title: [Clinical thinking and decision-making in practice. A patient with arthritis, skin lesions and a perforated nasal septum].
abstract: A man aged 38 years had arthritis, skin lesions and a perforation of the nasal septum. He had slight deterioration of renal function and a few granular casts in the urine. Antineutrophil cytoplasmic antibody and other immune parameters were normal. A biopsy of the nasal septum did not show granulomatous lesions. The differential diagnosis on the available clinical grounds could be narrowed to Wegener's disease, Henoch-Schönlein vasculitis or microscopic polyangiitis. A biopsy of the skin showed leukocytoclastic vasculitis, with IgA and IgM depositions compatible with Henoch-Schönlein vasculitis. A renal biopsy showed small segmental necrotising lesions of the glomerular capillaries, with minimal extracapillary proliferation; immune fluorescence did not detect any significant depositions. The picture was compatible with Wegener's disease. A nasal septum defect together with glomerulonephritis, which could be suspected from only minimal abnormalities in the urine, is almost conclusive for the diagnosis.
authors.affiliation: Academisch Ziekenhuis, Utrecht. g.b.braam@digd.azu.nl
authors.forename: B
authors.initials: B
authors.lastname: Braam
authors.forename: R
authors.initials: R
authors.lastname: Goldschmeding
authors.forename: R H
authors.initials: RH
authors.lastname: Derksen
authors.forename: B S
authors.initials: BS
authors.lastname: van Asbeck
mesh_terms: D000328:Adult; D001168:Arthritis / Q000209:etiology*; D003937:Diagnosis, Differential; D005921:Glomerulonephritis / Q000150:complications* / Q000473:pathology; D014890:Granulomatosis with Polyangiitis / Q000150:complications / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D011695:IgA Vasculitis / Q000175:diagnosis; D007668:Kidney / Q000473:pathology*; D008297:Male; D009300:Nasal Septum / Q000473:pathology*; D012867:Skin / Q000473:pathology*; D014657:Vasculitis / Q000175:diagnosis