COVID-19-
induced Granulomatosis with Polyangiitis:a Case Report and Literature
Review
【Abstract】 Objective To report a case of Granulomatosis with
Polyangiitis (GPA)with Diffuse alveolar hemorrhage(DAH)that developed
following Coronavirus disease 2019 (COVID-19) in an adolescent boy, and
perform a literature review to better understand this
disorder.Methods Retrospectively analyze the data of a case of
GPA following COVID-19 infection, to summarize the clinical
characteristics of GPA following COVID-19 infection by searching the
database (PubMed,Wanfang Data,CNKI) and comprehensively analyze the
literature results. Results9 cases were reported,combined with
our case,there were 10 cases of GPA
following COVID-19 infection,including 4 males and 6
females,with an average age
of(40.6±18.6)years,and the time
interval between COVID-19 and diagnosis of GPA ranged from 1 day to 3
months for all 10 cases. The rate of mortality was
10.0%(1/10).Commonly seen clinical
manifestations were cough(70.0%),dyspnea(50.0%),and
Arthralgia/Myalgia(40.0%). CT scans showed ground-glass
opacities,multifocal pulmonary nodules.Of all these patients, c-ANCA
and PR3-antibody
positivity were found
.Conclusion COVID-19 pneumonia
and
COVID-19- induced new-onset GPA
share many clinical and radiological features, making it challenging for
clinicians to distinguish between the two. Our study also provided some
clues about the diagnostic challenge of GPA induced by COVID-19.
【Key words】 Coronavirus disease 2019;granulomatosis with
polyangiitis;Case report;Literature Review
Background Granulomatosis with Polyangiitis (GPA) is a
potentially fatal multisystem disease marked by necrotising
granulomatous vasculitis of the minor arteries and veins. This condition
mostly affects the lungs, upper respiratory tract and kidney.Although
the processes behind the development of GPA are unknown, several factors
such as infection, medications, and environmental exposure may play a
role in the disease’s pathophysiology by inducing autoimmunity[1, 2]
.Since the advent of the Coronavirus
disease 2019 (COVID-19)pandemic, several reports have described AAV(anca
associated systemtc vasculitis) occurrence after COVID-19 , indicating
the potential of COVID-19 to trigger the development of GPA .We herein
present a case of new-onset GPA with DAH(diffuse alveolar hemorrhage)
that developed following COVID-19 infection in an adolescent
patient,this is the first case of GPA with DAH in an adolescent in Hunan
province of China, which developed shortly after COVID-19 infection, and
we review the literature of GPA following COVID-19 infection by
searching the database,to summarize the clinical characteristics of GPA
following COVID-19.
Case Presentation
A 16-year-old boy with no past medical history presented to our Hospital
with a 1-month history of
fever,cough and shortness of breath,
accompanying symptoms were epistaxis and tinnitus.One month prior to the
onset of illness, the patient was exposed to a COVID-19 positive sick
contact, so at the onset of symptoms, our patient was tested and
returned positive for COVID-19 nucleic acid test.Before coming to our
hospital, the patient was given active anti-infective treatment in a
local hospital, but the symptoms were still not controlled, and the O2
saturation(SPO2) gradually decreased. So he went to the superior
hospital for further diagnosis and treatment.
On admission, he was fever (37.6 C) with tachycardia (105 bpm), blood
pressure 97/60 mm Hg, respiratory rate 25 beats per minute, and SPO2
90% on ambient air. He had saddle nose and bleeded from the bulbar
conjunctiva.Wet rales could be heard on auscultation of the lung.
Blood tests were remarkable for:
leukocytosis (20.8X10^9/L,normal value 4-10.0X10^9/L) with
neutrophils
(17.48X10^9/L,
normal value 1.5-8.0X10^9/L),thrombocytosis (700X10^9/L,normal
value 100-300X10^9/L) . PCT
(0.88ng/L, normal value0-0.05
ng/ml),ESR(112 mm/ h, normal value
0~15 mm/ h),
C-reactive protein (80mg/dL, normal value 0-8 mg/L)
and hypoalbuminemia with albumin
26.9g/L(normal value 35-55g/L) .Renal,liver
functions and coagulation function
were normal, and serum c-ANCAs ,PR3- antibody were positivity. COVID-19
nucleic acid test was negative.
On pulmonary CT showed multiple nodules and cavities in both
lungs,creating“an island in the lung”(Fig. 1). Paranasal sinus CT scan
showed bilateral maxillary sinus and left frontal sinusitis.No
pathogenic bacteria were found in 2 rounds of alveolar lavage fluid mNGS
(Metagenomic next-generation sequencing).
Pathological examination of the
puncture specimen of the left lung mass showed that a small amount of
lung tissue was examined, and fibrous tissue was significantly
proliferated in some areas, with a large number of inflammatory cells
infiltration.
The patients were identified as having GPA and met the 2022
classification criteria for GPA established by the American College of
Rheumatology and European Association of Rheumatology[3]. He started
receiving pulsed intravenous methylprednisolone(0.5 g/day for 3 days).
Cyclophosphamide was not administered because of its negative effects,
particularly on sperm function. Rituximab 500 mg was provided twice,
spaced by two weeks, in place of cyclophosphamide.
During the course of treatment, the patient developed massive
hemoptysis, and the oxygenation index further decreased.Diffuse
hemorrhage in the airway was observed under bronchoscopy, and GPA
combined with DAH was considered. After endotracheal intubation and
plasma exchange, hemoptysis stopped and fever improved, but the patient
eventually died from acute pulmonary embolism.