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Chest Infections |

Atypical Infection With Atypical Inflammation

Frank Courmier*, MD; Richard Beckendorf, MD; Phillip Rascoe, MD
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Scott and White Memorial Hospital, Temple, TX


Chest. 2012;142(4_MeetingAbstracts):182A. doi:10.1378/chest.1382205
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Abstract

SESSION TYPE: Infectious Disease Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Vasculitides are more commonly associated with autoimmune conditions. We report a case of atypical mycobacterial lung infection initially suspected to be Wegener’s granulomatosis (granulomatosis with polyangiitis, or GPA).

CASE PRESENTATION: 48 year-old white male with extensive smoking history was found to have a right upper lobe mass during disability evaluation. Chest CT showed a spiculated right upper lobe lung mass measuring 7.1 x 5.2 cm. A CT guided needle biopsy was performed which showed granulomatous inflammation and bronchoscopy revealed non malignant disease. Repeat CT chest showed enlargement of the lung mass with new cavitation. CT surgery performed a VATS with right upper lobectomy. Pathology showed a necrotizing granulomatous vasculitis consistent with GPA. Subsequent serological testing was performed and was negative for ANA, ANCA, anti-PR-3 and anti MPO. Cultures of the specimen were positive for Mycobacterium avium-intracellulare. Based on negative serology, lack of other organ involvement and evidence of infection, it was decided to treat the infection rather than beginning immunosuppressive therapy.

DISCUSSION: GPA is described as a small vessel vasculitis that has an association with antineutrophil cytoplasmic antibodies (ANCA). Patients with organ-limited disease have much lower rates of ANCA positivity as in this case 2. ANCA vasculitis can be associated with various infections occurring as a complication of immunosuppressive therapy. There is also an association between infection and relapse3. However, there is also some debate as to whether these ANCA vasculitides can be caused by infection1. Specifically, Mycobacterium avium-intracellulare has been described to be associated with small vessel vasculitis. Whether infection is the inciting event or vasculitis is predisposed to such infections or mycobacterial infections can mimic vasculitis remains to be debated.

CONCLUSIONS: We present a case of a patient with strong risk factors and clinical presentation concerning for malignancy that resulted in a confusing diagnosis of vasculitis by biopsy and MAI by culture. This case highlights the importance of obtaining pathological diagnosis as well as ruling out infection before initiating any immunosuppressive therapy. This case also adds evidence that there may be an association between mycobacterial infection and vasculitis which has important aspects to management.

1) Chaiamnuay S and Heck L. Antineutrophil Cytoplasmic Antibody vasculitis associated with Mycobacterium avium intracellulare infection. The Journal of Rheumatology 2005; 32:1610-12.

2) Cohen P, Guillevin L, Baril L, et al. Persistence of antineutrophil cytoplasmic antibodies in asymptomatic patients with polyarteritis nodosa or Churg-Strauss Syndrome: follow up of 53 patients. Clin Exp Rheumatol 1995;13:193.

3) Pinching A, Rees A, Pussell B, et al. Relapses in Wegener's granulomatosis: the role of infection. British Medical Journal 1980; 281:836-38.

DISCLOSURE: The following authors have nothing to disclose: Frank Courmier, Richard Beckendorf, Phillip Rascoe

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Scott and White Memorial Hospital, Temple, TX

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