Christopher O Alabi, Nadia Lakhdar, Rafaela G Basso, Adebanke O Oderinde and Fortune O Alabi*
Introduction: Chest radiographic findings in patients with granulomatosis with polyangiitis can be highly variable. Most of them present with multiple unilateral or bilateral nodules which may be sometimes associated with cavities. When the disease causes formation of pulmonary cavities, the cavitary lesions seen on chest imaging are mostly multiple, found in both lung fields and small in size. A solitary cavitary lesion in the chest radiographic image of a patient with granulomatosis with polyangiitis is not common. We present a case of granulomatosis with polyangiitis manifesting as a solitary thick-walled pulmonary cavity.
Case presentation: A 20-year old male presents to the emergency department complaining of a persistent dry cough of ten days and associated intermittent fever of three days. He reports night sweats and weight loss of ten pounds in the past month. The patient denies chills, nausea, vomiting and hemoptysis. He denies travelling outside the United States or exposure to anyone with similar symptoms.
Discussion: On initial evaluation, the patient was febrile and tachycardic. Blood pressure and respiratory rate were within normal limit and oxygen saturation was 100%. His labs revealed leukocytosis and mildly elevated procalcitonin. The induced sputum culture came back negative for acid-fast bacilli but grew Achromobacter denitrificans. The fungi culture, blood culture, urine antigen for legionella and Quantiferon TB gold came back negative. Other lab values including renal function and urinalysis were within normal limits.
The patient had a chest x-ray that showed a right upper lobe cavitary opacity on PA view which was further investigated with a chest CT that showed a solitary thick walled cavitary lesion measuring 3.5 cm × 3.6 cm in the right upper lobe with adjacent pulmonary consolidation. Treatment for pneumonia with lung abscess was commenced with appropriate antibiotics. After about a week of receiving meropenem, he developed pleuritic chest pain, his fever and cough also did not abate. Pulmonary vasculitis was considered and was confirmed by positive CANCA and subsequent respiratory mucosa biopsy which showed necrotizing granulomatous inflammation.
Conclusion: Our patient would have been diagnosed earlier if tests for C-ANCA and Anti-PR3 tests had been done to rule-out vasculitis based on the initial chest image findings. We believe this case shows that pulmonary vasculitis should be considered in the differential diagnosis in a patient presenting with a solitary cavitary pulmonary lesion when there are other constitutional symptoms known to be associated with it.
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Journal of Lung Diseases & Treatment received 247 citations as per Google Scholar report
