A 35-year-old previously healthy woman comes to the hospital due to increasing shortness of breath and cough. Over the past few months, she has had arthralgias, fatigue, low-grade fever, and weight loss. Laboratory results are as follows: CT scan of chest is shown in the exhibit.
Histologic examination of the lung would most likely reveal which of the following findings?

Question

A 35-year-old previously healthy woman comes to the hospital due to increasing shortness of breath and cough.  Over the past few months, she has had arthralgias, fatigue, low-grade fever, and weight loss.  Laboratory results are as follows:  CT scan of chest is shown in the exhibit. 
 Histologic examination of the lung would most likely reveal which of the following findings?

Quizplus · Accepted Answer

11ec160b_38cf_1718_9249_4d3e1fa657cb_MD0001_00 This patient has chronic constitutional and pulmonary symptoms associated with patchy lung infiltrates/cavitation and laboratory findings of glomerulonephritis (hematuria, increased creatinine). These findings are suggestive of granulomatosis with polyangiitis (GPA), a small vessel vasculitis associated with antineutrophilic cytoplasmic antibodies (ANCA). Patients with GPA generally present with weeks or months of constitutional symptoms (eg, arthralgias, fatigue, low-grade fever, weight loss) and manifestations in the following areas: Laboratory evaluation frequently shows anemia of chronic disease due to elevated levels of inflammatory cytokines and renal insufficiency due to glomerulonephritis (eg, microscopic hematuria, red cell casts, negative nitrate/bacteriuria). Chest imaging often reveals patchy lung infiltrates, nodules, and/or cavitations. Although ANCA is positive in >85% of patients with GPA (c-ANCA in particular), it is a non-specific marker. Therefore, tissue biopsy is generally required for diagnosis; histopathology will show a necrotizing arteritis with granulomatous inflammation (eg, epithelioid histiocytes, multinucleated giant cells) and a mixture of surrounding inflammatory cells. Veins and capillaries are also frequently affected. (Choice A) Polyarteritis nodosa (PAN) is marked by transmural segmental inflammation of medium-sized muscular arteries with fibrinoid necrosis, which causes lumen narrowing, thrombosis, and organ ischemia. Although PAN often affects the kidney, the lung is generally spared. In contrast to GPA, PAN is not associated with ANCA. (Choice C) Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) is marked by the formation of necrotizing granulomas with a predominance of eosinophils. Although renal insufficiency and glomerulonephritis occur in a minority of patients, almost all patients have years of preceding asthma. In addition, cavitary lesions are uncommon. (Choice D) Adenocarcinoma of the lung is generally marked by the proliferation of irregular glands and pleiomorphic cells. Although this condition can cause normocytic anemia, cough, shortness of breath, and weight loss, it is not strongly associated with renal insufficiency or cavitary lung lesions (cavitary lesions are more common with squamous cell carcinoma). In addition, most cases arise in older patients. Educational objective: Granulomatosis with polyangiitis is an ANCA-associated systemic vasculitis that typically presents with upper (eg, purulent nasal discharge) and lower (eg, cavitary lung lesion) respiratory manifestations and renal insufficiency due to glomerulonephritis. Biopsy typically reveals a necrotizing arteritis with granulomatous inflammation (eg, epithelioid histiocytes, multinucleated giant cells) and lack of immunoglobulin/complement deposition. __________ References: The usefulness of histopathological examinations of non-renal biopsies in the diagnosis of granulomatosis with polyangiitis. (http://www.ncbi.nlm.nih.gov/pubmed/29332961)

A 35-Year-Old Previously Healthy Woman Comes to the Hospital Due