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Pai S, Panda M. Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report. Cases J. 2008;1(1):417doi: 10.1186/1757-1626-1-417.
Pai, S., & Panda, M. (2008). Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report. Cases journal, 1(1), 417. https://doi.org/10.1186/1757-1626-1-417
Pai, Sushma, and Panda, Mukta. "Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report." Cases journal vol. 1,1 (2008): 417. doi: https://doi.org/10.1186/1757-1626-1-417
Pai S, Panda M. Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report. Cases J. 2008 Dec 23;1(1):417. doi: 10.1186/1757-1626-1-417. PMID: 19105841; PMCID: PMC2621135.
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Cases J. 2008 Dec 23;1(1):417. doi: 10.1186/1757-1626-1-417.

Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report.

Cases journal

Sushma Pai, Mukta Panda

Affiliations

  1. Department of Medicine, University of Tennessee, Chattanooga, Tennessee, USA. [email protected].

PMID: 19105841 PMCID: PMC2621135 DOI: 10.1186/1757-1626-1-417

Abstract

BACKGROUND: Rheumatoid arthritis has varied pleuroparenchymal manifestations. Wegener's granulomatosis can develop in an established case of rheumatoid arthritis and this association although previously reported is very rare.

CASE PRESENTATION: A 60-year-old lady had been diagnosed with rheumatoid arthritis on the basis of her clinical symptoms and serological tests which were positive RA factor and anti-CCP antibodies. Her rheumatoid arthritis activity had been mild and well controlled with hydroxychloroquine and low dose prednisone. She presented with a productive cough and right-sided pleuritic chest pain. CT scan of the chest showed three lung nodules with increased uptake on PET CT scan, raising concerns for an inflammatory or malignant process. The differential diagnosis included rheumatoid nodules, infections or malignancy. A CT-guided needle biopsy of the largest nodule was undertaken which showed vasculitis typical of Wegener's granulomatosis. Stains and cultures of the biopsy specimen were negative for bacteria, fungi and acid fast bacilli. A panel of serological tests for vasculitis were checked and showed elevated titers of cANCA and anti-proteinase 3 antibodies. Urine analysis and CT scan of paranasal sinuses was normal. Since the upper respiratory tract and the kidneys were spared a diagnosis of limited Wegener's granulomatosis affecting only the lungs was made. Due to the toxicity of cyclophosphamide, her relatively mild disease sparing the kidneys and the underlying rheumatoid arthritis, weekly methotrexate was started and low dose prednisone was continued. She had marked symptomatic improvement and complete resolution of the nodules was documented on subsequent imaging.

CONCLUSION: Wegener's granulomatosis developing in a patient with rheumatoid arthritis is very rare but should be considered as it warrants a different and possibly more aggressive treatment approach.

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