Case 28-1998

Abstract

A 64-year-old man was admitted to the hospital because of a productive cough during treatment for suspected Wegener's granulomatosis.The patient had been well until seven months earlier, when he began to have unsteadiness and rightsided tinnitus, with constant maxillary, nasal, frontal, and temporal pain, which was more prominent on the right side. Treatment with prednisone (40 mg daily) was begun, with considerable improvement of the headache. A biopsy of the left temporal artery showed no evidence of arteritis. Two months before admission, a test for antineutrophil cytoplasmic antibody (ANCA) was positive, with a perinuclear pattern of staining (P-ANCA), and an enzyme-linked immunosorbent assay was positive for antibodies to myeloperoxidase at a titer of 18 U (normal value, less than 2.8). Three weeks later, another ANCA test was positive, with a P-ANCA pattern and an antimyeloperoxidase-antibody titer of 6.8 U.Three weeks before the current admission, the patient was first admitted to this hospital because of right facial weakness with dysarthria.The results of an examination were normal except for an almost complete right peripheral facial palsy and sensorineural hearing loss in the right ear.The urine was normal. The levels of urea nitrogen, creatinine, uric acid, bilirubin, calcium, phosphorus, magnesium, and aspartate aminotransferase were normal. The results of other laboratory tests are shown in Tables 1 and 2. Radiographs of the chest showed scarring or subsegmental atelectasis at the base of the left lung. A computed tomographic (CT) scan of the head, obtained without the administration of contrast material because of a reported allergy, revealed mucosal thickening of the left maxillary sinus and a soft-tissue mass in the right petrous apex. A CT scan of the temporal bones (Fig. 1) revealed a soft-tissue mass with bony destruction involving the right petrous apex and the petrous carotid canal and extending along the right aspect of the clivus and the floor of the middle cranial fossa. A magnetic resonance imaging (MRI) study of the brain (Fig. 2), performed be-T ABLE 1. H EMATOLOGIC L ABORATORY V ALUES .