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Granulomatosis With Polyangiitis Presenting as Large Pleural-Based Lung Masses in a Patient With Headache
Pulmonary Manifestations of Systemic Disease SESSION TITLE: Fellow Case Report Poster - Pulmonary Manifestations of Lung Disease SESSION TYPE: Affiliate Case Report Poster
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Granulomatosis With Polyangiitis Presenting as Large Pleural-Based Lung Masses in a Patient With Headache Lauren Blackwell MD* Yuriy Takhalov MD Shahida Ahmed MD Donghong Cai MD; and Jenny Kim MD Rutgers, New Jersey Medical School, Bloomfield, NJ INTRODUCTION: Granulomatosis with polyangiitis commonly manifests with pulmonary nodules. We present at case of granulomatosis with polyangiitis presenting as large pleural-based lung masses. CASE PRESENTATION: The patient is a 62 year old man with history of tobacco dependence who presented with complaints of right and left sided chest pain and severe frontal headaches. The headaches were present for one month and not relieved with ibuprofen. His physical exam was normal except for splinting. CT head was negative. CT chest revealed a 2.7 x 2.5cm right upper lobe (RUL) mass, a 5.3 x 5.6cm left lower lobe (LLL) mass, and multiple pleural based nodules. Both masses were PET/CT positive. BAL was negative for infection. Transthoracic needle biopsy showed chronic granulomatous inflammation. The creatinine increased from 0.8 to 3.3 mg/dl. Auto-immune testing demonstrated ESR 115 mm/hr, CRP 38 mg/L, ANA negative, RF negative, HIV test negative, P-ANCA negative, and C-ANCA positive at 1:320 dilution. Renal biopsy demonstrated c-ANCA related necrotizing crescentic glomerulonephritis and 22/27 glomeruli with crescents. A diagnosis of granulomatosis with polyangiitis was made and treatment with rituximab followed by maintenance corticosteroids resulted in symptomatic improvement as well as radiologic improvement in lung masses. DISCUSSION: Granulomatosis with polyangiitis often imitates pneumonia, septic emboli, or metastatic disease on chest imaging1. Typical CT chest findings in granulomatosis with polyangiitis include lung masses and nodules, which are typically, diffuse, bilateral, and have subpleural or bronchioalveolar distribution2. In one study, the number of parenchymal lung nodules ranged from 2-12 with a diameter of 10-75mm with appearances ranging from consolidation to ground glass to cavitary3. Though trans-bronchial biopsies are more likely to be falsely negative, the finding of granulomatous inflammation may be suggestive of an auto-immune disorder. CONCLUSIONS: Granulomatosis with polyangiitis can mimic many diseases and in this case presented as large pleural based masses with concern for metastatic disease. Reference #1: Ananthakrishnan, L. et al. Wegener’s granulomatosis in the chest: high-resolution CT findings. AJR Am J Roentgenol. 2009 Mar;192(3):676-82. Reference #2: Samara, KD. et al. A patient presenting with bilateral lung lesions, pleural effusion, and proteinuria. Case Rep Med. 2013;2013:489362. Reference #3: Gómez-Gómez, A. et al. Pulmonary manifestations of granulomatosis with polyangiitis. Reumatol Clin. 2014 SepOct;10(5):288-93. DISCLOSURE: The following authors have nothing to disclose: Lauren Blackwell, Yuriy Takhalov, Shahida Ahmed, Donghong Cai, Jenny Kim No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1161
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1054A
[
150#4S CHEST OCTOBER 2016
]
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Granulomatosis With Polyangiitis Presenting as Large Pleural-Based Lung Masses in a Patient With Headache Lauren Blackwell MD* Yuriy Takhalov MD Shahida Ahmed MD Donghong Cai MD; and Jenny Kim MD Rutgers, New Jersey Medical School, Bloomfield, NJ INTRODUCTION: Granulomatosis with polyangiitis commonly manifests with pulmonary nodules. We present at case of granulomatosis with polyangiitis presenting as large pleural-based lung masses. CASE PRESENTATION: The patient is a 62 year old man with history of tobacco dependence who presented with complaints of right and left sided chest pain and severe frontal headaches. The headaches were present for one month and not relieved with ibuprofen. His physical exam was normal except for splinting. CT head was negative. CT chest revealed a 2.7 x 2.5cm right upper lobe (RUL) mass, a 5.3 x 5.6cm left lower lobe (LLL) mass, and multiple pleural based nodules. Both masses were PET/CT positive. BAL was negative for infection. Transthoracic needle biopsy showed chronic granulomatous inflammation. The creatinine increased from 0.8 to 3.3 mg/dl. Auto-immune testing demonstrated ESR 115 mm/hr, CRP 38 mg/L, ANA negative, RF negative, HIV test negative, P-ANCA negative, and C-ANCA positive at 1:320 dilution. Renal biopsy demonstrated c-ANCA related necrotizing crescentic glomerulonephritis and 22/27 glomeruli with crescents. A diagnosis of granulomatosis with polyangiitis was made and treatment with rituximab followed by maintenance corticosteroids resulted in symptomatic improvement as well as radiologic improvement in lung masses. DISCUSSION: Granulomatosis with polyangiitis often imitates pneumonia, septic emboli, or metastatic disease on chest imaging1. Typical CT chest findings in granulomatosis with polyangiitis include lung masses and nodules, which are typically, diffuse, bilateral, and have subpleural or bronchioalveolar distribution2. In one study, the number of parenchymal lung nodules ranged from 2-12 with a diameter of 10-75mm with appearances ranging from consolidation to ground glass to cavitary3. Though trans-bronchial biopsies are more likely to be falsely negative, the finding of granulomatous inflammation may be suggestive of an auto-immune disorder. CONCLUSIONS: Granulomatosis with polyangiitis can mimic many diseases and in this case presented as large pleural based masses with concern for metastatic disease. Reference #1: Ananthakrishnan, L. et al. Wegener’s granulomatosis in the chest: high-resolution CT findings. AJR Am J Roentgenol. 2009 Mar;192(3):676-82. Reference #2: Samara, KD. et al. A patient presenting with bilateral lung lesions, pleural effusion, and proteinuria. Case Rep Med. 2013;2013:489362. Reference #3: Gómez-Gómez, A. et al. Pulmonary manifestations of granulomatosis with polyangiitis. Reumatol Clin. 2014 SepOct;10(5):288-93. DISCLOSURE: The following authors have nothing to disclose: Lauren Blackwell, Yuriy Takhalov, Shahida Ahmed, Donghong Cai, Jenny Kim No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1161
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1054A
[
150#4S CHEST OCTOBER 2016
]