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The diagnosis of ANCA-associated vasculitides (AAV) consists of clinical symptoms, results of technical procedures and a characteristic histology. The diagnostic workup should focus on the prominent clinical symptoms and should involve an interdisciplinary team of specialists. The therapy is divided into induction and maintenance treatment. Cyclophosphamid remains standard therapy for the induction of remission, whereas azathioprine, methotrexate and leflunomide are often used for maintenance therapy. The introduction of a stage-adapted treatment has contributed to a significant improvement of the long-time prognosis of patients with AAV.

A 63-year-old man developed a Churg-Strauss syndrome with predominantly motor-sensory polyneuropathy. Initial treatment with cyclophosphamide and steroids achieved complete remission. Subsequent relapse with marked retinal vasculitis at first was refractory to the standard treatment. Renewed remission was obtained with additional infliximab, and was maintained with azathioprine for 12 months before the patient again presented with symmetrical polyarthritis.Clinical examination revealed a symmetrical polyarthritis involving the joints of the hand and fingers. The acute-phase parameters were raised, the rheumafactor was highly positive. Radiology showed early erosions in the bones of the hand. There were no indices of renewed activity of the Churg-Strauss syndrome.These findings indicated sero-positive rheumatoid arthritis and methotrexate was started, later supplemented with sulfsalazine and hydroxychloroquine because of continuing signs of activity. Infliximab was again given because of further progression, but a severe infusion reaction developed during the second infusion. After changing to etanercept remission of the rheumatoid arthritis was achieved.The development of rheumatoid arthritis during remission achieved with azathioprine in Churg-Strauss syndrome of four-year duration is very rare. Repeated dosis of infliximab at long intervals greatly increases the risk of an intolerance.

A 28-year-old man, known to have abnormal intestinal magnesium absorption, presented with recurrent cerebral seizures. Despite daily intravenous sulphate infusions, magnesium concentration remained inadequate. Physical examination was unremarkable.Serum magnesium concentration was markedly reduced to 0.48 mmol/l. The parenteral magnesium tolerance test indicated reduced enteric magnesium absorption of20%. Absolute magnesium concentration in 24-hour urine was normal at 6.3 mmol/24 h, but high in proportion to the hypomagnesaemia. All other laboratory data were within normal limits.In addition to the known intestinal malabsorption the patient also had isolated renal loss of magnesium. It was only by continuous magnesium infusion with a recently developed portable subcutaneous pump system that normal serum magnesium concentrations were attained and all symptoms disappeared.This patient has combined magnesium transport defects, which could not be effectively treated by conventional methods, but required continuous magnesium infusion with an indwelling subcutaneous infusion pump. This case serves as an example of the way in which subcutaneous infusion can provide physiological substitution of electrolytes.