SHM Converge Scientific Abstract ePoster Gallery-Pulmonary Cavities Beyond Tuberculosis: Lessons From a Complex Case

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This case report describes a 45-year-old man recently immigrated from India who was initially treated for presumed pulmonary tuberculosis because of cavitary lung lesions and epidemiologic risk. After three weeks of RIPE therapy, he worsened with dyspnea, epistaxis, hearing loss, and eye irritation. RIPE was stopped due to abnormal liver tests and a previously negative TB work-up. Repeat chest imaging showed enlarging cavitary lesions, but further examination revealed findings strongly suggestive of granulomatosis with polyangiitis (GPA), including nasal septal perforation, tympanic membrane perforations, subretinal/choroidal eye lesions, strawberry gingivitis, and palpable purpura.<br /><br />Laboratory testing supported GPA, with positive c-ANCA and elevated proteinase 3 (PR3)-IgG. Bronchoalveolar lavage was negative for MTB PCR and AFB culture, helping exclude active TB. The patient was treated with methylprednisolone and rituximab.<br /><br />The report highlights the diagnostic challenge of cavitary lung lesions, which can occur in both TB and GPA. In this case, the patient’s geography and symptoms initially favored TB, but lack of improvement on RIPE therapy and multisystem findings prompted reconsideration. The authors emphasize that ANCA and PR3 testing can be useful in distinguishing GPA from TB-like presentations. They also note that, even when TB has not been definitively excluded, early corticosteroid treatment for suspected GPA may be reasonable because available evidence suggests limited harm and possible benefit if TB is concurrently present.<br /><br />Overall, the case warns against diagnostic bias and underscores the importance of broad differential diagnosis when evaluating cavitary pulmonary lesions.

Asset Subtitle

Jonathon M. Monroe

Meta Tag

Author List Babar Junaidi, David Krakow, Evan Heiderscheit, Jonathon M. Monroe

Category Clinical Vignettes

Concept Granulomatosis with Polyangiitis

Concept Tuberculosis

Concept Cavitary Lung Lesion

Concept Proteinase 3 ANCA

Concept MTB PCR

Distinguished Non-Finalist

Presenter Organization Emory University School of Medicine

Presenting Author Jonathon M. Monroe

Track Adult

Keywords

granulomatosis with polyangiitis

cavitary lung lesions

tuberculosis differential

c-ANCA

PR3-IgG

nasal septal perforation

strawberry gingivitis

palpable purpura

rituximab

methylprednisolone

Granulomatosis with Polyangiitis

Tuberculosis

Cavitary Lung Lesion

Proteinase 3 ANCA

MTB PCR