elsewhere for the same. He also had a history of hypertension. Physical examination revealed fever, pallor, bilateral parotid enlargement and left-ear serous discharge. Clinical examination, imaging of chest revealed consolidation with cavitation on the left side, bilateral pleural effusion. Laboratory testing revealed normocytic normochromic anaemia (haemoglobin 6.6 g/dL); neutrophilic leucocytosis (total leucocyte count 13,100 cells/mm3; polymorphs 87%); raised erythrocyte sedimentation rate (110 mm at the end of the first hour); elevated serum creatinine (2.69 mg/dL) and an active urine sediment. Flexible fibreoptic bronchoscopy showed alveolar haemorrhages. Bronchoalveolar lavage fluid Xpert MTB/RIF testing, cytopathology were negative. Computed tomography-guided biopsy from the lesion was suggestive of granulomatous vasculitis. Cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) tested positive. The patient was diagnosed to have granulomatosis with polyangitis (GPA). As arterial hypoxaemia was evident, tracheal intubation and mechanical ventilatory support were initiated. Renal replacement therapy, intravenous (iv) methyl prednisolone and cyclophosphamide pulse therapy and five sessions of plasmapheresis were administered. As remission could not be achieved, iv rituximab was started. On the 36th day of admission, the patient developed septic shock and died. The present case documents the uncommon association of GPA with prostate abscess, acute urinary retention.

Keywords: Acute urinary retention, granulomatosis with polyangitis, prostate, Wegener's granulomatosis abscess


How to cite this article:
Bhargav K M, S Manasa C V, Sindhu G, Mohan A, Chowhan A K, Sirisha K. Prostate abscess with acute urinary retention as the initial presentation of granulomatosis with polyangitis. J Clin Sci Res 2022;11, Suppl S1:5-8

How to cite this URL:
Bhargav K M, S Manasa C V, Sindhu G, Mohan A, Chowhan A K, Sirisha K. Prostate abscess with acute urinary retention as the initial presentation of granulomatosis with polyangitis. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 2];11, Suppl S1:5-8. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/5/355071




  Introduction Top


Granulomatosis with polyangitis (GPA), previously referred to as Wegener's granulomatosis, is a rare disease of unknown aetiology, with an incidence reported between 7 and 22 new cases per million per year.[1] GPA is characterised by necrotising small-vessel vasculitis, which mainly affects the upper respiratory tract, lungs and kidneys.[2],[3] Other manifestations of GPA include skin and mucocutaneous lesions; peripheral neuropathy; mononeuritis multiplex as well as ocular (conjunctivitis, dacrocystitis and corneal and retinal lesions), cardiac (pericarditis and cardiomopathy) and gastrointestinal involvement. Genitourinary involvement is rare, being reported in <1% of patients.[4] We report an uncommon occurrence of prostatic abscess and episodes of acute urinary retention in a patient in whom diagnostic work-up confirmed the diagnosis of GPA.


  Case Report Top


A 50-year-old male with a history of cough, haemoptysis, exertional dyspnoea, loss of appetite, generalised weakness and left-ear discharge of 1-month duration presented to us with acute urinary retention.

Two months ago, he had experienced an episode of acute urinary retention. Evaluation revealed prostate abscess for which he had received antibiotics in an outside hospital and had got discharged. Fifteen days later, the patient had developed another episode of acute urinary retention and visited another outside hospital where channel transurethral resection of prostate (TURP) was done. He was also diagnosed to have essential hypertension 2 months ago.

At the time of admission in the medicine ward, physical examination revealed pallor, bilateral parotid enlargement and left-ear serous discharge. He was febrile (temperature 101 oF) and had tachypnoea (respirations 28/min); blood pressure was 160/90 mmHg. Physical examination, chest radiograph and computed tomography (CT) of the chest revealed soft tissue lesion with cavitation on the right side, bilateral pleural effusion [Figure 1]. Review of histopathological examination report following TURP issued by the outside hospital was suggestive of chronic prostatitis. The specimen block and slides could not be obtained from the outside hospital for review at our institute. Further laboratory testing revealed normocytic normochromic anaemia (haemoglobin 6.6 g/dL), neutrophilic leucocytosis (total leucocyte count 13,100 cells/mm3; polymorphs 87%) and elevated erythrocyte sedimentation rate (110 mm at the end of the 1st hour). Serum creatinine was elevated (2.69 mg/dL). Sputum Xpert MTB/RIF®, bacterial and fungal cultures tested negative. The patient was started on empirical antibiotics and other supportive treatment. Urinalysis showed active urinary sediment. Flexible fibreoptic bronchoscopy showed alveolar haemorrhages. Bronchoalveolar lavage fluid Xpert MTB/RIF® tested negative; cytopathological examination did not reveal malignant cells. Positron emission tomography-CT showed increased activity in the bilateral parotid glands, left lacrimal gland, lesion in the left lung, mediastinal lymph nodes, right kidney and prostate. CT-guided biopsy from the lesion was suggestive of granulomatous vasculitis [Figure 2] and [Figure 3]. Cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) tested positive. The patient was diagnosed to have GPA as per the American College of Rheumatology/European League Against Rheumatism provisional 2017 classification criteria for GPA[5] (C-ANCA positive = 5 points; cavity on chest imaging = 2 points; granuloma on biopsy = 3 points and hearing loss = 1 point; total score 11). He was treated with renal replacement therapy, intravenous pulse methyl prednisolone and cyclophosphamide. Hypoxia due to recurrent alveolar haemorrhages mandated tracheal intubation and mechanical ventilatory support; five sessions of plasmapheresis was also given. As these measures did not achieve remission, rituximab was started. The patient developed critical illness neuropathy during the course. On the 36th day of admission, the patient developed septic shock and died due to refractory shock.
Figure 1: NCCT thorax (mediastinal window) in prone position showing soft tissue lesion with cavity on the right side (arrow) and bilateral pleural effusion (asterisk)
NCCT = Non-contrast-enhanced computed tomography


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Figure 2: Photomicrograph of CT-guided lung biopsy specimen showing necrosis with karyorrhectic debris and hyalinisation (Haematoxylin and eosin, ×100)
CT = Computed tomography


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Figure 3: Photomicrograph of CT-guided lung biopsy showing fibrocollagenous stroma with prominent capillary sized vessels with proliferating dense intervening lymphocytic collections and fibrosis (Haematoxylin and eosin, ×400)
CT = Computed tomography


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  Discussion Top


GPA is an inflammatory disease with systemic involvement characterised histopathologically by the presence of granulomas, necrosis and vasculitis. GPA is a rare disease of unknown aetiology. The mean age of diagnosis of GPA is 40 years with a wide range.[6] Both genders are equally affected. GPA typically affects the upper and lower airways along with kidney. Autoimmune antibodies such C-ANCA are frequently associated with GPA.

Pulmonary involvement in GPA typically appears as bilateral, multiple, nodular cavitary infiltrates, which on biopsy reveal the typical necrotising granulomatous vasculitis. Upper airways typically reveal inflammation, necrosis and formation of granulomas with or without vasculitis. In the initial stages, renal involvement is characterised by a focal and segmental glomerulitis which may evolve into a rapidly progressive crescentic glomerulonephritis. Renal biopsy rarely reveals granuloma formation. Apart from the classical sites of organ involvement, upper and lower respiratory tracts and kidney, any organ can be affected with granuloma, vasculitis or both.

Prostatic involvement in GPA is rare.[7] Prostatic involvement is usually encountered in the context of systemic involvement. Very rarely, prostatic involvement has been reported as the primary manifestation of the disease.[8] In a retrospective analysis[9] of 11 patients with urogenital Wegener's from France, only two patients presented with acute urinary retention. The other causes of granulomatous prostatitis such as Mycobacteria, fungi and spirochetes, the Brucellaceae family, and non-infectious causes such as sarcoidosis should be excluded.[10]

In our patient, prostatic abscess was documented when the first episode of acute urinary retention had occurred; thereafter, following the second episode of acute urinary retention, the patient had undergone channel TURP, and histopathological examination revealed chronic prostatitis. There was no mention regarding granulomatous prostatitis in this report.

Therefore, we could not establish as to whether the occurrence of prostatic abscess was merely an association, or was due to GPA in this patient. Our case highlights the fact that when a 50-year-old male patient presents with acute urinary retention, such a patient should be evaluated for causes other than benign prostatic hypertrophy (BPH) for acute urinary retention as 50 years is an early age for classical BPH to occur. Accordingly, a high index of suspicion for other causes should always be considered when working up such a patient.

The diagnosis of GPA is established by the demonstration of necrotising granulomatous vasculitis on tissue biopsy in a patient with compatible clinical features. The specificity of a positive antiproteinase-3 ANCA for GPA is very high, especially if active glomerulonephritis is present. However, the presence of ANCA should be adjunctive to biopsy.

GPA is a serious disease, which has nearly always fatal outcome in the absence of treatment. The combination of glucocorticoids and immunosuppressants is the mainstay of treatment. Treatment decisions are based on severity of the initial manifestations, presence of comorbidities and coexisting infections. Treatment includes an induction phase, in which the disease is put into remission, and lasts about 3–6 months according to the clinical response. The maintenance phase must follow the initial phase to consolidate the remission and limit the risk of relapse. Relapses during GPA occur frequently. One-fourth of the patients relapse within 2 years of the diagnosis, and over half relapse within 5 years.[11] A higher relapse rate of GPA has been reported which is associated with chronic nasal carriage of Staphylococcus aureus, however, there is no evidence for a role of this organism in the pathogenesis of the disease.

Variable clinical manifestations of GPA due to its multisystem nature often lead to difficulty in the early diagnosis and treatment of this potentially treatable vasculitis. The disease has been associated with significant mortality and morbidity, if untreated. Considering the morbidity and mortality of this progressive vasculitis, knowledge of the various modes of presentation is the key to early diagnosis and treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Alladi Mohan is an Editor of Journal of Clinical and Scientific Research. The other authors are faculty members/research scholars of Sri Venkateswara Institute of Medical sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with peer review handled independently of these faculty and their research groups.



 
  References Top

1.
Mohammad AJ, Jacobsson LT, Westman KW, Sturfelt G, Segelmark M. Incidence and survival rates in Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and polyarteritis nodosa. Rheumatology (Oxford) 2009;48:1560-5.  Back to cited text no. 1
    
2.
Woywodt A, Haubitz M, Haller H, Matteson EL. Wegener's granulomatosis. Lancet 2006;367:1362-6.  Back to cited text no. 2
    
3.
Leavitt RY, Fauci AS, Bloch DA, Michel BA, Hunder GG, Arend WP, et al. The American College of Rheumatology 1990 criteria for the classification of Wegener's granulomatosis. Arthritis Rheum 1990;33:1101-7.  Back to cited text no. 3
    
4.
Huong DL, Papo T, Piette JC, Wechsler B, Bletry O, Richard F, et al. Urogenital manifestations of Wegener's granulomatosis. Medicine 1995;74:152-61.  Back to cited text no. 4
    
5.
Craven A, Robson J, Ponte C, Grayson PC, Suppiah R, Judge A, et al. ACR/EULAR-endorsed study to develop diagnostic and classification criteria for vasculitis (DCVAS). Clin Exp Nephrol 2013;17:619-21.  Back to cited text no. 5
    
6.
Gubbels SP, Barkhuizen A, Hwang PH. Head and neck manifestations of Wegener's granulomatosis. Otolaryngol Clin N Am 2003;36:685-705.  Back to cited text no. 6
    
7.
Stillwell TJ, DeRemee RA, McDonald TJ, Weiland LH, Engen DE. Prostatic involvement in Wegener's granulo-matosis. J Urol 1987;138:1251-3.  Back to cited text no. 7
    
8.
Gunnarsson R, Omdal R, Kjellevold KH, Ellingsen CL. Wegener's granulomatosis of the prostate gland. Rheumatol Int 2004;24:120-2.  Back to cited text no. 8
    
9.
Dufour JF, Le Gallou T, Cordier JF, Aumaître O, Pinède L, Aslangul E, et al. Urogenital manifestations in Wegener granulomatosis: A study of 11 cases and review of the literature. Medicine (Baltimore) 2012;91:67-74.  Back to cited text no. 9
    
10.
Stillwell TJ, Engen DE, Farrow GM. The clinical spectrum of granulomatous prostatitis: A report of 200 cases. J Urol 1987;138:320-3.  Back to cited text no. 10
    
11.
Mukhtyar C, Flossmann O, Hellmich B, Bacon P, Cid M, Cohen-Tervaert JW, et al. Out-comes from studies of antineutrophil cytoplasm antibody associated vasculitis: A systematic review by the European League Against Rheumatism systemic vasculitis task force. Ann Rheum Dis 2008;67:1004-10.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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