The patients creatinine was also increased from 0

The patients creatinine was also increased from 0.5-0.7 mg/dL on initial presentation to 1.1 mg/dL. to facilitate clinical recognition and treatment for the same. strong class=”kwd-title” Keywords: lung biopsy, cavitary lesions, anca-associated vasculitis, rheumatoid arthritis (ra), granulomatosis with polyangiitis (gpa) Introduction Granulomatosis with polyangiitis (GPA) is one of the few small/medium-sized vessel vasculitides with a wide systemic distribution [1]. It is an antineutrophil cytoplasmic antibody (ANCA)-associated granulomatous inflammatory process that has a predilection for the upper and lower respiratory tracts and the kidneys. GPA has variable clinical presentations, which may cause a delay in diagnosis and prompt management. It has a mortality rate of about 80% if left untreated [1,2]. A detailed history, imaging findings, and biopsy results could help in early treatment, which may reduce mortality. We present a case of a 55-year old female with a history of rheumatoid arthritis (RA) who presented with recurrent upper/lower respiratory tract symptoms and responded poorly to antibiotics. Biopsy-proven GPA led to appropriate management with the resolution of symptoms. Although other overlap syndromes have been described in association with rheumatoid arthritis, ANCA-associated vasculitides overlapping with RA is extremely rare, with few cases described in the medical literature [3]. Furthermore, an overlap between GRK4 RA and cytoplasmic-ANCA (c-ANCA)-associated GPA is rare, and there should be high suspicion for GPA in patients with similar symptoms who were previously diagnosed with RA. Case presentation A 55-year- old female with a past medical history of RA, diagnosed five years ago with a positive rheumatoid factor of 118 IU/mL (normal reference 14 IU/mL), presented to the emergency department (ED) with complaints of worsening sinus congestion that started three months prior to admission. Symptoms included post-nasal drip, worsening cough, night sweats, perforated nasal septum, episodes of nosebleeds, and a 15-pound unintentional excess weight loss during this period. She experienced also recently noticed a collapse of the HG-9-91-01 bridge of her nose. Of notice, she experienced multiple appointments to otolaryngologists for the same issues. Antibiotics and bi-nasal washes did not provide any relief from her symptoms. She refused any chest pain, fever, chills, loss of smell/taste, shortness of breath, nausea, vomiting, or HG-9-91-01 recent ill contacts. Home medications were methotrexate, hydroxychloroquine, folic acid, and ibuprofen. Family history was impressive for breast tumor in the mother and melanoma in the brother. She refused any tobacco or recreational drug use in the past and drank alcohol occasionally.? Her initial vital signs showed a blood pressure of 132/60 mmHg, heart rate of 102 beats per minute, respiratory rate of 20 breaths per minute, temp of 97H, and oxygen saturation of 97% on space air. Examination of the individuals nose showed saddle nose deformity with septal perforation. The cardiopulmonary exam was impressive for tachycardia and diffuse? lung crackles bilaterally on auscultation. The musculoskeletal exam was significant for slight swelling of the remaining third metacarpophalangeal (MCP) joint, slight fullness of the remaining third MCP joint with slight tenderness, and slight tenderness of the second and third proximal interphalangeal (PIP) bones. Initial laboratory analysis is demonstrated in Table ?Table11.? Table 1 Laboratory results?c-ANCA: cytoplasmic antineutrophil cytoplasmic antibody; ANCA: antineutrophil cytoplasmic antibody; RBCs: reddish blood cells; HPF: high power field Name of the testResults?Research rangeHemoglobin (g/dL)8.8 (g/dL)12.0-16.0 (g/dL)White blood cells (103/uL)12.9 (103/uL)4.5-11.0 (103/uL)Sodium (mmol/L)137 (mmol/L)136-145 (mmol/L)Potassium (mmol/L)3.5 (mmol/L)3.5-5.0 (mmol/L)Blood urea nitrogen (BUN) (mg/dL)10 (mg/dL)5-25 (mg/dL)Creatinine (mg/dL)0.65 (mg/dL)0.44-1.0 (mg/dL)Antiproteinase-3 antibodies (U/mL)10.4 (U/mL)0.0-3.5 (U/mL)Cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) IgG titer1:40 1:20Perinuclear ANCA 1:20 1:20Anti-myeloperoxidase antibodies? 9.0 (U/mL)0-9.0 (U/mL)Anti-glomerular basement membrane antibodies (devices)2 (devices)0-20 (devices)?Urinalysis; reddish blood cells/high power field (RBCs/HPF)3-100-2?Urine protein/creatinine percentage?269 (mg/g)0-200 (mg/g) Open in a separate window Initial chest x-ray revealed multiple cavitating and non-cavitating masses scattered throughout the lungs bilaterally, largest on the right, measuring 7.4 cm in diameter HG-9-91-01 (Number ?(Figure11). Number 1 Open in a separate window Chest x-ray showing multiple bilateral non-cavitating and cavitating people (reddish arrows) Computed tomography angiography of the chest exposed cavitary and non-cavitary people with the?largest cavitary lesion in the superior section of HG-9-91-01 the right lower lobe (Figures ?(Numbers2A,2A, ?,2B2B).? Number 2 Open in a separate windowpane Computed tomography angiography of the chest.