Case Presentation: A 50-year-old male with a history of smoking and current vape use presented with bilateral flank pain, chills, and dysuria. Two days earlier, he had been seen at an urgent care center, where urinalysis showed hematuria without infection, and a CT scan of the abdomen and pelvis was unremarkable. He was also diagnosed with right-sided conjunctivitis and prescribed lubricant drops. Other complaints included arthritic pain and a chronic dry cough. Physical examination revealed right-sided conjunctivitis and mild suprapubic discomfort. Laboratory studies showed hematuria with no evidence of infection, elevated inflammatory markers (CRP and ESR), and C-ANCA positivity. CT imaging revealed cavitary pulmonary nodules. A lung biopsy showed benign tissue with inflammation, and bronchoscopy confirmed diffuse intraalveolar hemorrhage. The patient was treated with plasmapheresis, corticosteroids, and scheduled for outpatient rituximab.
Discussion: ANCA-associated vasculitis (AAV) is an autoimmune disorder causing small- to medium-sized blood vessel inflammation, often affecting multiple organs. Subtypes include granulomatosis with polyangiitis (GPA), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. In this case, the patient presented with pulmonary, renal, and ocular involvement, strongly suggesting GPA. Pulmonary manifestations, including cavitary nodules, occur in up to 50% of GPA cases, and diffuse alveolar hemorrhage is a critical, life-threatening complication. Renal involvement is common, and though this patient had microscopic hematuria, creatinine levels remained relatively normal, indicating early-stage glomerular involvement. Treatment for AAV typically involves immunosuppressive therapy with corticosteroids and either cyclophosphamide or rituximab for more severe cases. Plasmapheresis is used for cases with severe pulmonary hemorrhage or rapidly progressive glomerulonephritis. Early diagnosis and aggressive treatment are key to preventing irreversible organ damage and improving outcomes.
Conclusions: ANCA-associated vasculitis, particularly GPA, can present with a variety of symptoms, making diagnosis difficult. This case emphasizes the importance of considering vasculitis in patients with multisystem involvement. Early and aggressive treatment, including plasmapheresis, corticosteroids, and rituximab, was crucial in controlling the disease and preventing further complications.