Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Granulomatosis with Polyangiitis (GPA) is a small vessel vasculitis disorder that classically involves the upper and lower respiratory tract as well as the kidneys. However, its presentation is not limited to these organ systems as it can present with ocular, dermatological or cardiac involvement, thus creating a broad differential when evaluating patients. This case illustrates the diagnostic challenges with infectious and inflammatory etiologies in a patient with systemic symptoms, concerning imaging and travel to a TB-endemic region. A 57-year-old female with a pertinent history of recurrent sinusitis, left otitis media, and prior sinus surgeries was evaluated for suspicion of possible tuberculosis (TB) due to 2-month chronic productive cough with occasional hemoptysis and CT findings of multiple pulmonary nodules. This suspicion was prompted due to imaging findings and history of recent 1-month travel history to India with an indeterminate exposure to possible TB contacts. Prior to her return from India she was treated for recurrent sinusitis with multiple courses of antibiotics. Additionally, she reported weight fluctuations and night sweats. Subsequent IGRA testing and fungal cultures yielded negative results. Further investigation revealed chronic sinusitis over the past 2 years and a prior nasal surgery performed in India the year prior that did show a necrotizing granuloma within the sinus contents. A repeat CT of sinus passages revealed extensive inflammatory disease within the paranasal sinuses. As a result, the patient underwent rheumatological evaluation which revealed a positive ANA titer and cANCA level consistent with a diagnosis of GPA for which she underwent CT guided lung biopsy for definitive diagnosis. The patient’s presentation raised concerns about tuberculosis (TB), fungal infections, or inflammatory diseases such as granulomatosis with polyangiitis (GPA). Despite her travel to India and potential exposure to symptomatic individuals, IGRA testing was negative, and biopsy samples showed no acid-fast bacilli (AFB) or fungal organisms. The chronicity of symptoms, imaging findings, and history of necrotizing granulomas prompted a broader differential diagnosis, including sarcoidosis and nontuberculous mycobacteria (NTM) infections. Concurrent evaluation of inflammatory etiologies despite the suspicion of an infectious cause can lead to a more timely diagnosis and earlier initiation of management. This case underscores the importance of integrating clinical, microbiological, and radiological findings to avoid premature empiric treatment and ensure an accurate diagnosis. Multi-systemic disorders such as Granulomatosis with Polyangiitis (GPA) often present a diagnostic challenge due to their enumerable presentations. The classical triad of involvement of necrotizing granulomas of the upper and lower respiratory system, systemic vasculitis and necrotizing glomerulonephritis is often not evident on presentation as renal involvement is only present in 11-20% of cases. A limited form of GPA however, usually presents with sparing of the kidneys and subsequently can lead to suspicion of other diagnoses as was the case with our patient given her storied social and travel history leading to prioritization of ruling out more insidious causes such as tuberculosis and fungal diseases. Prompt diagnosis is paramount as a delay in management can lead to further progression of the disease and lead to ocular, renal and dermatological manifestations.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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