A 62yearold man with a ho HTN and DM was referred for evaluation of pleural effusion' Three months p

1
A 62-year-old man with a h/o HTN and DM was
referred for evaluation of pleural effusion.
Three months prior to presentation, he developed
hematuria and ARF.
2
A renal biopsy revealed a pauci-immune,
crescentic glomerulonephritis and he was started
on a course of prednisone.He had a negative
anti-GBM antibody and C-ANCA, but a positive
P-ANCA at 180
3
After two months of prednisone he reported
resolution of his hematuria, but noted the onset
of a nonproductive cough. Additionally, he
reported dyspnea with exertion. He denied fever
or chills and reported no hemoptysis or chest
pain.
4
A CXR was performed and reportedly revealed a
left pleural effusion. He was given a course of
antibiotics without improvement and subsequently
referred to our facility for further evaluation.
5
On presentation to our hospital, he continued to
complain of a dry cough with dyspnea on
exertion.His PMH was significant only for HTN
and DM, both of which were well-controlled with
lisinopril and insulin.His only other
medication was prednisone and a multivitamin.He
was a nonsmoker and reported a FH of diabetes.
6
Physical examination revealed an elderly, white
man appearing comfortable in bed. He was afebrile
and his vital signs were normal. His lung exam
revealed coarse crackles and dullness at the
right base. The remainder of the exam was normal.
7
Labs

• BUN 107, creatinine 3.7
• 24 hr urine nephrotic-range proteinuria
• WBC 23, 000 (96 segs)
• H/H 10.1/29.8 (MCV 83)

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CXR
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Thoracentesis

• WBC 567 (87 PMNs)
• RBC 800
• protein 3.2 LDH 2618 glu 343 pH 7.0
• Negative microbiological cultures
• Negative pleural cytology

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Chest CT
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To further evaluate the possibility of WG, he
underwent VATS. Extensive adhesions and
purulent material were noted. Frozen section
biopsy revealed non-caseating granulomas. Gram
stain revealed numerous PMNs and a gram-variable,
beaded rod
15
Nocardia asteroides
16
Microscopic Polyangiitis and Opportunistic Lung
Infection Mimicking Wegeners Granulomatosis
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ACR Clinical Criteria 1990

• Nasal or oral inflammation
• Compatible CXR
• Active urinary sediment
• Granulomatous inflammation on biopsy

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ANCA Testing

• C-ANCA stain cytoplasm diffusely, directed
  against serine protease, present in majority of
  WG
• P-ANCA perinuclear stain, directed against
  myeloperoxidase, present in minority of WG and
  majority of MPA

19
Nocardiosis

• Immunocompromised host
• Multi-organ dissemination is common
• Multiple radiographic findings nonspecific sxs
• Prolonged course of sulfonamides
• Relapse is common