View Abstract

A3085 - A Challenging Case of Granulomatous Lung Disease
Author Block: C. R. Pendkar1, S. Shankar2, S. Nasreen1; 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY, United States, 2maimonides medical center, Brooklyn, NY, United States.
A granuloma is a compact aggregate of histiocytes (macrophages) formed as a result of the persistence of a nondegradable product or as the result of hypersensitivity responses.Differential diagnosis is challenging and includes both infectious and noninfectious lung diseases. We present to you a case of granulomatosis with polyangiitis which was a diagnostic challenge due to confounding infection. A 69-year-old male with a past medical history of hypertension and hyperlipidemia presented with a cough and hemoptysis associated with fevers, chills, night sweats, and weight loss. The patient was recently admitted for similar complaints, and at the time, 3 AFBs were negative, sputum cultures were noted to be positive for Staphylococcus aureus, and a DNA probe was positive for Mycobacterium avium intracellulare. He previously discharged on a course of steroids and antibiotics. His symptoms progressed, and also, he was noted to have diffuse palpable purpura. During the prior admission, the patient also had a biopsy of a lung nodule, which demonstrated a necrotizing granuloma. He recently emigrated from China but had no previous tuberculosis history. The patient was admitted to the ICU, on high flow nasal cannula and was empirically treated for Hospital-Acquired Pneumonia and tuberculosis due to high clinical suspicion.CXR demonstrated multiple airspace opacifications with a CT angiogram demonstrative of extensive consolidation along with subcarinal and paratracheal lymphadenopathy. The alternate diagnosis of possible vasculitis was considered, and a skin biopsy, endobronchial biopsy, ANCA levels and C3 and 4 levels were obtained. The risks versus benefits of steroids and immunosuppressive therapy were considered, however, due to high suspicion for infectious etiology, empiric treatment for vasculitides was held.Despite the current treatment, the patient’s respiratory status worsened, leading to endotracheal intubation and repeat bronchoscopy was significant for diffuse edema, erythema, and bleeding. The patient’s hemodynamics also deteriorated requiring vasopressors. Patient’s AFB were confirmed to be negative, C3 and 4 were low, the skin biopsy was suggestive of leukocytoclastic vasculitis and biopsies were proved to be necrotizing vasculitis highly indicative of Granulomatosis with polyangiitis. The patient was started on pulse dose steroids arrangements for plasmapheresis were made. Unfortunately, the patient decompensated rapidly and died.This case highlights the significance of maintaining a wide differential diagnosis in similar clinical scenarios. It also demonstrates the difficult decision of starting immunosuppressive therapy in a patient with high suspicion for infections, especially M. tuberculosis.