Answer to previous #DiagnosticDilemma
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A 26-year-old woman presented at week 20 of pregnancy with a 3-month history of fever, cough, and breathlessness. She had hearing loss, epistaxis, nasal crusting, haemoptysis, and a purpuric rash over her legs. No significant weight loss was reported. Chest x-ray (with abdominal shield) showed bilateral cannonball opacities, and contrast-enhanced chest CT (with abdominal shield) revealed multiple nodules, without pleural effusion or lymphadenopathy.

A diagnosis of granulomatosis with polyangiitis was made. The most common chest radiological finding at presentation in patients with granulomatosis with polyangiitis is bilateral nodules or masses (reported in up to 90% of patients in case series). In the current case, hearing loss, purpuric rash, and upper respiratory symptoms led us to suspect granulomatosis with polyangiitis. The absence of pleural effusion or lymphadenopathy on chest radiology made a diagnosis of malignancy or infection less likely, the normal pelvic ultrasound helped to rule out choriocarcinoma, and the negative Mantoux test, sputum workup, and fungal serology helped to rule out infection. Elevated concentrations of anti-proteinase 3 antibodies and the patient’s rapid response to immunosuppression contributed to confirmation of the diagnosis.

Granulomatosis with polyangiitis is a small-vessel vasculitis that can mimic malignancy and infections. This diagnosis should be suspected in patients with lung nodules when there are accompanying upper respiratory tract symptoms, rash, neuropathy, or eye, ear, or renal involvement.

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