WEGENER
GRANULOMATOSIS”
Unusual Cause of Necrotizing MARJORIE
FOWLER,
SCOTT A. MARTIN, WILLIAM ROBERT
M.D. M.D.
T. BOWLES, PACKMAN,
ANNA-LUISE
Urethritis
M.D. M.D.
KATZENSTEIN,
M.D.
From the Divisions of Surgical Pathology, Medicine, and Urology, Washington University School of Medicine, St. Louis, Missouri
ABSTRACT - We report a case of Wegener granulomatosis presenting as a destructive urethral mass. The initial clinical impression was carcinoma, and a urinary diverting procedure was considered before the correct diagnosis was established. The importance of recognizing this unusual disease and its dramatic response to appropriate therapy are emphasized+
Wegener granulomatosis is a systemic vasculitis which involves primarily the lung and upper respiratory tract and is often associated with a focal glomerulonephritis. Involvement of other organ systems especially skin and central nervous system may occur, but lesions in the lower genitourinary tract are unusual. We report the development of a necrotizing urethritis due to Wegener granulomatosis two years following lung involvement at a time when there was no evidence of pulmonary recurrence or other extrapulmonary lesions. The difficulties in diagnosing this unusual disease are discussed, and dramatic response to appropriate therapy is emphasized. Case Report A fifty-six-year-old Caucasian woman was admitted to the urology service on October 10, 1977, for evaluation of dysuria and a urethral discharge of six months’ duration. She had experienced one episode of hematuria six weeks prior to admission. Her past medical history in*Supported
66
in part by USPHS
Grant 5 TO1 CA5201-08.
eluded a hysterectomy for leiomyomas in 1965 and an anterior and posterior vaginoplasty in 1976. In 1975, she underwent a right lower lobectomy at another hospital for an asymptomatic density which had been detected on a routine chest film. The diagnosis of “necrotizing granulomatous inflammation” was made, and she received no further treatment. She denied any history of asthma or allergies. On physical examination a 3 by 4-cm. indurated erythematous, periurethral mass was found which exuded pus from the urethral meatus on pressure. Cystoscopy revealed a shaggy and necrotic appearance to the entire urethra. The bladder neck was elevated and edematous; the remaining bladder mucosa was normal. Excretory urography showed a defect on the left side of the bladder base which suggested an extrinsic mass. Urinalysis showed trace amounts of protein, and 20 red blood cells and 50 white blood cells per high-power field. Urine cultures were negative. The peripheral leukocyte count was 5,500 with 10 per cent eosinophils. No abnormalities were detected in the blood chemistries, including blood urea nitrogen and creatinine. A chest roentgenogram
UROLOGY
/ JULY 1979
/ VOLUME
XIV, NUMBER
1
demonstrated only changes referable to the previous thoracotomy. The clinical impression was periurethral carcinoma, and multiple biopsies were taken from the bladder neck, urethra, and periurethral soft tissues. Microscopic sections showed large irregularly shaped areas of necrosis surrounded by palisading histiocytes (Fig. 1). Eosinophils were abundant within the infiltrate and Charcot-Leydon crystals were present in the necrotic areas. The urethral mucosa was destroyed by the necrotizing inflammation in numerous places. No organisms were identified with special stains for acid-fast bacilli, fungi, or spirochetes. The diagnosis of acute and chronic inflammation with necrosis was made. 14, 1977, the patient was disOn October charged from the hospital on a regimen of trimethoprim-sulfamethoxazole (Septra), betamethazone dipropionate (Diprosone) ointment, and nitrofurazone (Furacin AC) urethral suppositories. No improvement occurred with these medications, and she was readmitted to 14, 1977, with comthe hospital on November plaints of dysuria, pain, and a serosanguineous urethral discharge. On physical examination the periurethral mass appeared larger than at the time of the previous admission. Cystoscopy again revealed necrosis along the entire length of the urethral mucosa. Necrotic urethral and periurethral soft tissue was excised, and microscopic examination showed an identical pathologic process to that observed in the previous biopsy material. The diagnosis of acute and chronic inflammation and granulomas with eosinophils was made. Because of the severity and the progression of the patient’s symptoms, urinary diversion was considered. The perplexing nature of the lesion clinically and the unusual histologic appearance of necrotizing granulomatous inflammation without identifiable organisms suggested the possibility of a granulomatous vasculitis and prompted us to review the material from the previous pulmonary resection. These sections of lung showed similar extensive necrotizing granulomatous inflammation with prominent palisading histiocytes, numerous eosinophils, and Charcot-Leydon crystals. Necrotizing vasculitis was found involving several vessels within the adjacent viable areas of parenchyma (Fig. 2). Stains for acid-fast bacilli and fungi were negative. These histologic findings were interpreted as Wegener granulomatosis. Subsequent sinus roentgenograms demonstrated
UROLOGY
i
IULY 1979
/ VOLUME
XIV, NUMBER
1
FIGURE 1. Photomicrograph of urethral lesion showing areas of necrosis (top halfi surrounded by palisading histiocytes (arrows). Adjacent infiltrate (bottom) is composed of lymphocytes, plasma cells, and numerous eosinophils. Urethral lumen would be at top. (Hemntoxylin and eosin, X 150).
bilateral maxillary sinusitis. Additional laboratory data at this time included an erythrocyte sedimentation rate of 45, and an absolute peripheral eosinophil count of 496. There was no clinical evidence of glomerulonephritis. Treatment with prednisone and cyclophosphamide was started, and after less than one week of therapy the patient’s symptoms abated dramatically, the urethral inflammatory mass had regressed to one-half its original size, and the erythrocyte sedimentation rate had dropped to 22. Comment Wegener granulomatosis is a necrotizing granulomatous disease of unknown origin. In its classic form there is necrotizing vasculitis in the upper respiratory tract and lung and a focal glomerulonephritis. l Other organ systems, particularly skin and nervous system, may be involved.* A limited form of the disease has been described in which glomerulonephritis is absent, although other extrapulmonary lesions may be present3
67
-
_ _ .___^ . -I_-
_
_ _.__ __._______ _.._.
Photomicrograph of pulmonary lesion. (A) Edge histiocytes (arrows) (hematoxylin and eosin, x 90). (B) Small injiltration and partial destruction of its wall by plasma cells, lamina is outlined in black by this stain. (Verhoeff-van Gieson, FIGURE
2.
Histologically in Wegener granulomatosis there are large areas of necrosis surrounded by palisading histiocytes, lymphocytes, and plasma cells. Multinucleated giant cells and eosinophils are found in variable numbers. The presence of a necrotizing vasculitis involving both small arteries and veins located in areas of viable tissue is necessary for the diagnosis. The pulmonary lesion in our patient was typical of Wegener granulomatosis. The diagnosis based on the biopsies of the urethral lesions alone was difficult, however, since the tissue was extensively necrotic and blood vessels were scarce in the small amount of viable tissue present. Involvement of the lower genitourinary tract may occur in Wegener granulomatosis but is 10 reuncommon. Yalowitz et al4 reviewed ported cases with prostatic involvement and presented one of their own. Contiguous spread to the bladder and urethra occurred in several of these patients. Primary urethral involvement by Wegener granulomatosis, as in our case, was reported by Matsuda et aL5 in a man who presented with penile necrosis. Unilateral ureteral
68
_ _____._ of necrotic region (right) lined by palisading artery showing obliteration of its lumen and lymphocytes, and eosinophils. lnternal elastic x 90.)
obstruction due to Wegener granulomatosis has been recently discussed. 6 In most of the reported cases of Wegener granulomatosis with lower genitourinary tract lesions there has been evidence of active disease elsewhere. Our case is different in that the urethral lesion developed two years after the appearance of the lung lesion and no other sites of active disease were evident. Delay in diagnosis occurred because the significance of the previous lung resection was not initially appreciated. Other types of vasculitides may occur in the lower genitourinary tract and should enter into the differential diagnosis. Allergic angiitis and granulomatosis (Churg-Strauss) has been reported in the prostate. ’ Patients with this disease have asthma and peripheral blood eosinophilia; lung, skin, and nervous system are the most common sites of involvement. Our patient had neither asthma nor an allergic history. Lymphomatoid granulomatosis, a recently described angiocentric lymphoproliferative disease occurring primarily in the lungs but often having widespread extrapulmonary manifestations,
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
may occur in the prostate and bladder.’ Histologically this lesion contains a primarily mononuclear infiltrate with atypical lymphoreticular cells; eosinophils, palisading histiocytes, and multinucleated giant cells are usually absent. Hypersensitivity angiitis related to sulfonamide therapy has been reported in the bladder.g Our patient gave no history of antibiotic therapy. Infection is a far more common cause of necrotizing granulomatous inflammation and must be excluded before diagnosing a vasculitis. Tuberculosis, atypical mycobacteriosis, lo various mycoses,” syphilis, or parasitic infection can have similar histologic appearances. In our patient no organisms were demonstrable either by culture or microscopic examination of the tissue. Other more unusual causes of granulomatous inflammation and necrosis which have been reported in the lower genitourinary tract include rheumatoid nodules, l2 eosinophilic granuloma, l3 Crohn disease, l4 Behcet disease,” foreign body reactions, and, rarely, urethral caruncles. These diseases were excluded in our case by a combination of clinical history and histologic features. Most patients with Wegener granulomatosis respond well to a combination of corticosteroids and cyclophosphamide therapy.2 In our patient, the tumor-like appearance of the lesion with partial urinary tract obstruction and progressive destruction of normal structures led to consideration of a urinary diversion procedure before the correct diagnosis was established. Her dramatic response to medical management was typical of Wegener granulomatosis and obviated surgical intervention. In summary, this case demonstrates a rare manifestation of Wegener granulomatosis, namely necrotizing urethritis with partial urinary obstruction. Diagnosis was delayed in this case because other features of Wegener granulomatosis were absent. A dramatic improvement occurred following institution of ap-
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
propriate therapy. The consideration of urinary diversion to alleviate this patient’s symptoms emphasizes the importance of recognizing genitourinary tract involvement by Wegener granulomatosis. Northwestern
*Memorial Hospital Passavant Room 300 Superior St. and Fairbanks Ct. Chicago, Illinois 60611 (DR. KA’IZENSTEIN)
References 1. Godman GC, and Churg J: Wegener’s granulomatosis, Arch. Pathol. 58: 533 (1954). 2. Fauci AS, and Wolff SM: Wegener’s granulomatosis. Studies in 18 patients and a review of the literature, Medicine 52: 535 (1973). 3. Carrington CB, and Liebow AA: Limited forms of angiitis and granulomatosis, Am. J. Med. 41: 497 (1966). 4. Yalowitz PA, Greene LF, Sheps SG, and Carlin MR: Wegener’s granulomatosis involving the prostate gland, J. Urol. 96: 801 (1966). 5. Matusda S, Mitsukawa S, I&i N, and Shivai M: A case of Wegener’s granulomatosis with necrosis of the penis, Tohoku J. Exp. Med. 118: 145 (1976). 6. Partridge REH, and Calvin RE: Necrotizing glomeruhtis and arteritis, pulmonary nodules and ureteral obstruction, N. Engl. J. Med. 297: 1164 (1977). 7. Chumbley LC, Harrison EG, and DeRemee RA: Allergic granulomatosis and angiitis (Churg-Strauss syndrome). Report and analysis of 30 cases, Mayo Clin. Proc. 52: 477 (1977). 8. Liebow AA, Carrington CB, and Friedman PJ: Lymphomatoid granulomatosis, Hum. Pathol. 3: 457 (1972). 9. Engel W, and McCormack L: Acute necrotizing angiitis of the bladder, J. Urol. 79: 230 (1958). 10. Lee LW, Burgher LW, Price EB, and Cassidy E: Granulomatous prostatitis. Association with isolation of Mycobacterium Kansasii and Mycobacterium fortuitum, J.A.M.A. 237: 2408 (1977). 11. Bissada NK, Finkbeiner AE, and Redman JF: Prostatic mycosis. Nonsurgical diagnosis and management, Urology 9: 327 (1977). 12. Berman HH, and Wilets AJ: Rheumatoid pseudotumor of urinary bladder simulating carcinoma, ibid. 9: 83 (1977). 13. Brown EW: Eosinonhilic zranuloma of the bladder. _ 1. Urol. 83: 665 (1960). 14. Kao MS, Paulson JD, and Askin FB: Crohn’s disease of the vulva, Obstet. Gynecol. 46: 329 (1975). 15. Carswell GF: A case of Behcet’s disease involving the bladder, Br. J. Urol. 48: 199 (1976). I
-
69
GRANULOMATOSIS”
Unusual Cause of Necrotizing MARJORIE
FOWLER,
SCOTT A. MARTIN, WILLIAM ROBERT
M.D. M.D.
T. BOWLES, PACKMAN,
ANNA-LUISE
Urethritis
M.D. M.D.
KATZENSTEIN,
M.D.
From the Divisions of Surgical Pathology, Medicine, and Urology, Washington University School of Medicine, St. Louis, Missouri
ABSTRACT - We report a case of Wegener granulomatosis presenting as a destructive urethral mass. The initial clinical impression was carcinoma, and a urinary diverting procedure was considered before the correct diagnosis was established. The importance of recognizing this unusual disease and its dramatic response to appropriate therapy are emphasized+
Wegener granulomatosis is a systemic vasculitis which involves primarily the lung and upper respiratory tract and is often associated with a focal glomerulonephritis. Involvement of other organ systems especially skin and central nervous system may occur, but lesions in the lower genitourinary tract are unusual. We report the development of a necrotizing urethritis due to Wegener granulomatosis two years following lung involvement at a time when there was no evidence of pulmonary recurrence or other extrapulmonary lesions. The difficulties in diagnosing this unusual disease are discussed, and dramatic response to appropriate therapy is emphasized. Case Report A fifty-six-year-old Caucasian woman was admitted to the urology service on October 10, 1977, for evaluation of dysuria and a urethral discharge of six months’ duration. She had experienced one episode of hematuria six weeks prior to admission. Her past medical history in*Supported
66
in part by USPHS
Grant 5 TO1 CA5201-08.
eluded a hysterectomy for leiomyomas in 1965 and an anterior and posterior vaginoplasty in 1976. In 1975, she underwent a right lower lobectomy at another hospital for an asymptomatic density which had been detected on a routine chest film. The diagnosis of “necrotizing granulomatous inflammation” was made, and she received no further treatment. She denied any history of asthma or allergies. On physical examination a 3 by 4-cm. indurated erythematous, periurethral mass was found which exuded pus from the urethral meatus on pressure. Cystoscopy revealed a shaggy and necrotic appearance to the entire urethra. The bladder neck was elevated and edematous; the remaining bladder mucosa was normal. Excretory urography showed a defect on the left side of the bladder base which suggested an extrinsic mass. Urinalysis showed trace amounts of protein, and 20 red blood cells and 50 white blood cells per high-power field. Urine cultures were negative. The peripheral leukocyte count was 5,500 with 10 per cent eosinophils. No abnormalities were detected in the blood chemistries, including blood urea nitrogen and creatinine. A chest roentgenogram
UROLOGY
/ JULY 1979
/ VOLUME
XIV, NUMBER
1
demonstrated only changes referable to the previous thoracotomy. The clinical impression was periurethral carcinoma, and multiple biopsies were taken from the bladder neck, urethra, and periurethral soft tissues. Microscopic sections showed large irregularly shaped areas of necrosis surrounded by palisading histiocytes (Fig. 1). Eosinophils were abundant within the infiltrate and Charcot-Leydon crystals were present in the necrotic areas. The urethral mucosa was destroyed by the necrotizing inflammation in numerous places. No organisms were identified with special stains for acid-fast bacilli, fungi, or spirochetes. The diagnosis of acute and chronic inflammation with necrosis was made. 14, 1977, the patient was disOn October charged from the hospital on a regimen of trimethoprim-sulfamethoxazole (Septra), betamethazone dipropionate (Diprosone) ointment, and nitrofurazone (Furacin AC) urethral suppositories. No improvement occurred with these medications, and she was readmitted to 14, 1977, with comthe hospital on November plaints of dysuria, pain, and a serosanguineous urethral discharge. On physical examination the periurethral mass appeared larger than at the time of the previous admission. Cystoscopy again revealed necrosis along the entire length of the urethral mucosa. Necrotic urethral and periurethral soft tissue was excised, and microscopic examination showed an identical pathologic process to that observed in the previous biopsy material. The diagnosis of acute and chronic inflammation and granulomas with eosinophils was made. Because of the severity and the progression of the patient’s symptoms, urinary diversion was considered. The perplexing nature of the lesion clinically and the unusual histologic appearance of necrotizing granulomatous inflammation without identifiable organisms suggested the possibility of a granulomatous vasculitis and prompted us to review the material from the previous pulmonary resection. These sections of lung showed similar extensive necrotizing granulomatous inflammation with prominent palisading histiocytes, numerous eosinophils, and Charcot-Leydon crystals. Necrotizing vasculitis was found involving several vessels within the adjacent viable areas of parenchyma (Fig. 2). Stains for acid-fast bacilli and fungi were negative. These histologic findings were interpreted as Wegener granulomatosis. Subsequent sinus roentgenograms demonstrated
UROLOGY
i
IULY 1979
/ VOLUME
XIV, NUMBER
1
FIGURE 1. Photomicrograph of urethral lesion showing areas of necrosis (top halfi surrounded by palisading histiocytes (arrows). Adjacent infiltrate (bottom) is composed of lymphocytes, plasma cells, and numerous eosinophils. Urethral lumen would be at top. (Hemntoxylin and eosin, X 150).
bilateral maxillary sinusitis. Additional laboratory data at this time included an erythrocyte sedimentation rate of 45, and an absolute peripheral eosinophil count of 496. There was no clinical evidence of glomerulonephritis. Treatment with prednisone and cyclophosphamide was started, and after less than one week of therapy the patient’s symptoms abated dramatically, the urethral inflammatory mass had regressed to one-half its original size, and the erythrocyte sedimentation rate had dropped to 22. Comment Wegener granulomatosis is a necrotizing granulomatous disease of unknown origin. In its classic form there is necrotizing vasculitis in the upper respiratory tract and lung and a focal glomerulonephritis. l Other organ systems, particularly skin and nervous system, may be involved.* A limited form of the disease has been described in which glomerulonephritis is absent, although other extrapulmonary lesions may be present3
67
-
_ _ .___^ . -I_-
_
_ _.__ __._______ _.._.
Photomicrograph of pulmonary lesion. (A) Edge histiocytes (arrows) (hematoxylin and eosin, x 90). (B) Small injiltration and partial destruction of its wall by plasma cells, lamina is outlined in black by this stain. (Verhoeff-van Gieson, FIGURE
2.
Histologically in Wegener granulomatosis there are large areas of necrosis surrounded by palisading histiocytes, lymphocytes, and plasma cells. Multinucleated giant cells and eosinophils are found in variable numbers. The presence of a necrotizing vasculitis involving both small arteries and veins located in areas of viable tissue is necessary for the diagnosis. The pulmonary lesion in our patient was typical of Wegener granulomatosis. The diagnosis based on the biopsies of the urethral lesions alone was difficult, however, since the tissue was extensively necrotic and blood vessels were scarce in the small amount of viable tissue present. Involvement of the lower genitourinary tract may occur in Wegener granulomatosis but is 10 reuncommon. Yalowitz et al4 reviewed ported cases with prostatic involvement and presented one of their own. Contiguous spread to the bladder and urethra occurred in several of these patients. Primary urethral involvement by Wegener granulomatosis, as in our case, was reported by Matsuda et aL5 in a man who presented with penile necrosis. Unilateral ureteral
68
_ _____._ of necrotic region (right) lined by palisading artery showing obliteration of its lumen and lymphocytes, and eosinophils. lnternal elastic x 90.)
obstruction due to Wegener granulomatosis has been recently discussed. 6 In most of the reported cases of Wegener granulomatosis with lower genitourinary tract lesions there has been evidence of active disease elsewhere. Our case is different in that the urethral lesion developed two years after the appearance of the lung lesion and no other sites of active disease were evident. Delay in diagnosis occurred because the significance of the previous lung resection was not initially appreciated. Other types of vasculitides may occur in the lower genitourinary tract and should enter into the differential diagnosis. Allergic angiitis and granulomatosis (Churg-Strauss) has been reported in the prostate. ’ Patients with this disease have asthma and peripheral blood eosinophilia; lung, skin, and nervous system are the most common sites of involvement. Our patient had neither asthma nor an allergic history. Lymphomatoid granulomatosis, a recently described angiocentric lymphoproliferative disease occurring primarily in the lungs but often having widespread extrapulmonary manifestations,
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
may occur in the prostate and bladder.’ Histologically this lesion contains a primarily mononuclear infiltrate with atypical lymphoreticular cells; eosinophils, palisading histiocytes, and multinucleated giant cells are usually absent. Hypersensitivity angiitis related to sulfonamide therapy has been reported in the bladder.g Our patient gave no history of antibiotic therapy. Infection is a far more common cause of necrotizing granulomatous inflammation and must be excluded before diagnosing a vasculitis. Tuberculosis, atypical mycobacteriosis, lo various mycoses,” syphilis, or parasitic infection can have similar histologic appearances. In our patient no organisms were demonstrable either by culture or microscopic examination of the tissue. Other more unusual causes of granulomatous inflammation and necrosis which have been reported in the lower genitourinary tract include rheumatoid nodules, l2 eosinophilic granuloma, l3 Crohn disease, l4 Behcet disease,” foreign body reactions, and, rarely, urethral caruncles. These diseases were excluded in our case by a combination of clinical history and histologic features. Most patients with Wegener granulomatosis respond well to a combination of corticosteroids and cyclophosphamide therapy.2 In our patient, the tumor-like appearance of the lesion with partial urinary tract obstruction and progressive destruction of normal structures led to consideration of a urinary diversion procedure before the correct diagnosis was established. Her dramatic response to medical management was typical of Wegener granulomatosis and obviated surgical intervention. In summary, this case demonstrates a rare manifestation of Wegener granulomatosis, namely necrotizing urethritis with partial urinary obstruction. Diagnosis was delayed in this case because other features of Wegener granulomatosis were absent. A dramatic improvement occurred following institution of ap-
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
propriate therapy. The consideration of urinary diversion to alleviate this patient’s symptoms emphasizes the importance of recognizing genitourinary tract involvement by Wegener granulomatosis. Northwestern
*Memorial Hospital Passavant Room 300 Superior St. and Fairbanks Ct. Chicago, Illinois 60611 (DR. KA’IZENSTEIN)
References 1. Godman GC, and Churg J: Wegener’s granulomatosis, Arch. Pathol. 58: 533 (1954). 2. Fauci AS, and Wolff SM: Wegener’s granulomatosis. Studies in 18 patients and a review of the literature, Medicine 52: 535 (1973). 3. Carrington CB, and Liebow AA: Limited forms of angiitis and granulomatosis, Am. J. Med. 41: 497 (1966). 4. Yalowitz PA, Greene LF, Sheps SG, and Carlin MR: Wegener’s granulomatosis involving the prostate gland, J. Urol. 96: 801 (1966). 5. Matusda S, Mitsukawa S, I&i N, and Shivai M: A case of Wegener’s granulomatosis with necrosis of the penis, Tohoku J. Exp. Med. 118: 145 (1976). 6. Partridge REH, and Calvin RE: Necrotizing glomeruhtis and arteritis, pulmonary nodules and ureteral obstruction, N. Engl. J. Med. 297: 1164 (1977). 7. Chumbley LC, Harrison EG, and DeRemee RA: Allergic granulomatosis and angiitis (Churg-Strauss syndrome). Report and analysis of 30 cases, Mayo Clin. Proc. 52: 477 (1977). 8. Liebow AA, Carrington CB, and Friedman PJ: Lymphomatoid granulomatosis, Hum. Pathol. 3: 457 (1972). 9. Engel W, and McCormack L: Acute necrotizing angiitis of the bladder, J. Urol. 79: 230 (1958). 10. Lee LW, Burgher LW, Price EB, and Cassidy E: Granulomatous prostatitis. Association with isolation of Mycobacterium Kansasii and Mycobacterium fortuitum, J.A.M.A. 237: 2408 (1977). 11. Bissada NK, Finkbeiner AE, and Redman JF: Prostatic mycosis. Nonsurgical diagnosis and management, Urology 9: 327 (1977). 12. Berman HH, and Wilets AJ: Rheumatoid pseudotumor of urinary bladder simulating carcinoma, ibid. 9: 83 (1977). 13. Brown EW: Eosinonhilic zranuloma of the bladder. _ 1. Urol. 83: 665 (1960). 14. Kao MS, Paulson JD, and Askin FB: Crohn’s disease of the vulva, Obstet. Gynecol. 46: 329 (1975). 15. Carswell GF: A case of Behcet’s disease involving the bladder, Br. J. Urol. 48: 199 (1976). I
-
69
