Case Report
A 44 Year-old-man With Cavitary Pulmonary Disease
Paciente masculino de 44 años con enfermedad cavitaria pulmonar
Marco Ulises Martínez-Martíneza, Alejandro Gómez-Gómezb, Cuauhtémoc Oros-Ovallec, Carlos Abud-Mendozaa,
Corresponding author
a Unidad de Investigaciones Reumatológicas, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
b Departamento de Neumología, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
c Departamento de Patología, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
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Carlos Abud-Mendoza" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Marco Ulises" "apellidos" => "Martínez-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Alejandro" "apellidos" => "Gómez-Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Cuauhtémoc" "apellidos" => "Oros-Ovalle" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Carlos" "apellidos" => "Abud-Mendoza" "email" => array:1 [ 0 => "c_abud@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Investigaciones Reumatológicas, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Neumología, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Patología, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paciente masculino de 44 años con enfermedad cavitaria pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 542 "Ancho" => 1750 "Tamanyo" => 194840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray showing multiple cavitations, a giant one in the right lower lobe. (B) Chest CT showing a thick-walled cavity. (C) Material from the lung biopsy showing acid-fast bacilli (arrow) (Ziehl–Neelsen).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The association of pulmonary tuberculosis granulomas with polyangiitis (Wegener) (GPA) is rare. Both diseases have similar clinical features including cavitary lung disease. We describe the case of a patient with clinical features and laboratory and imaging findings common in both diseases, something which represents a challenge for diagnosis and treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Male patient, 44 years, with GPA diagnosed in April 2003 due to weight loss, cough, recurrent episodes of nodular scleritis, mononeuritis multiplex and cavitary nodules in a chest CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A); he also presented proteinuria (50<span class="elsevierStyleHsp" style=""></span>mg/dl), and dysmorphic microhematuria with positive neutrophil cytoplasmic antibodies (cANCA). He received glucocorticoids and 7 cycles of IV cyclophosphamide, with methotrexate as maintenance therapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In July 2009 he relapsed, presenting productive cough without hemoptysis, mononeuritis multiplex, proteinuria (50<span class="elsevierStyleHsp" style=""></span>mg/dl), dysmorphic hematuria and elevated CRP (16.7<span class="elsevierStyleHsp" style=""></span>mg/dl). Chest CT showed a suggestive image with a crescent sign (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), characteristic of aspergiloma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To exclude infection, we performed a biopsy of the lesion, which reported granulomas (disease activity). Cultures and stains for mycobacteria and fungal infections ruled them out (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Again, he received cyclophosphamide (7 cycles), methylprednisolone, and azathioprine for maintenance.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In October 2010, the patient required hospitalization due to weight loss and a 4 week history of cough and hemoptysis, presenting leukocytosis (11×10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>μl<span class="elsevierStyleSup">−1</span>), anemia (11.8<span class="elsevierStyleHsp" style=""></span>g/dl), thrombocytosis (603×10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>μl<span class="elsevierStyleSup">−1</span>), high titers of antibodies to proteinase 3 (130.7<span class="elsevierStyleHsp" style=""></span>U/ml) and elevated C-reactive protein (11.74<span class="elsevierStyleHsp" style=""></span>mg/dl). The radiograph showed multiple bilateral nodules, some cavitated, and a large cavitation in the right lower lobe (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A); a CT scan confirmed the findings, showing cavitations with thick walls (more than 5<span class="elsevierStyleHsp" style=""></span>mm) and increased irregularity (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). PPD testing was negative. A bronchoscopy with biopsy was performed, showing the presence of acid-fast resistant bacilli (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C); a polymerase chain reaction reported <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis of cavitary lung disease in this patient with immunosuppressive therapy included both disease activity and an infectious process as well as, ultimately, cancer. The high titers of anti-proteinase 3 antibodies and the presence of nodules are related to disease activity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Among the factors associated with severe infections is the use of cyclophosphamide and glucocorticoids, essential for the management of GPA.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In developing countries, infectious disease due to cavitary pulmonary tuberculosis is very common and has clinical and radiological features similar to GPA.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Additionally, there are reports that highlight the presence of cANCA in 40% of patients with tuberculosis,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> however, positive proteinase 3 antibodies may be due to treatment for tuberculosis, as pointed out by Esquivel-Valerio et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Because our patient had not received TB treatment, the context suggested GPA activity. On the other hand, the biopsy diagnosed pulmonary tuberculosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0030" class="elsevierStylePara elsevierViewall">GPA and pulmonary tuberculosis have similar clinical characteristics. On the one hand, pulmonary involvement with cavitation, hemoptysis, fever and weight loss, and on the other hand, patients on TB treatment may have antiproteinase 3 antibody positivity. There are a few reported cases of the association of GPA and tuberculosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Our patient is of interest since the first biopsy ruled out the diagnosis of infectious disease and the second confirmed the presence of tuberculosis; in addition, the patient had high levels of antibodies to proteinase 3, which also suggest disease activity. We emphasize the obligation to look for infection in patients with rheumatic diseases receiving immunosuppressive therapy, even when clinical and paraclinical features are suggestive of disease activity.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres124471" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec111756" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres124470" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec111755" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-24" "fechaAceptado" => "2012-01-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec111756" "palabras" => array:4 [ 0 => "Wegener granulomatosis" 1 => "Granulomatosis with polyangiitis" 2 => "Tuberculosis" 3 => "Pulmonary tuberculosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec111755" "palabras" => array:4 [ 0 => "Granulomatosis de Wegener" 1 => "Granulomatosis con poliangeítis" 2 => "Tuberculosis" 3 => "Tuberculosis pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Granulomatosis with polyangiitis (Wegener) (GPA) was diagnosed in a 44 year-old-man who had a relapse 6 years after diagnosis with the “air crescent” sign on chest CT. Seven years after his diagnosis the patient presented a new relapse with cavitary lung disease, and high levels of anti-proteinase 3 antibodies, suggesting disease activity; however, a transbronchial biopsy showed histological findings of tuberculosis (TB). The association between TB and GPA is rarely informed; moreover TB and GPA have similar findings including both clinical and anti-proteinase 3 antibodies.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Paciente masculino de 44 años, con diagnóstico de granulomatosis con poliangeítis (Wegener) (GPA) y recaída 6 años después, con el signo de la media luna creciente en la tomografía. Siete años después del diagnóstico, el paciente presentó otro episodio con empeoramiento de la enfermedad cavitaria pulmonar y altos niveles de anticuerpos antiproteinasa 3, lo que sugirió actividad de la enfermedad; adicionalmente, la biopsia transbronquial informó tuberculosis pulmonar (Tb). La asociación entre Tb y GPA es rara, aunque estas 2 enfermedades tienen características clínicas similares y se acompañan de anticuerpos antiproteinasa 3 que se han asociado a tratamiento antifímico.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Martínez-Martínez MU, et al. Paciente masculino de 44 años con enfermedad cavitaria pulmonar. Reumatol Clin. 2013;<span class="elsevierStyleBold">9</span>:62–64.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 489 "Ancho" => 1750 "Tamanyo" => 155967 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Multiple bilateral nodules on chest CT, some cavitated, with areas of consolidation. (B) Sign of the air crescent (arrow). (C) Non casseus granuloma in the lung biopsy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 542 "Ancho" => 1750 "Tamanyo" => 194840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray showing multiple cavitations, a giant one in the right lower lobe. (B) Chest CT showing a thick-walled cavity. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 40 | 31 | 71 |
| 2024 September | 67 | 13 | 80 |
| 2024 August | 65 | 36 | 101 |
| 2024 July | 56 | 27 | 83 |
| 2024 June | 67 | 35 | 102 |
| 2024 May | 59 | 37 | 96 |
| 2024 April | 68 | 16 | 84 |
| 2024 March | 75 | 19 | 94 |
| 2024 February | 35 | 25 | 60 |
| 2024 January | 86 | 25 | 111 |
| 2023 December | 58 | 21 | 79 |
| 2023 November | 72 | 52 | 124 |
| 2023 October | 77 | 25 | 102 |
| 2023 September | 87 | 44 | 131 |
| 2023 August | 59 | 18 | 77 |
| 2023 July | 54 | 31 | 85 |
| 2023 June | 50 | 22 | 72 |
| 2023 May | 47 | 16 | 63 |
| 2023 April | 51 | 6 | 57 |
| 2023 March | 77 | 38 | 115 |
| 2023 February | 69 | 26 | 95 |
| 2023 January | 66 | 18 | 84 |
| 2022 December | 88 | 34 | 122 |
| 2022 November | 96 | 34 | 130 |
| 2022 October | 147 | 50 | 197 |
| 2022 September | 148 | 47 | 195 |
| 2022 August | 87 | 50 | 137 |
| 2022 July | 70 | 56 | 126 |
| 2022 June | 103 | 41 | 144 |
| 2022 May | 72 | 45 | 117 |
| 2022 April | 114 | 69 | 183 |
| 2022 March | 85 | 57 | 142 |
| 2022 February | 82 | 39 | 121 |
| 2022 January | 79 | 46 | 125 |
| 2021 December | 72 | 38 | 110 |
| 2021 November | 53 | 48 | 101 |
| 2021 October | 69 | 54 | 123 |
| 2021 September | 51 | 40 | 91 |
| 2021 August | 44 | 35 | 79 |
| 2021 July | 46 | 24 | 70 |
| 2021 June | 50 | 34 | 84 |
| 2021 May | 47 | 33 | 80 |
| 2021 April | 114 | 92 | 206 |
| 2021 March | 65 | 35 | 100 |
| 2021 February | 31 | 25 | 56 |
| 2021 January | 34 | 21 | 55 |
| 2020 December | 42 | 22 | 64 |
| 2020 November | 23 | 13 | 36 |
| 2020 October | 21 | 13 | 34 |
| 2020 September | 31 | 32 | 63 |
| 2020 August | 35 | 14 | 49 |
| 2020 July | 35 | 16 | 51 |
| 2020 June | 39 | 12 | 51 |
| 2020 May | 40 | 14 | 54 |
| 2020 April | 31 | 18 | 49 |
| 2020 March | 22 | 12 | 34 |
| 2020 February | 2 | 0 | 2 |
| 2019 July | 1 | 0 | 1 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 1 | 0 | 1 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 5 | 0 | 5 |
| 2018 December | 15 | 0 | 15 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 47 | 7 | 54 |
| 2018 March | 55 | 9 | 64 |
| 2018 February | 26 | 8 | 34 |
| 2018 January | 33 | 8 | 41 |
| 2017 December | 42 | 6 | 48 |
| 2017 November | 37 | 7 | 44 |
| 2017 October | 35 | 5 | 40 |
| 2017 September | 44 | 5 | 49 |
| 2017 August | 36 | 8 | 44 |
| 2017 July | 34 | 9 | 43 |
| 2017 June | 62 | 13 | 75 |
| 2017 May | 66 | 11 | 77 |
| 2017 April | 43 | 7 | 50 |
| 2017 March | 55 | 16 | 71 |
| 2017 February | 41 | 8 | 49 |
| 2017 January | 47 | 8 | 55 |
| 2016 December | 96 | 21 | 117 |
| 2016 November | 84 | 13 | 97 |
| 2016 October | 114 | 11 | 125 |
| 2016 September | 106 | 10 | 116 |
| 2016 August | 104 | 9 | 113 |
| 2016 July | 56 | 8 | 64 |
| 2016 May | 1 | 0 | 1 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 4 | 0 | 4 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 44 | 4 | 48 |
| 2015 June | 57 | 15 | 72 |
| 2015 May | 90 | 15 | 105 |
| 2015 April | 59 | 14 | 73 |
| 2015 March | 74 | 15 | 89 |
| 2015 February | 70 | 13 | 83 |
| 2015 January | 73 | 20 | 93 |
| 2014 December | 50 | 13 | 63 |
| 2014 November | 53 | 7 | 60 |
| 2014 October | 47 | 16 | 63 |
| 2014 September | 47 | 19 | 66 |
| 2014 August | 57 | 17 | 74 |
| 2014 July | 56 | 10 | 66 |
| 2014 June | 69 | 12 | 81 |
| 2014 May | 70 | 17 | 87 |
| 2014 April | 84 | 13 | 97 |
| 2014 March | 84 | 17 | 101 |
| 2014 February | 63 | 11 | 74 |
| 2014 January | 73 | 11 | 84 |
| 2013 December | 77 | 8 | 85 |
| 2013 November | 61 | 9 | 70 |
| 2013 October | 89 | 12 | 101 |
| 2013 September | 83 | 10 | 93 |
| 2013 August | 84 | 25 | 109 |
| 2013 July | 72 | 17 | 89 |
| 2013 June | 67 | 19 | 86 |
| 2013 May | 74 | 17 | 91 |
| 2013 April | 77 | 25 | 102 |
| 2013 March | 76 | 34 | 110 |
| 2013 February | 18 | 8 | 26 |
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