Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I |

Distinguishing Vasculitis From TB: A Diagnostic Challenge in Differentiating Granulomatosis With Polyangiitis From TB FREE TO VIEW

Lokesh Dayal, MD; Jeongwon Choi, MD; Jonathan Shammash, MD
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Icahn School of Medicine at Mount Sinai, Englewood Hospital, Englewood, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1073A. doi:10.1016/j.chest.2016.08.1180
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Granulomatosis with Polyangiitis (GPA) is rare small vessel vasculitis that has multi-organ involvement including cavitary lesions of the lung. We describe a unique case that presented with mastoiditis, facial paralysis, hearing loss and pulmonary cavitations on CT Scan that presented as a diagnostic challenge when distinguishing from Tuberculosis (TB).

CASE PRESENTATION: A 69-year-old man presents with 6 months of progressive unilateral hearing loss, recurrent fever, chills, sweats and unilateral facial paralysis. Laboratory testing showed mild leukocytosis. Urinalysis had large blood and elevated BUN of 29 mg/dL and Creatinine of 2.3 mg/dL. An initial AFB of the sputum was positive. CT Chest showed multiple scattered pulmonary nodular opacities with central cavitations and mediastinal lymphadenopathy. The patient had no personal history of TB but a positive history in many immediate family members. The patient was placed on respiratory precautions for suspected TB. Further specimens were obtained via bronchoscopy including AFBs, TB-PCR and cytology specimens. He was prophylactically started on rifampin, isoniazid, pyrazinamide and ethambutol. Inflammatory markers, CRP and ESR, were mildly elevated and anti-MPO Ab were increased without anti-PR-3, nor anti-GBM Ab. The involvement of renal pulmonary systems prompted further investigation via renal biopsy. It showed diffuse, necrotizing and crescentic glomerulonephritis with MPO-ANCA. A diagnosis of GPA was made. Bronchoscopic TB tests were negative. The patient was promptly started on methylprednisolone and cyclophosphamide. His creatinine improved dramatically and the facial paralysis resolved.

DISCUSSION: Given this patient’s history, presenting symptoms and positive sputum AFB, TB was the likely initial diagnosis. TB can cause facial paralysis and mastoiditis (1). Cavitary lesions on CT furthered our suspicion. Further, TB glomerulonephritis, an extra-pulmonary manifestation, often presents with hematuria. However, the crux of differentiating this as a vasculitis arose with the detection of MPO-ANCA Ab in both the serum and renal biopsy. Typically, PR3-ANCA is a more sensitive marker in GPA than MPO-ANCA Ab (2). With the assistance of a renal biopsy we identified the appropriate course of treatment with immunosuppressants rather than antibiotics.

CONCLUSIONS: GPA can present similarly to pulmonary TB, with mastoiditis, facial paralysis, hematuria and pulmonary cavitations. In some cases, the diseases must be differentiated via biopsy, serological marker testing and TB-PCR to determine the appropriate management.

Reference #1: Mongkolrattanothai, et al. (2003). Tuberculous otitis media with mastoiditis and central nervous system involvement. The Pediatric Infectious Disease Journal, 22(5), 453-456.

Reference #2: Savige, J., Pollock, W., & Trevisin, M. (2005). What do antineutrophil cytoplasmic antibodies (ANCA) tell us? Best Practice & Research Clinical Rheumatology, 19(2), 263-276.

DISCLOSURE: The following authors have nothing to disclose: Lokesh Dayal, Jeongwon Choi, Jonathan Shammash

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