Current clinical and therapeutic approach to tumour-like mass lesions in granulomatosis with polyangiitis

Mass-Forming Variants in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Diagnostic Complexities in Granulomatous Disease. A Case Report

A middle-aged woman presented with a granulomatous breast lesion in 2018. By 2021, antibiotic-resistant pneumonia led to the discovery of granulomatous inflammation in the lung and thyroid. Initially misdiagnosed as Erdheim-Chester disease (ECD), she was treated with interferon without success. Histopathology later ruled out ECD, suggesting an unspecified granulomatous disease, with granulomatosis with polyangiitis (GPA) initially excluded due to negative antineutrophil cytoplasmic antibodies (ANCAs) and foamy histiocytes. In 2023, repeated lung biopsy and PR3-ANCA positivity led to a revised diagnosis of mass-forming GPA. Rituximab therapy resulted in remission. This case highlights the diagnostic complexity of GPA with atypical histopathological features.

Rare association of granulomatosis with polyangiitis with an underdiagnosed spondyloarthritis effectively treated with rituximab: A case-report

RATIONALE

Associations of autoimmune diseases are rare but interesting and challenging situations from a diagnostic, pathophysiological, and therapeutic point of view. This article studies a rare association of autoimmune diseases by discussing the pathophysiological hypotheses and an original therapeutic management. The coexistence of antineutrophil cytoplasmic antibody-associated vasculitis and spondyloarthritis has rarely been described.

PATIENT CONCERNS

We present a patient with inflammatory back pain, stiffness, and enthesopathies followed by pulmonary and ear, nose and throat granulomatous involvement.

DIAGNOSES

A combination of spondyloarthritis and granulomatosis with polyangiitis, with spinal, enthesopathic, pulmonary, and ear, nose and throat involvement.

INTERVENTIONS AND OUTCOMES

Effective treatment with rituximab both on spondyloarthritis and vasculitis.

LESSONS

We discuss the pathogenic, diagnostic, and therapeutic implications of this rare but intriguing association between these 2 inflammatory conditions.

Granulomatosis with polyangiitis, complicated by ocular adnexa lesion and vascular changes in retina and choroid (literature review with a clinical case)

Granulomatosis with polyangiitis (GPA) is manifested as ocular pathology in almost a third of patients, which can either be detected at the onset of the disease or occur in the late stages. The pathological process involves the orbit, sclera, episclera, cornea, conjunctiva, eyelids, nasolacrimal system, optic nerve, retina and choroid. Lesion of eye and its surrounding structures determines the severity of the pathological process, the patient’s quality of life and prognosis. The article presents a clinical case of a 38-year-old man with an unfavorable course of GPA, lesion to upper and lower respiratory tract, kidneys, and musculoskeletal system. The authors consider ocular manifestations in the context of a systemic disease. An ophthalmological examination of the patient revealed changes in sclera and choroid, which had not previously been described in detail in the literature. The patient underwent cataract phacoemulsification in the right eye with implantation of a posterior chamber intraocular lens. The dynamics of clinical manifestations of eye lesion in the near future is positive, but in the long term it remains doubtful due to pronounced changes in the orbit and adnexa of the eye against the background of ongoing small vessels vasculitis. Early consultation with an ophthalmologist and optical coherence tomography in patients with GPA are necessary at any stage of the disease. The clinical case is presented with consideration to the CARE 2021 recommendations.

Cutting-Edge Strategies for Renal Tumour-like Lesions in Granulomatosis with Polyangiitis: A Systematic Review

BACKGROUND

Granulomatosis with polyangiitis (GPA) is characterised by granulomatous inflammation and small-to-medium vessel necrotising vasculitis, mainly affecting respiratory tract and kidneys. Renal involvement presenting as tumour-like lesions poses diagnostic and treatment challenges.

METHODS

Following the observation of a GPA patient presenting with multiple renal tumour-like lesions, we conducted a systematic literature review on MEDLINE/PubMed, EMBASE, and Cochrane databases. Data gathered from the literature were analysed to summarise the diagnostic approach, management, and outcome of renal GPA-related tumour-like lesions.

RESULTS

a 49-year-old female presented with persistent constitutional symptoms and multiple bilateral renal lesions. Renal biopsy showed chronic interstitial inflammation with necrotising granulomas. Laboratory tests disclosed positive anti-proteinase 3 (PR3) anti-neutrophil cytoplasmic antibody (ANCA) leading to a final diagnosis of GPA. She was effectively treated with high-dose glucocorticoids and rituximab. Literature search yielded 41 articles, concerning 42 GPA patients with renal masses, presenting bilaterally in 23.8% of the cases. Positive PR3-ANCA was observed in 86.5% of the cases. Half of 42 patients showed kidney abnormalities. Treatment with glucocorticoids (83.3%) and immunosuppressive agents (80.9%) resulted in an overall good remission rate and favourable prognosis.

CONCLUSIONS

GPA should be considered in the differential diagnoses of kidney tumour-like lesions. The diagnosis is challenging, and histological examination greatly contributes to the diagnostic work-up.

Imaging of Small Artery Vasculitis

Small artery vasculitis of the CNS is a rare and serious condition characterized by the inflammation of blood vessels within the brain and spinal cord. There are two groups of small artery vasculitis determined by the presence or absence of immunoglobulin complex deposition in the vessel wall. The former includes anti-glomerular basement membrane disease, cryoglobulinemic vasculitis, and IgA vasculitis. Absence of immune complex deposition is associated with anti-neutrophil cytoplasmic antibody (ANCA) and includes microscopic polyangiitis, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and primary angiitis of the CNS. These conditions present a diagnostic challenge in which imaging plays a crucial role.

Mass-like Lesions Causing Compression of Large Vessels in Granulomatosis with Polyangiitis

A 69-year-old woman with a history of otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitis who had been receiving corticosteroid monotherapy presented with shortness of breath. The otitis media had been alleviated, but she had saddle nose. Chest enhanced computed tomography showed stenoses of the bronchi and large vessels surrounded by mass-like lesions in the mediastinum. These manifestations indicated an active state of granulomatosis with polyangiitis (GPA). After she was started on high-dose corticosteroids and intravenous cyclophosphamide, the mass-like lesions disappeared with improvements of the stenoses. Ameliorating mass-like lesions resulting from GPA requires therapeutic intervention using corticosteroids and immunosuppressants.

The eye is a common site of granulomatosis with polyangiitis. A collaborative study

BACKGROUND

Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%).

METHODS

Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination.

RESULTS

The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined.

CONCLUSIONS

The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.

Simultaneous testicle and epididymis vasculitis revealing granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing granulomatous vasculitis, which predominantly affects small-sized blood vessels. We aimed to report a case of GPA involving testicles and epididymis taken for malignancy. A 75-year-old patient was admitted for a painful left testicular mass. There was no extra urogenital manifestations on examination and the workup was unremarkable. Histological findings after orchidectomy revealed granulomatous inflammation of the testis and epididymis with fibrinoid necrosis and necrotic vasculitis consisting with the diagnosis of GPA. Further investigations regarding ear, nose, throat, pulmonary, and renal involvement were negative. Proteinase 3 antineutrophil cytoplasmic antibodies (PR3-ANCA) test was negative. Furthermore, infectious diseases especially tuberculosis were ruled out. Based on histopathological findings, limited GPA was diagnosed. The patient was treated with methotrexate and prednisone with good outcome. There was no relapse after 1 year of follow-up. Isolated urogenital involvement may occur at the onset of GPA and can be taken for malignancy. Histopathological findings are the gold standard for the diagnosis. Treatment is based on steroids and immunosuppressive drugs.