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

Pulmonary Nodules in a Patient With Advanced Cancer: An Unusual Occurrence of Granulomatosis With Polyangitis FREE TO VIEW

David DeLapp, DO; Christopher Chan, DO; James Murphy, MD
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Wright State University Boonshoft School of Medicine Internal Medicine Program, Dayton, OH

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

Chest. 2016;150(4_S):1074A. doi:10.1016/j.chest.2016.08.1181
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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 polyangitis (GPA) is a rare, multiorgan, autoimmune disorder that leads to granulomatous lesions and necrotizing vasculitis predominantly affecting the respiratory tract and kidneys. In the respiratory tract, it can present with signs and symptoms of cough, sinusitis, and new pulmonary nodules. Multiple pulmonary nodules in a patient with a known primary malignancy greatly increases the likelihood of those nodules being malignant.

CASE PRESENTATION: A 71 year old white female with a history of advanced stage 3C ovarian cancer presents to a pulmonary clinic after multiple pulmonary masses were identified on surveillance CT chest and abdomen. She was diagnosed with ovarian cancer a year ago and considered to be in remission after extensive abdominal surgery and chemotherapy. On history, the patient had been complaining of chronic sinusitis for 1.5 years. Recently, she had complaints of progressive dyspnea, cough with blood tinged sputum, and refractory left eye conjunctivitis. Her physical exam was benign. On laboratory evaluation, C-ANCA was positive (1:80 titer), PR-3 elevated to 70.8 (ref <3.5), creatinine 0.7 mg/dl, rheumatoid factor of 52 units/ml, ESR 100 mm/hr, and urinalysis revealed microscopic hematuria. Kidney biopsy was negative. On CT chest multiple bilateral pulmonary masses were seen, the largest (5cm) in the right lower lobe was biopsied. It showed necrotizing granulomatous inflammation and no malignant cells. She was diagnosed with GPA and started on cyclophosphamide and steroids. Over the next year her respiratory symptoms and pulmonary mass size improved until she had a recurrence of her ovarian cancer in her abdomen and unfortunately passed away.

DISCUSSION: This case highlights two important points demonstrating the nonspecificity of GPA symptoms and the differential of pulmonary nodules in a patient with a known malignancy. Despite increasing knowledge and management of GPA, it is still a rare disorder with a prevalence of 20 cases per 1 million people that occurs less commonly in the elderly. GPA can present with symptoms of cough, sinusitis, and fatigue and in the setting of advanced cancer can make the diagnosis difficult. Further, the likelihood of multiple pulmonary nodules being anything but a malignancy in a patient with a known primary malignancy is low. According to one study, nodules that are larger than 1cm in patients with known cancer have a 84% probability of being malignant. In patients with advanced cancer, there are no data reporting the chances of patients presenting with multiple nodules >1cm being benign.

CONCLUSIONS: GPA symptomatically presents nonspecifically, but a high suspicion must remain particularly in patients with chronic sinusitis and multiple pulmonary nodules even in the setting of advanced cancer.

Reference #1: Ginsberg et al. (1999). Pulmonary nodules resected at video-assisted thoracoscopic surgery: Etiology in 426 patients. Radiology,213(1), 277-282.

DISCLOSURE: The following authors have nothing to disclose: David DeLapp, Christopher Chan, James Murphy

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