Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:11

Granulomatous Vasculitis 649

➣Wegener’s granulomatosis & polyarteritis nodosa

➣Central retinal artery occlusion, retinal detachment, glaucoma

➣Thyroid disease

➣Polymyositis, SLE, rheumatoid arthritis

➣Arterial fibrodysplasia

■WG, CS

➣Chronic sinusitis

➣Polyarteritis nodosa; microscopic polyangiitis

➣Fungal, bacterial diseases; syphilis

➣SLE

management

What to Do First

■Assess extent & severity of vascular disease by history & physical

exam; angiography especially in suspected TA

■Control blood pressure

■W/ impending organ damage (eg, visual loss, evolving stroke), begin

immediate “pulse” steroids (methylprednisolone, 1 g/d qd×3).

■Ophthalmologic consultation in GCA (eye disease often unilateral

initially, but may soon involve the other eye)

■ENT consultation in WG

specific therapy

■GCA

➣Prednisone is usually dramatically effective w/in 2–3 days. Taper

slowly.

■TA, WG, CS

➣Prednisone, tapering slowly over months, usually sufficient for

TA or CS

➣Cyclophosphamide IV to induce remission in WG, then orally

➣Methotrexate may suffice for remission induction in milder or

controlled WG

➣Trimethoprim-sulfamethoxazole may suffice in pts w/ WG con-

fined to the upper airways; should be considered even in systemic

disease

➣Other options include mycophenolate mofetil, azathioprine

Side Effects & Contraindications

■As in nongranulomatous vasculitis