New Onset Granulomatosis with Polyangiitis Associated with C
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A 46-year-old man with a past medical history of diabetes presented to the emergency room with symptoms of cough, shortness of breath, and fevers for four weeks. He was treated for suspected pneumonia with azithromycin two weeks prior to presentation and denied any improvement in respiratory symptoms thereafter. In addition, he developed a painful and pruritic rash that was progressively worsening over the last two weeks.

On physical examination, he was afebrile (36.9?C) with tachycardia (110?bpm), blood pressure 127/77?mm Hg, respiratory rate 20, and O2 saturation 94% on room air. He had erosions on bilateral nasal mucosa and vermillion lips with overlying crusts. Oropharynx was clear. There were purpuric macules and papules on bilateral palms, arms, and legs, few with overlying vesicular changes and collarettes of scale. He also had retiform purpuric macules and patches on buttocks and thighs, as well as ulcerations on buttocks at the gluteal cleft.

Laboratory evaluation showed an elevated white blood cell count (15.3K/?L), decreased hemoglobin (10.3?g/dL), elevated blood urea nitrogen (48?mg/dL), creatine (2.9?mg/dL), and D-dimer (8,922?ng/mL). He was cANCA positive, coronavirus PCR negative via nasopharyngeal swab, and coronavirus antibody IgM positive and IgG negative. CT scan of the chest showed patchy ground-glass opacities in the lungs.

Biopsy of skin showed superficial and deep perivascular inflammation with thrombus formation. High-power view showed an infiltrate composed of lymphocytes, histiocytes, neutrophils, and eosinophils, with prominent erythrocyte extravasation, leukocytoclasia, and fibrinoid necrosis of vessels. Renal biopsy showed interstitial mixed cell infiltrates and intraglomerular thrombi and necrosis, concerning for GPA.

Based upon his clinical presentation, histologic findings, and laboratory studies, the patient was diagnosed with GPA in the setting of suspected coronavirus infection. He was first treated for coronavirus with five-day course of hydroxychloroquine, followed by treatment of GPA with systemic steroids and rituximab infusion. Kidney function improved, and his rash completely resolved. He was discharged on a steroid taper.