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Granulomatosis with polyangiitis: Rheumatoid arthritis overlap syndrome: A case report

Abstract

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) may rarely be associated with other immune-mediated diseases. Knowledge of these overlap syndromes is important in early recognition of potential complications and differences in clinical courses and management pathways. In this paper we describe the case of a male Egyptian patient, 52 years old, with hypertension and rheumatoid arthritis on disease-modifying antirheumatic drugs, with a recent history of ocular and renal manifestations suggesting vasculitis, who presented to our Emergency Department with acute interstitial pneumonitis, which was successfully treated with high-dose steroids. His clinical course had deteriorated because of self-stoppage of the maintenance dose of steroid and appearance of bilateral nodular infiltrates in the lungs on the chest radiographs. His cytoplasmic c-ANCA autoantibodies were positive, in addition to the histopathological examination of open lung biopsy, which was consistent with granulomatosis with polyangiitis. He was successfully treated with high-dose steroids and cyclophosphamide. We reported a new case of granulomatosis with polyangiitis developing during adalimumab therapy for rheumatoid arthritis. This clinical observation must be considered in all patients treated with antitumor necrosis factor. On the basis of the previously published cases of AAV associated with rheumatoid arthritis as well as our case, the suggestion of a rare form of an AAV autoimmune overlap should be recognized and investigated for rapid initiation of appropriate management.

References

  1. Frankel SK, Cosgrove GP, Fischer A, Meehan RT, Brown KK. Update in the diagnosis and management of pulmonary vasculitis. Chest 2006; 129:452–465.

    Article  Google Scholar 

  2. Schwarz MI, Brown KK. Small vessel vasculitis of the lung. Thorax 2000; 55:502–510.

    CAS  Article  Google Scholar 

  3. Kalluri R, Meyers K, Mogyorosi A, Madaio MP, Neilson EG. Goodpasture syndromeinvolvingoverlapwithWegener’sgranulomatosisandantiglomerular basement membrane disease. J Am Soc Nephrol 1997; 8:1795–1800.

    CAS  PubMed  Google Scholar 

  4. Weber MF, Andrassy K, Pullig O, Koderisch J, Netzer K. Antineutrophil cytoplasmic antibodies and antiglomerular basement membrane antibodies in Goodpasture’s syndrome and in Wegener’s granulomatosis. J Am Soc Nephrol 1992; 2:1227–1234.

    CAS  PubMed  Google Scholar 

  5. Derrett-Smith EC, Nihtyanova SI, Harvey J, Salama AD, Denton CP. Revisiting ANCA-associated vasculitis in systemic sclerosis: clinical, serological and immunogenetic factors. Rheumatology (Oxford) 2013; 52:1824–1831.

    CAS  Article  Google Scholar 

  6. Tetikkurt C, Yuruyen M, Tetikkurt S, Bayar N, Ozdemir I. Propylthiouracil induced lupus-like or vasculitis syndrome. Multidiscip Respir Med 2012;7:14.

    Article  Google Scholar 

  7. Gaber LW, Wall BM, Cooke CR. Coexistence of anti-neutrophil cytoplasmic antibody-associated glomerulonephritis and membranous glomerulopathy. Am J Clin Pathol 1993; 99:211–215.

    CAS  Article  Google Scholar 

  8. Tse WY, Howie AJ, Adu D, Savage CO, Richards NT, Wheeler DC. Association of vasculitic glomerulonephritis with membranous nephropathy: a report of 10 cases. J Nephrol Dial Transplant 1997; 12: 1017–1027.

    CAS  Article  Google Scholar 

  9. Draibe J, Salama AD. Association of ANCA associated vasculitis and rheumatoid arthritis: a lesser recognized overlap syndrome. Springer Plus 2015; 4:50.

    Article  Google Scholar 

  10. Aletaha D, Neogi T, Silman AJ, et al. Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative [published correction appears in Ann Rheum Dis. 2010; 69(10): 1892]. Ann Rheum Dis 2010; 69: 1580–1588.

    Article  Google Scholar 

  11. Sorensen SF, Slot O, Tvede N, Petersen J. A prospective study of vasculitis patients collected in a five years period evaluation of the Chapel Hill nomenclature. Ann Rheum Dis 2000; 59:478–482.

    CAS  Article  Google Scholar 

  12. Jennette JC, Falk RJ, Bacon PA, et al. Revised International Chapel Hill Consensus Conference nomenclature of vasculitides. Arthritis Rheum 2012; 65:1–11.

    Article  Google Scholar 

  13. Leavitt RY, Fauci AS, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Wegener’s granulomatosis. Arthritis Rheum 1990; 33:1101–1107.

    CAS  Article  Google Scholar 

  14. Koldingsnes W, Nossent H. Epidemiology of Wegener’s granulomatosis in Northern Norway. Arthritis Rheum 2000; 43:2481–2487.

    CAS  Article  Google Scholar 

  15. Tattersfield AE, Schwarz MI, Brown KK. Small vessel vasculitis of the lung. Thorax 2000; 55:502–510.

    Article  Google Scholar 

  16. Belavic Z, Vitas B, Doko A, Baskot A, Polovic A, Mlinac-Lucijanic M. Multiple no dose shadows of the lungs as a differential diagnosis problem. Acta Med Croatica 2006; 60:265–271.

    PubMed  Google Scholar 

  17. Jolly M, Molta C, Hoffman G. Wegener’s granulomatosis: pitfalls in the management of pulmonary disease: a case of Wegener’s granulomatosis with a hilar mass. J Rheumatol 2000; 27:2511–2512.

    CAS  PubMed  Google Scholar 

  18. Lyons PA, Rayner TF, Trivedi S. Genetically distinct subsets within ANCAassociated vasculitis. N Eng J Med 2012; 367:214–223.

    CAS  Article  Google Scholar 

  19. Farago B, Talian GC, Komlosi K, Nagy G, Berki T, Gyetvai A, et al. Protein tyrosine phosphatase gene C1858Tallele confers risk for rheumatoid arthritis in Hungarian subjects. Rheumatol Int 2009; 29:793–796.

    Article  Google Scholar 

  20. Jagiello P, Aries P, Arning L, Wagenleiter SE, Csernok E, Hellmich B, et al. The PTPN22 620W allele is a risk factor for Wegener’s granulomatosis. Arthritis Rheum 2005; 52:4039–4043.

    CAS  Article  Google Scholar 

  21. Johansson M, Arlestig L, Hallmans G, Rantapaa-Dahlqvist S. PTPN22 polymorphism and anti-cyclic citrullinated peptide antibodies in combination strongly predicts future onset of rheumatoid arthritis and has a specificity of 100% for the disease. Arthritis Res Ther 2006; 8:R19.

    Article  Google Scholar 

  22. Lee AT, Li W, Liew A, Bombardier C, Weisman M, Massarotti EM, et al. The PTPN22 R620W polymorphism associates with RF positive rheumatoid arthritis in a dose-dependent manner but not with HLA-SE status. Genes Immun 2005; 6:129–133.

    CAS  Article  Google Scholar 

  23. Saint Marcoux B, De Bandt M. Vasculitides induced by TNF alpha antagonists: a study in 39 patients in France. Joint Bone Spine 2006; 73:710–713.

    CAS  Article  Google Scholar 

  24. Ramos-Casals M, Brito-Zeron P, Soto MJ, Cuadrado MJ, Khamashta MA. Autoimmune diseases induced by TNF-targeted therapies. Best Pract Res Clin Rheumatol 2008; 22:847–861.

    CAS  Article  Google Scholar 

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Correspondence to Ashraf E. Sileem.

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Sileem, A.E., Said, A.M. Granulomatosis with polyangiitis: Rheumatoid arthritis overlap syndrome: A case report. Egypt J Bronchol 11, 56–61 (2017). https://doi.org/10.4103/1687-8426.198995

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Keywords

  • adalimumab
  • overlap syndrome
  • rheumatoid arthritis
  • Wegener’s granulomatosis