Pulmonary granulomas in a patient with positive ANCA and history of tuberculosis: case report

BACKGROUND: Granulomatous polyangiitis (GPA) is a rare multisystem autoimmune disease of unknown aetiology that is pathologically characterised by necrotising vasculitis, tissue necrosis and granulomatous inflammation, typically in the presence of anti-neutrophil cytoplasmic antibodies (ANCA). However infectious diseases may induce high titre ANCA and mimic vasculitis. Tuberculosis may share many clinical features with GPA including fever, arthralgia, granulomatous inflammation and pulmonary lesions and patients. CASE PRESENTATION: A 39 year old patient was admitted with ocular irritation and redness, arthralgia and multiple new pulmonary lesions. The past medical history was significant for two episodes of tuberculosis previously requiring prolonged treatment. ANCA antibodies were positive and CT showed multiple pulmonary lesions including cavitatory lesions. After extensive investigation, the patient was treated for GPA with high dose immune suppression with good clinical response. CONCLUSIONS: Here we review the diagnostic considerations between differentiating GPA and tuberculosis in patients from endemic regions. It is recommended that biopsies of lung lesions, sputum microscopy and multidisciplinary team input are sought as part of the workup when these two differentials are being considered.