This is the chest X-ray of a middle-aged man with haemoptysis. Mantoux tests and 
sputum culture are negative. His blood tests show high creatinine and urea.

a. What does the chest X-ray show?

There are cavitating lesions with infiltration of pulmonary parenchyma 
in the right lung.

b. What is the most likely diagnosis?

Wegener's granulomatosis.
It is a multi-system disorders of unknown origin with lesions typically involving the upper respiratory tract, lungs and kidneys. Nose bleed, haemoptysis and renal failure are common. The chest X-ray typically shows single or multiple cavitation with peumonic infiltration. Diagnosis is helped by the presence of positive ANCA (antineutrophilic cytoplasmic antibody) in the serum.

c. In what ways can the eyes be affected?

Anterior segment:

• episcleritis
• scleritis
• peripheral corneal infiltrate and ulceration
• nasolacrimal obstruction

Posterior segment

• cotton wool spots
• posterior scleritis
• vein occlusion

Orbital involvement:

• proptosis
• ophthalmoplegia

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