Ursea et al.

Journal of Ophthalmic Inflammation and Infection (2015) 5:1

DOI 10.1186/s12348-014-0033-9

BRIEF REPORT

Open Access

The role of conjunctival biopsy in the diagnosis of

granulomatosis with polyangiitis
Roxana Ursea1*, Dawn De Castro2, Trent J Bowen3 and Chi-Chao Chan4

Abstract
Background: The purpose of this study is to describe a patient who was diagnosed with granulomatosis with
polyangiitis based on conjunctival biopsy. This study is a case report and review of the literature.
Findings: A 48-year-old Caucasian woman presented with a 2-week history of a left eye peripheral corneal ulcer
with adjacent conjunctivitis and a 4-month history of a non-resolving productive cough. Given her elevated serum
perinuclear antineutrophil cytoplasmic antibody (P-ANCA) and erythrocyte sedimentation rate (ESR) levels as well as
a chest computed topography (CT) that showed bilateral patchy infiltrates, suspicion of limited granulomatosis with
polyangiitis with lung and ocular involvement was high. Because bronchoalveolar lavage was nondiagnostic for
granulomatous disease, conjunctival biopsy was initially attempted in order to avoid a more invasive lung biopsy.
The conjunctival biopsy revealed mixed subacute inflammatory mediators and vasculitis consistent with granulomatosis
with polyangiitis.
Conclusions: Conjunctival biopsy may be a valuable, minimally invasive method for diagnosing systemic granulomatosis
with polyangiitis.
Keywords: Conjunctivitis; Cornea; Ulceration; Biopsy; Granulomatosis with polyangiitis

Findings
Background

Granulomatosis with polyangiitis is a rare, potentially

life-threatening primary systemic vasculitis of unknown
etiology. It was first described in 1931 by Heintz Klinger,
a medical student, as a form of polyarteritis nodosa [1],
but the clinical features were more fully delineated in
1937 by Frederick Wegener and the disease was also
known as Wegener's granulomatosis [2]. The prevalence
of granulomatosis with polyangiitis in the United States
has been estimated at nearly 3 cases per 100,000 [3]. It is
a multisystem inflammatory disease characterized in its
complete form by necrotizing granulomatous inflammation of the upper and lower respiratory tracts, systemic
vasculitis predominantly affecting small vessels, and
focal glomerulonephritis [4-6]. Patients without renal involvement have the limited form of the disease [4,7-10].
Ocular manifestations are thought to be relatively
common and occur in approximately 50% (range: 28% to
* Correspondence: roxanaursea@hotmail.com
1
Department of Ophthalmology and Vision Science, College of Medicine,
University of Arizona, Tucson, AZ 85711, USA
Full list of author information is available at the end of the article

87%) of cases of generalized granulomatosis with polyangiitis [11,12]. Furthermore, ophthalmic disease may be
the presenting symptom in 8% to 16% of patients
[12,13]. Almost any ocular or adnexal tissue can be affected. According to Harman and Margo [14], the most
common findings are proptosis, described in nearly one
fifth of patients, as well as keratoscleritis. Proptosis can
result either from primary orbital involvement or secondarily from extensive sinusitis. Other common ocular
manifestations of granulomatosis with polyangiitis include conjunctivitis (4% to 15%) [4,13], episcleritis, scleritis, retinal and optic nerve vasculitis, nasolacrimal duct
obstruction, uveitis, and dacryocystitis.
The diagnostic workup of granulomatosis with polyangiitis includes laboratory tests, imaging studies, and biopsy of affected tissues. Testing for serum antineutrophil
cytoplasmic antibodies (ANCAs) has significant value in
the diagnosis of Wegener's as well as other systemic vasculitides. Although cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA) testing in Wegener's has a
sensitivity of 85%, perinuclear antineutrophil cytoplasmic antibody (P-ANCA) testing has a much lower sensitivity of 10% [15].

2015 Ursea et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.

Ursea et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:1

While biopsy is an integral component of the diagnostic workup, the classic pathologic triad of parenchymal
necrosis, vasculitis, and granulomatous inflammation is
not commonly seen in extrapulmonary sites, with 91%
of open lung biopsies yielding positive results [4] compared to 54% of orbital biopsies [16]. Only a few case reports have been published in the literature on the role of
conjunctival biopsy in the diagnosis of systemic granulomatosis with polyangiitis [17-20]. Furthermore, to date,
there have been no publications regarding the diagnosis
of Wegener's based on conjunctival biopsy in the setting
of elevated P-ANCA titers.
Methods and results
Case report

A 48-year-old Caucasian woman presented with a 2week history of left eye redness and pain. She had initially been treated by a local emergency room physician
with ciprofloxacin 0.3% ophthalmic solution twice daily,
which after 4 days did not alleviate her symptoms. Her
primary care physician subsequently diagnosed her with
allergic conjunctivitis and instructed her to stop the
antibiotic drops and start topical allergy medications.
When her symptoms worsened, the patient was placed
on erythromycin ophthalmic ointment three times daily
and referred to a cornea specialist in the community.
This specialist diagnosed her with a left eye peripheral
corneal ulcer and immediately referred her to the authors for further evaluation and treatment.
This patient's past medical history was significant for
symptomatic cholelithiasis, mild hypertension, and a 4month history of recurrent left lower lobe pneumonia
for which her primary care physician had been treating
her with multiple courses of cephalexin 500 mg orally
three times daily as well as oral montelukast, a fluticasone inhaler, and an albuterol inhaler. Despite mild improvement in response to this regimen, her symptoms
persisted. Computed topography (CT) imaging of the
thorax with contrast was consequently performed, which
was significant for left lower lobe lateral and posteromedial basilar segment patchy infiltrates that were suggestive of primary granulomatous disease, and she was
referred to a pulmonologist. Bronchoalveolar lavage was
negative for acid-fast bacilli and fungi and was nondiagnostic with regard to granulomatous disease.
On presentation to the authors, the patient reported
redness and itchiness of the left eye with severe photophobia but no discharge. Her uncorrected vision was 20/
20 right eye and 20/25 left eye. Her pupils were equally
round and reactive to light with no afferent pupillary defect. Intraocular pressure measured 14 mmHg right eye
and 11 mmHg left eye. Slit lamp examination of the
right eye was within normal limits, and that of the left
eye revealed 2+ left upper lid edema and a 2.2 0.8 mm

Page 2 of 5

corneal ulcer with rolled edges located at the limbus at 3

o'clock. There was 1+ diffuse conjunctival injection with
3+ chemosis and prominent tortuous vessels adjacent to
the corneal ulcer (Figure 1). There was also a mild anterior chamber reaction with 1+ cells and no flare. The rest
of the ocular examination, including dilated funduscopic
exam, was within normal limits for both eyes. Anterior segment optical coherence topography (AS-OCT) was performed, which was significant for corneal thinning in the
area of the ulcer, with the thinnest site measuring 560 m
(Figure 2), as well as thickening of the adjacent conjunctiva
with cystic spaces and few central keratic precipitates.
Cultures were taken from the left eye corneal ulcer.
Blood tests revealed a normal white blood cell count
with a slightly elevated (6%) eosinophilic component, a
normal hemoglobin level, and a normal platelet count.
Erythrocyte sedimentation rate (ESR) was mildly elevated at 25. P-ANCA level (myeloperoxidase, MPO) was
elevated at 21 (positive if 1.0). C-ANCA (proteinase 3,
PR3) was negative. Rheumatoid factor level was elevated
at 326, while anti-dsDNA antibodies and antinuclear
antibodies (ANA) were negative. No casts or hematuria
was noted on urine sedimentation analysis.
The patient was immediately started on gatifloxacin
0.3% ophthalmic solution four times daily in the left eye.
Fortified vancomycin and tobramycin were later added,
which were initially used every hour and gradually tapered to four times daily.
Minimal improvement was noted on clinical exam after 4
days of intensive topical antibiotic therapy, and corneal cultures were negative for bacterial, fungal, and viral organisms.
There was a high suspicion of granulomatosis with polyangiitis given her elevated P-ANCA and ESR levels, as well as
the patient's persistent pulmonary symptoms and chest CT
findings suggestive of granulomatous disease. As above, her
bronchoalveolar lavage was nondiagnostic, and therefore, a
more definitive diagnostic approach was sought.
Although open lung biopsy was considered in this
patient's case, it was suggested that conjunctival biopsy
first be attempted as a less invasive procedure. This biopsy
was performed, and results were significant for diffuse infiltration of polymorphonuclear leukocytes (PMNs), eosinophils, lymphocytes, and macrophages in the substantia
propria (Figure 3a). Many T- and B-lymphocytes, CD80+
cells (activated B cells and monocytes), and M2 (CD163+)
macrophages were surrounding dilated blood vessels
(Figure 3b,c). The diagnosis of the conjunctival biopsy
showed severe subacute inflammation with aggregates
of CD68+ macrophages (granulomatous formation) and
vasculitis (Figure 3d), findings consistent with granulomatosis with polyangiitis.
These histopathological and immunopathological findings, together with the clinical signs and symptoms,
treatment, and long-term prognosis of this rare disease,

Ursea et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:1

Page 3 of 5

Figure 1 External and slit lamp photos of the left eye showing corneal ulceration.

were discussed with the patient. The topical antibiotic

drops were stopped, and the patient was referred to her
primary physician for long-term systemic management.
The patient had no recurrence of keratitis or uveitis at 1
and 3 months follow-up in the ophthalmology clinic.
Discussions

The diagnosis of granulomatosis with polyangiitis or

Wegener's is dependent not only solely on biopsy but
also on the appropriate clinical presentation in conjunction with laboratory tests and imaging studies, namely
chest radiography to rule out infiltrates or nodules. With
regard to laboratory investigation, serum ANCA testing
for granulomatosis with polyangiitis had become an essential component of the workup since the 1980s [21].
When neutrophils are fixed in alcohol, two different immunofluorescent patterns emerge - a diffuse granular
fluorescence of the cytoplasm (i.e., C-ANCA) or a predominantly perinuclear pattern of staining (i.e., P-ANCA).
The C-ANCA pattern of staining is most often directed

against proteinase-3, and the P-ANCA pattern against

myeloperoxidase. The sensitivity of C-ANCA has been reported to be as high as 85% to 96% in patients with
complete Wegener's, but drops to 80% when including patients with limited disease. The P-ANCA pattern is considered an insensitive marker of Wegener's because it is
only positive in 10% of patients with the disease [15]. Our
patient demonstrated an elevated P-ANCA titer with a
negative C-ANCA test and is therefore considered a relatively atypical case of granulomatosis with polyangiitis.
Ophthalmic involvement in granulomatosis with polyangiitis is an important manifestation, and histological diagnosis is essential for the disease [22]. Conjunctivitis is
common and may be ulcerative, necrotic, and/or cicatricial [23]. In a recent review of 1,286 patients with systemic
necrotizing vasculitides, 214 (16.6%) had ocular involvement; conjunctivitis was the most common documented
finding of ocular presentation [24]. In this cohort, granulomatosis with polyangiitis was the most common disease
that manifests with ophthalmic involvement.

Figure 2 Anterior segment optical coherence tomography (Visante) of the affected left cornea showing significant peripheral thinning.
Top: anterior segment scan; bottom: angle view.

Ursea et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:1

Page 4 of 5

Figure 3 Histopathology and immunopathology of the conjunctival biopsy. (a) Severe conjunctival inflammation with prominent vasculitis
in the deep substantia propria (hematoxylin & eosin, original magnifications: upper left 100, upper right 200, lower 400). (b-d) Strong
immunoreactivities to T cells (CD3), B cells (CD20), macrophages (CD68), M2 macrophages (CD163), and costimulatory signal (CD80) (avidin-biotin
complex immunohistochemistry, original magnification: 400).

With regard to cases that were diagnosed based on biopsy of the conjunctiva in particular, there are only a
few case reports in the literature. Karakousis et al. [17]
described an 18-year-old boy with scleritis, refractory sinusitis, and an elevated C-ANCA titer. He was diagnosed with granulomatosis with polyangiitis after his
conjunctival biopsy revealed perivascular inflammation
with areas of necrosis. In addition, Toh et al. [18] reported a 61-year-old woman who presented with mild
proptosis, bulbar conjunctival ulceration adjacent to the
limbus, and central retinal artery occlusion, along with
marked nasal turbinate hypertrophy. Biopsy obtained
during her turbinectomy demonstrated non-specific acute
inflammation only, but when the margins of the conjunctival ulcer were biopsied, the histopathology showed
pauci-immune granulomatous inflammation consistent

with Wegener's. In another report [19], conjunctival biopsy in two patients with palpebral conjunctivitis revealed
granulomatous infiltration with focal vasculitis in one patient and mixed inflammatory cellular reaction in the
other. Finally, a 70-year-old man with cicatricial palpebral
conjunctival inflammation and secondary trichiasis and
marginal ectropion underwent palpebral conjunctival biopsy in order to rule out malignancy. The biopsy was significant for chronic granulomatous inflammation with
multinucleated giant cells and areas of perivascular inflammation consistent with Wegener's [20]. In general,
given the possible risk of surgically induced scleritis in
patients with serological and/or clinical evidence of collagen vascular disease, performing a biopsy should be a
well-thought-after decision. In our patient's case, given
her nondiagnostic CT and BAL, a definitive diagnosis

Ursea et al. Journal of Ophthalmic Inflammation and Infection (2015) 5:1

was imperative; the biopsy performed was able to elicit

a conclusive diagnosis showing granulomatous inflammation in the conjunctiva. The immunopathological
findings of CD80+ cells and M2 macrophages surrounding
conjunctival vessels are novel and suggest activated B cells
and monocytes that provide B7-1, a costimulatory signal
protein needed for autoreactive T cell activation. The data
support the important role for activated T cells in granulomatosis with polyangiitis [25,26].

Page 5 of 5

4.

5.

6.
7.
8.

Conclusions

Conjunctival biopsy is a relatively simple, minimally invasive means of supporting the diagnosis of granulomatosis
with polyangiitis. It can be considered as a possibility in
patients who present with conjunctivitis and in which biopsy of other involved organs such as the nasal passages,
lungs, or kidneys is contraindicated. Results of this type of
biopsy will likely not include the full classic histopathological triad but, when considered in combination with the
clinical presentation and other diagnostic findings, can be
strongly supportive of the diagnosis. Larger studies are
needed in order to more fully elucidate the diagnostic utility of conjunctival biopsy in patients with conjunctival involvement and suspected granulomatosis with polyangiitis.

9.
10.

11.

12.

13.
14.
15.

16.

Consent
The patient presented in this case report agreed and gave
her consent for the report to be published.
Competing interests
The authors declare that they have no competing interests.

17.

18.

19.

Authors' contributions
RU participated in the conception and design of this work, as well as the
writing of the manuscript. DDC participated in the writing of the manuscript.
CCC participated in the design of this work, the writing of the manuscript, and
the histopathologic preparation of the tissue and its evaluation. TJB participated
in the critical review. All authors read and approved the final manuscript.

20.

Acknowledgements
This brief report was an unfunded project.

22.

Author details
1
Department of Ophthalmology and Vision Science, College of Medicine,
University of Arizona, Tucson, AZ 85711, USA. 2Oculoplastics Service,
Massachusetts Eye and Ear Infirmary, Boston, MA 02114, USA. 3College of
Medicine, University of Arizona, Tucson, AZ 85711, USA. 4Immunopathology
Section, National Eye Institute, Bethesda, MD 20892, USA.

23.

Received: 2 September 2014 Accepted: 22 December 2014

25.

References
1. Klinger H (1931) Grenzformen der Periarteriitis nodosa. Frankf Z Pathol 4:45580
2. Wegener F (1937) Uber generalisierte septische Gefasserkrankungen. Verh
Disch Path Ges 29:20210
3. Kurkland LT, Hauser WA, Ferguson RH, Holley, KE (1969) Epidemiologic features
of diffuse connective tissue disorders in Rochester, Miss, 1951 through 1967,
with special reference to systemic lupus erythematosus. Mayo Clin Proc
44:64963

21.

24.

26.

Hoffman GS, Kerr GS, Leavitt RY, Hallahan CW, Lebovics RS, Travis WD, Fauci
AS (1992) Wegener granulomatosis: an analysis of 158 patients. Ann Intern
Med 116:48898
Leavitt RY, Fauci AS, Block DA, Michel BA, Hunder GG, Arend WP, Calabrese
LH, Fries JF, Lie JT, Lightfoot RW Jr, Masi AT, McShane DJ, Mills JA, Stevens
MB, Wallace SL, Zvaifler NJ (1990) The American College of Rheumatology
1990 criteria for the classification of Wegener's granulomatosis. Arthritis
Rheum 33:11017
McDonald JB, Edwards RW (1960) Wegener's granulomatosis: a triad. JAMA
173:12059
Carrington CB, Leibow AA (1966) Limited forms of angiitis and
granulomatosis of Wegener's type. Am J Med 41:497527
Cassan SM, Coles DT, Harrison EG Jr (1970) The concept of limited forms of
Wegener's granulomatosis. Am J Med 49:36679
Coutu RE, Klein M, Lessel S, Friedman E, Snider GL (1975) Limited form of
Wegener's granulomatosis: eye involvement as a major sign. JAMA 233:86871
Luqmani RA, Bacon PA, Beaman M, Scott DG, Emery P, Lee SJ, Howie AJ,
Richards N, Michael J, Adu D (1994) Classical versus non-renal Wegener's
granulomatosis. QJM 87:1617
Fauci AS, Haynes BF, Katz P, Wolff SM (1983) Wegener's granulomatosis:
prospective clinical and therapeutic experience with 85 patients for
21 years. Ann Intern Med 90:27990
Haynes BF, Fishman ML, Fauci AS, Wolff SM (1977) The ocular
manifestations of Wegener's granulomatosis: 15 years experience a review
of the literature. Am J Med 63:13141
Bullen CL, Liesegang TJ, McDonald TJ, DeRemee RA (1983) Ocular
complications of Wegener's granulomatosis. Ophthalmology 90:27990
Harman LE, Margo CE (1998) Reviews in medicine, Wegener's
granulomatosis. Surv Ophthalmol 42:45880
Kallenberg CG, Brouwer E, Weening JJ, Tervaert JW (1994) Anti-neutrophil
cytoplasmic antibodies: current diagnostic and pathophysiological potential.
Kidney Int 46:115
Kalina PH, Lie JT, Campbell RJ, Garrity JA (1992) Diagnostic value and limitations
of orbital biopsy in Wegener's granulomatosis. Ophthalmology 99:1204
Karakousis PC, Lee MS, Grostern RJ, Nichols CW (2002) The role of
conjunctival biopsy in the diagnosis of Wegener's granulomatosis: a case
report. Can J Ophthalmol 37:17981
Toh TY, Cooper RL, Parker A, Vote BJ (2006) Wegener's granulomatosis
presenting with painless bulbar-conjunctival ulcer and central retinal artery
occlusion. Clin Experiment Ophthalmol 34:513
Jordan DR, Addison DJ (1994) Wegener's granulomatosis: eyelid and
conjunctival manifestations as the presenting feature in two individuals.
Ophthalmology 101:6027
Jordan DR, Zafar A, Brownstein S, Faraji H (2006) Cicatricial conjunctival
inflammation with trichiasis as the presenting feature of Wegener
granulomatosis. Ophthal Plast Reconstr Surg 22:6971
Van der Woude FJ, Rasmussen N, Lobatto S, Wiik A, Permin H, van Es LA,
van der Giessen M, van der Hem GK, The TH (1985) Autoantibodies against
neutrophils and monocytes: tool for diagnosis and marker of disease
activity in Wegener's granulomatosis. Lancet 1:4259
Tarabishy AB, Schulte M, Papaliodis GN, Hoffman GS (2010) Wegener's
granulomatosis: clinical manifestations, differential diagnosis, and
management of ocular and systemic disease. Surv Ophthalmol 55(5):42944
Robinson MR, Lee SS, Sneller MC, Lerner R, Langford CA, Talar-Williams C,
Cox TA, Chan CC, Smith JA (2003) Tarsal-conjunctival disease associated
with Wegener's granulomatosis. Ophthalmology 110:177080
Rothschild PR, Pagnoux C, Seror R, Brzin AP, Delair E, Guillevin L (2012)
Ophthalmologic manifestations of systemic necrotizing vasculitides at
diagnosis: a retrospective study of 1286 patients and review of the
literature. Semin Arthritis Phem 42:50714
Moosig F, Csernok E, Wang G, Gross WL (1998) Costimulatory molecules in
Wegener's granulomatosis (WG): lack of CD28 and preferential up-regulation of
its ligands B7-1 (CD80) and B7-2 (CD86) on T cells. Clin Exp Immunol 114:1138
Berden AE, Kallenberg CG, Savage CO, Yard BA, Abdulahad WH, de Heer E,
Bruijn JA, Bajema IM (2009) Cellular immunity in Wegener's granulomatosis.
Characterizing T lymphocytes. Arthritis Rheumatisum 60:157887