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Kundu K, Singla T, Pandey H, Mittal H, Sehgal T, Ramanan AV, Bagri NK. Mycoplasma pneumoniae induced cold agglutinin syndrome: an unusual mimicker of childhood vasculitis. Arch Dis Child 2024; 109:948-949. [PMID: 38997139 DOI: 10.1136/archdischild-2024-327070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Kanupriya Kundu
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Tanya Singla
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Hem Pandey
- Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Harshita Mittal
- Department of Lab Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Sehgal
- Department of Lab Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Narendra Kumar Bagri
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
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2
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Ediboglu ED, Erpek E, Karasu S, Cakalagaoglu F, Akar S. An unusual presentation of granulomatosis with polyangiitis. Clin Rheumatol 2024; 43:2713-2714. [PMID: 38970751 DOI: 10.1007/s10067-024-07053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/06/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Affiliation(s)
- Elif Durak Ediboglu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Izmir Katip Celebi University, Basın Sitesi Street, 35150, Izmir, Turkey
| | - Esra Erpek
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Izmir Katip Celebi University, Basın Sitesi Street, 35150, Izmir, Turkey
| | - Sebnem Karasu
- Department of Radiology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Fulya Cakalagaoglu
- Department of Pathology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Servet Akar
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Izmir Katip Celebi University, Basın Sitesi Street, 35150, Izmir, Turkey.
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3
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Jud P, Bosch P, Tsybrovskyy O. Digital Necrosis in Granulomatosis with Polyangiitis. Balkan Med J 2023; 40:68-69. [PMID: 36604993 PMCID: PMC9874252 DOI: 10.4274/balkanmedj.galenos.2022.2022-10-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Philipp Jud
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Bosch
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
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4
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Sensory-Motor Polyneuropathy and Digital Ischemia: A Rare Presentation of Granulomatosis with Polyangiitis. Case Rep Rheumatol 2021; 2021:5353575. [PMID: 34751236 PMCID: PMC8572124 DOI: 10.1155/2021/5353575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/27/2021] [Accepted: 10/16/2021] [Indexed: 11/17/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) typically presents with upper or lower respiratory tract symptoms and/or with renal involvement. Although it can affect the peripheral nervous system frequently, with mononeuritis multiplex being the most common pattern, the occurrence of peripheral sensory-motor polyneuropathy as a presenting manifestation is distinctly rare. Prevalence of digital gangrene is also extremely rare in GPA. We describe a 46-year-old woman presenting with severe peripheral sensorimotor polyneuropathy affecting bilateral lower limbs preceded by a purpuric skin rash and multiple painful ulcers confined to the lower limbs. She had evidence of digital ischemia affecting multiple toes and dry gangrene of the left 4th toe. Diagnosis of GPA was made based on skin biopsy, positive ANCA serology, and clinical criteria. She made a good recovery following aggressive immunosuppressive treatment with methylprednisolone and cyclophosphamide and was maintained on prednisolone and azathioprine. This case highlights the importance of suspecting GPA in a patient presenting with sensorimotor polyneuropathy and/or digital ischemia even in the absence of more classic presenting features and underlies the necessity of accurate differential diagnosis in evaluating a case of peripheral neuropathy.
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5
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Vulasala SS, Ahmed S, Onteddu NK, Mannem M, Mukkera S. Raynaud's Secondary to Granulomatosis With Polyangiitis. Cureus 2021; 13:e17551. [PMID: 34646608 PMCID: PMC8481133 DOI: 10.7759/cureus.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 11/05/2022] Open
Abstract
Raynaud's phenomenon (RP) is an episodic digital vasospastic condition that is prevalent among 5% of the population. The symptoms range from reversible pallor to ischemia and gangrene. RP can be primary or secondary. We discuss a case of severe RP secondary to granulomatosis with polyangiitis (GPA) that presented with ischemia and gangrene. Studies show that approximately <1% of GPA cases have similar presentations. Early diagnosis and management are essential to halt the progression of ischemia. Calcium channel blockers are the first-line medications used in RP. Phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, and prostacyclin analogs are proven to be effective in cases of severe RP. Sympathectomy and amputation are considered as the extreme options in patients with refractory symptoms.
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Affiliation(s)
- Sai Swarupa Vulasala
- Radiology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Shohana Ahmed
- Internal Medicine, Texas Tech University Health Sciences Center - Permian Basin, Odessa, USA
| | | | - Maneesh Mannem
- Internal Medicine, Texas Tech University Health Sciences Center - Permian Basin, Odessa, USA
| | - Srikanth Mukkera
- Division of Rheumatology, Texas Tech University Health Sciences Center, Odessa, USA
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6
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Ravi P, Thabah MM, Verghese RJ, Dineshbabu S, Kadhiravan T. Diagnosis of Undifferentiated Connective Tissue Disease in a Patient With Digital Gangrene and Positive Antinuclear Antibodies. Cureus 2021; 13:e15883. [PMID: 34336409 PMCID: PMC8312813 DOI: 10.7759/cureus.15883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
The occurrence of ischemia of the digits or digital gangrene is a well-known complication of systemic autoimmune diseases, such as systemic sclerosis, systemic lupus erythematosus, and anti-phospholipid syndrome, among others. The pathophysiological mechanisms are small vessel vasculitis, vasospasm of Raynaud’s phenomenon, microthrombi due to antiphospholipid syndrome, and/or accompanying accelerated atherosclerosis. Digital ischemia can also occur in the context of disseminated bacterial infections and sepsis. We present here the case of a patient who had digital ischemia and positive antinuclear antibodies but without well-defined clinical features of a connective tissue disease. A diagnosis of undifferentiated connective tissue disease was made.
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Affiliation(s)
- Pradeep Ravi
- Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Molly Mary Thabah
- Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Rohan J Verghese
- Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Sekar Dineshbabu
- Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Tamilarasu Kadhiravan
- Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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7
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Pourdowlat G, Naderi Z, Seif F, Mansouri D, Raji H. Acrocyanosis and digital necrosis are associated with poor prognosis in COVID-19. Clin Case Rep 2020; 8:2769-2772. [PMID: 33363819 PMCID: PMC7752590 DOI: 10.1002/ccr3.3276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/03/2020] [Indexed: 11/12/2022] Open
Abstract
Acrocyanosis and digital necrosis, which caused by microangiopathic and immunothrombosis phenomenon, may accompanied by microvascular involvement of other organs. Therefore, this finding can play a prognostic role in covid-19 outcome.
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Affiliation(s)
- Guitti Pourdowlat
- Chronic Respiratory Diseases Research CenterNational Research Institute of Tuberculosis and Lung DiseasesShahid Beheshti University of Medical SciencesTehranIran
| | - Zohre Naderi
- Department of PulmonologyIsfahan University of Medical SciencesIsfahanIran
| | - Farhad Seif
- Department of Immunology and AllergyAcademic Center for Education, Culture, and ResearchTehranIran
- Neuroscience Research CenterIran University of Medical SciencesTehranIran
| | - Davood Mansouri
- Department of Clinical Immunology and Infectious DiseasesNational Research Institute of Tuberculosis and Lung DiseasesShahid Beheshti University of Medical SciencesTehranIran
- The Clinical Tuberculosis and Epidemiology Research CenterNational Research Institute of Tuberculosis and Lung DiseasesShahid Beheshti University of Medical SciencesTehranIran
- Pediatric Respiratory Diseases Research CenterNational Research Institute of Tuberculosis and Lung DiseasesShahid Beheshti University of Medical SciencesTehranIran
| | - Hanieh Raji
- Department of Internal MedicineAir pollution and Respiratory Diseases Research CenterAhvaz Jundishapur University of Medical SciencesAhvazIran
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Koh E, Kang N, Lee JY, Kim DK, Do YS, Lee BJ, Choi DC. Multiple hepatic aneurysms and dry gangrene of fingertips in eosinophilic granulomatosis with polyangiitis: a case report. Allergy Asthma Clin Immunol 2020; 16:90. [PMID: 33072160 PMCID: PMC7559129 DOI: 10.1186/s13223-020-00484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis mainly affecting small-sized arteries. Involvement of medium-sized vessels is very rare in EGPA. Here we present the case of a patient with EGPA who showed multiple hepatic aneurysms and distal gangrene. Case presentation A known EGPA patient visited to the emergency room (ER) with abrupt squeezing abdominal pain. She had suffered from gangrene in the fingertips of both hands for 1 year because of arterial thrombosis associated with hypereosinophilia. However, her absolute eosinophil count in the ER was 1120 cells/µL. An abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe. A celiac angiogram demonstrated multiple sized aneurysms in both hepatic lobes and some aneurysms in S7 and S8 were huge, more than 1 cm in size. The shape of the small aneurysms resembled a string of beads, as in polyarteritis nodosa. Given the clinical situation, emergency embolization was performed. Before this patient visited to the ER, she had been treated with a high dose of systemic corticosteroid, azathioprine, and cyclophosphamide. After addition of mepolizumab, the eosinophil count remained stable state with a near zero percentage of total white blood cell count. Conclusions Aneurysm and gangrene resulting from the involvement of medium-sized vessels can occur in EGPA. Destruction of vessels might occur even if eosinophil count is below 1500 cells/µL. If involvement of medium-sized arteries is suspected, thorough investigation to identify the involved organs and prompt management are needed to prevent fatal complications.
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Affiliation(s)
- Eunsil Koh
- Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Noeul Kang
- Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Young Lee
- Health Promotion Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Duk-Kyung Kim
- Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Soo Do
- Departments of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung-Jae Lee
- Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong-Chull Choi
- Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Abstract
Vasculitis mimickers are structural or pathologic entities that resemble the vasculitis clinical presentation and/or diagnostic findings. Their presence can be a conundrum, and physicians require careful assessment and adequate knowledge physicians when considering a diagnosis of vasculitis. Although they are considered mimickers, the therapeutic approach for most of them differs widely from that of vasculitis as high-dose steroids and potent immunosuppressive regimens are usually indicated in the latter. In fact, steroid therapy is contraindicated and is considered harmful in some of these mimickers (e.g. segmental arterial mediolysis). Therefore, it is important to distinguish them from vasculitis to prevent complications from immunosuppressive therapy. Hereby, we present a challenging case of a 64-year-old man who presented with acute gangrenous changes on his right fingers due to arterial thrombus after trauma resembling vasculitis.
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10
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Zhou D, Zhang P, Zhang Y, Zhang Y, Zhang X, Li J, Zhou Z, Zhu N. Main tract stenosis complicated by granulomatous with polyangiitis: A case report. Exp Ther Med 2020; 19:3332-3336. [PMID: 32266030 PMCID: PMC7132230 DOI: 10.3892/etm.2020.8603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rheumatic auto-immune disease involved in vasculitis. It is rarely reported that anti-neutrophil cytoplasmic antibodies (ANCAs) associated with GPA would cause main tract stenosis. The current report documents a 54-year-old woman, with a history of severe cough, presented with wheezing and shortness of breath. Although she was treated with cephalosporin antibiotics for half a month, the symptoms were not alleviated. Accordingly, laboratory testing, radiology and pathology was performed at the Department of Respiratory and Critical Care Medicine, Huashan Hospital. Blood samples were tested negative for ANCAs. Chest CT revealed stenosis of the main trachea and uneven thickening of the tracheal wall. Nasal sinuses CT scanning indicated thickening of the nasal mucosa. Pathological analysis demonstrated chronic granulomatous inflammation with focal lesions. According to the classification criteria of ACR/EULAR provisional 2017, the patient was diagnosed with the ANCAs-negative GPA. Following treatment with oral prednisone only for 6 months, obstruction of main tract was significantly improved. This case study is of interest for the promotion a potentially novel therapeutic intervention for GPA associated with the absence ANCA of in clinic.
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Affiliation(s)
- Daibing Zhou
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Peng Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Yuanyuan Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Youzhi Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Xiujuan Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Jing Li
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Zhongwen Zhou
- Department of Pathology, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Ning Zhu
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
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11
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Hines A, Bello V, Iftikhar A, Zein H. Rare presentation of granulomatosis with polyangiitis. BMJ Case Rep 2019; 12:12/2/e227218. [PMID: 30798274 DOI: 10.1136/bcr-2018-227218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 62-year-old man with no pertinent medical history presented with lower extremity weakness and worsening distal fingertips and toe cyanosis/gangrene. In the outpatient setting, he was initially being treated for Raynaud's phenomenon with a calcium channel blocker. On presentation, the patient had elevated inflammatory markers and white blood cell count. Serum vasculitis panel (proteinase-3 antibody) supported the diagnosis of granulomatosis with polyangiitis. His hospital course was complicated by ischaemic stroke and a diagnosis of mononeuritis multiplex in his lower extremities. After initiating therapy with intravenous steroid and rituximab, his symptoms overall improved including cyanotic fingertips/toes. His inflammatory markers and leucocytosis also improved. Outpatient follow-up consisted of further rituximab infusions and unrelated umbilical hernia incarceration which required surgery. He was found incidentally to have subsegmental pulmonary emboli which most likely occurred during the initial presentation prior to his diagnosis. The patient moved out of state and was lost to follow-up.
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Affiliation(s)
- Adam Hines
- Department of Internal Medicine, New York-Presbyterian/Queens, Flushing, New York, USA
| | - Vered Bello
- Department of Internal Medicine, New York-Presbyterian/Queens, Flushing, New York, USA
| | - Asma Iftikhar
- Department of Pulmonary and Critical Care, New York-Presbyterian/Queens, Flushing, New York, USA
| | - Hadi Zein
- Department of Internal Medicine, New York-Presbyterian/Queens, Flushing, New York, USA
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12
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Pokharel S, Singh S, Shaukat MS. An Unusual Presentation of Granulomatosis with Polyangiitis (GPA). AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1071-1073. [PMID: 30190451 PMCID: PMC6140452 DOI: 10.12659/ajcr.909718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Female, 72 Final Diagnosis: Granulomatosis with polyangiitis Symptoms: Finger pain • gangrene Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Sunil Pokharel
- Department of Internal Medicine, Albany Medical Center, Albany, NY, USA
| | - Sukhraj Singh
- Department of Internal Medicine, Albany Medical Center, Albany, NY, USA
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13
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Ning S, Zhang X, Xu C, Dang X, Cheng H, Zhu K, Han Y. Methylprednisolone and plasmapheresis are effective for life-threatening diffuse alveolar hemorrhage and gastrointestinal hemorrhage in granulomatosis with polyangiitis: A case report and literature review. Medicine (Baltimore) 2018; 97:e0592. [PMID: 29703056 PMCID: PMC5944511 DOI: 10.1097/md.0000000000010592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE The treatment of granulomatosis with polyangiitis (GPA) with life-threatening complications, such as diffuse alveolar hemorrhage (DAH) and gastrointestinal hemorrhage (GIH), remains challenging. PATIENT CONCERNS A 70-year-old female presented with a 6-month history of a productive cough and a 10-day history of arthralgia that progressed to respiratory failure and massive hematochezia. DIAGNOSES Chest high-resolution computed tomography (HRCT) revealed multiple nodules, masses, and cavities. Urinalysis indicated microscopic hematuria. Test of proteinase3-anti-neutrophil cytoplasmic autoantibody (PR3-ANCA) was positive. INTERVENTIONS The patient was transferred to the intensive care unit (ICU) and successfully treated with glucocorticoid pulse therapy and plasmapheresis. We combined mycophenolate mofetil (MMF) with glucocorticoid for maintenance treatment. OUTCOMES The patient survived and is in a stable condition. We report this case that presented with a productive cough, followed by arthralgia, DAH, and GIH. LESSONS Effective remission-induction therapy is a key to survival, while maintaining a balance between immunosuppression and avoiding infection is another challenge.
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