Suspected as Pulmonary Tuberculosis: A Case Report from a Tertiary Center in Nepal

Abstract

Granulomatosis with polyangiitis (GPA), previously called Wegener’s granulomatosis, is a rare type of small-vessel vasculitis that causes necrotizing granulomatous inflammation, mainly affecting the respiratory tract and kidneys. In areas where tuberculosis is common, it can easily be mistaken for an infection like pulmonary TB, which often leads to delayed diagnosis.
We report a case of a 66-year-old man who came in with hemoptysis and was initially thought to have pulmonary tuberculosis. His condition quickly deteriorated, developing massive hemoptysis, difficult-to-control hypertension, and acute kidney injury, with his serum creatinine rising sharply from 1.4 mg/dL to 5.3 mg/dL within a short time. Chest X-ray showed a homogeneous mass in the middle zone of the right lung, while CT scan findings were consistent with diffuse alveolar hemorrhage. Procalcitonin was normal, helping rule out bacterial infection. On further questioning, he mentioned a history of recurrent sinusitis. With involvement of multiple organ systems, we suspected vasculitis. Serology confirmed the diagnosis when cytoplasmic ANCA (c-ANCA) came back positive.
He was started on high-dose methylprednisolone and rituximab, but the response was limited. We then added plasmapheresis. After three sessions, there was a clear improvement in his hemoptysis and kidney function.
This case illustrates how challenging it can be to diagnose GPA in tuberculosis-endemic regions and emphasizes the need to keep vasculitis in mind when patients present atypically and do not respond as expected to standard treatment.