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A 19-year-old man presented with a 5-day history of vomiting and passing dark urine. He gave a 6-month history of arthralgias and joint swelling, particularly affecting larger joints. He had recurrent epistaxis and recent episcleritis. He was noted to be thin and pale, with conjunctival suffusion and deformity of his nasal bridge. He was normotensive (115/60 mm Hg) and apyrexic (35.5°C). Blood parameters revealed normocytic normochromic anemia and acute renal failure. Renal biopsy showed extensive crescent formation with segmental necrotizing inflammation and fibrin deposition of the glomeruli. cANCA was strongly positive (titer 1280; ELISA PR3+) and he was diagnosed with Wegener granulomatosis. He commenced hemodialysis, steroids, and oral cyclophosphamide, and he was discharged home.One month later, he presented with acute onset of throbbing headaches associated with nausea and photophobia, as well as recurrent generalized seizures necessitating sedation and intensive care unit admission. He was pyrexic (38°C) and hypertensive (165/95 mm Hg). Renal indices were abnormal (urea 29.1mmol/L; creatinine 755 μmol/L; potassium 5.4 mmol/L). Clinical examination revealed no focal neurologic deficits.Initial noncontrast brain CT was normal. Brain MRI with gadolinium showed small, ill-defined, nonenhancing high signal areas measuring 5–20 mm in several locations (figure, A).Figure Brain MRIs(A) Axial fluid-attenuated inversion recovery (FLAIR) brain MRI showing small, ill-defined, nonenhancing high signal areas measuring 5–20 mm in several locations. (B) Axial FLAIR brain MRI showing progression in radiologic changes over a further 1-month interval. Bright confluent lesions are seen in both parieto-occipital regions. (C) Axial FLAIR brain MRI showing marked progression …

Clinical Reasoning: A case of Wegener granulomatosis complicated by seizures and headaches