19A186

“Now You See Me, Now You Don’t”. Large Lung Mass In Granulomatosis With Polyangitis (GPA), responds rapidly to treatment

Author(s)

Harkins P, Shah Q, Camon A, Wheelan E, Mohammad A, O’Rourke K .

Department(s)/Institutions

Midlands Regional Hospital Tullamore

Introduction

Background:
Granulomatosis with polyangitis (GPA) is a multisystem non-caseating granulomatous c-ANCA positive vasculitis which often presents with pulmonary involvement. Prompt recognition is essential to limit organ damage.


The Case:
We present the case of a 62-year-old gentleman with a 3-year background of GPA and rheumatoid arthritis (not currently taking prescribed medications), along with a thirty pack-year smoking history.

He presented to the emergency department with new onset dyspnea, fevers, arthralgia and a 13-kilogram weight loss over the previous one month period.
His inflammatory markers were elevated (CRP 27mg/L).

Chest X-ray (CXR) demonstrated consolidation in the posterior left upper lobe. Subsequent CT Thorax showed a large soft-tissue mass in the anterior aspect of the left upper lobe – suspicious for a bronchogenic carcinoma, with evidence of mediastinal and left hilar lymphadenopathy.

Whilst undergoing work-up for presumed primary lung carcinoma his symptomatic rheumatoid arthritis was treated with IV methylprednisolone.

He subsequently underwent bronchoscopy, broncho-alveolar lavage and fluoroscopy guided trans-bronchial biopsy of his lung lesion - all of which failed to diagnose a neoplastic process.

CXR repeated two weeks later showed that the previous consolidation had resolved. His CRP had normalized to 0.5mg/L. Follow up CT thorax was performed which showed significant improvement with the main anterior left upper lobe mass being completely resolved.


Conclusion
GPA often presents with pulmonary manifestations which range from mild upper respiratory tract symptoms to life-threatening pulmonary hemorrhage. The presentation in our case highlights the ability of GPA to mimic primary lung neoplasia which frequently requires invasive tests to further evaluate diagnostic possibilities. Rapid response to Steroids however is an important indicator that reversible, rather than sinister pathology is present. It is important that a flare of GPA be considered in the differential for a new and evolving lung mass.

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