Case Presentation: A 45 year old female with no significant past medical history presents with one week of non-productive cough and nausea. Her symptoms are associated with fevers, chills, night sweats, and decreased oral intake accompanied by a six pound weight loss over the preceding week. A chest radiograph obtained one month prior to admission showed a nodular opacity for which a follow up computed tomography (CT) of the chest identified multiple solid spiculated nodules bilaterally, some with central cavitation. A current physical exam is significant for coarse breath sounds bilaterally with unremarkable vital signs and no peripheral edema. Laboratory evidence revealed new anemia with a hemoglobin of 7.2 g/dl and creatinine of 2.1 mg/dL with a baseline of 0.9 mg/dL, as well as a urinalysis with 3+ protein and 8.94 grams of proteinuria in 24 hours. She was initially placed in airborne isolation and evaluation for tuberculosis was performed. A bronchoscopy revealed an endobronchial lesion but other studies for tuberculosis were negative. She then underwent a renal biopsy and results were consistent with a small vessel vasculitis. It was at this time that further lab investigation returned with positive myeloperoxidase antineutrophil cytoplasmic antibodies (MPO ANCA), confirming the diagnosis of Granulomatosis with Polyangiitis. The patient’s symptoms resolved with supportive care and a treatment plan was developed with assistance from both the renal and rheumatology services. Since the patient’s renal function remained stable, she did not receive pulse dose steroids, but was discharged with oral steroids and close follow up in clinic with plans to start induction treatment with rituximab.
Discussion: Though cavitary lung lesions often necessitate consideration of tuberculosis, particularly in patients with a suspicious presentation and risk factors, a combination of pulmonary and renal symptoms should prompt further evaluation. As 82-94% of patients with Granulomatosis with Polyangiitis have a positive ANCA, it is not 100% sensitive, and therefore biopsy should be pursued early when clinical suspicion exists, as in our patient. Vasculitis should especially be considered in patients with pulmonary and renal involvement as there are great benefits including salvage of involved organs from early initiation of treatment.
Conclusions: An ANCA-associated vasculitis is a diagnosis commonly made in the hospital setting once patients begin to have clinical manifestations, which can greatly vary depending on the organs involved. It is important to consider this diagnosis, and early biopsy when appropriate, in patients that have multiple organ involvement at presentation. This patient represents a case of a vasculitis that was initially suspected to be tuberculosis, and a situation in which early biopsy led to prompt initiation of treatment and possible salvage of the kidneys.