Dr. Mayo presented a great case of an atypical presentation of GPA in an elderly female with a history of breast cancer who presented with progressive, non-productive cough and nasal congestion despite abx courses, found to have a single cavitary lung lesion that ultimately showed granulomas in addition to +PR3-ANCA.

Learning Points:

We reviewed the ddx of cavitary lung lesions, especially given our patient had an extensive travel history and personal history of breast cancer. The differential includes:

  • Infections (necrotizing infections with anaerobic or other bacteria, mycobacteria, fungi, parasites or septic pulmonary emboli)
  • Non-infectious (PE with infarction, vasculitis, neoplasm, COP, sarcoid, rheumatoid nodules, among others)

Dr. Mayo presented information regarding the ACR guidelines for diagnosis of GPA (included below).

ACR guidelines.PNG

She additionally reviewed a 2005 RCT by de Groot et al published in Arthritis & Rheumatology comparing cyclophosphamide and methotrexate for induction and remission of ANCA-associated vasculitis without significant renal involvement. This study found that remission with methotrexate took about 2 months longer compared to cyclophosphamide. Additionally, methotrexate had higher relapse rates as well. However, it is still important to consider the potential risk/benefit profile of MTX vs CYC for each individual patient.