The patient is a 67-year-old malewith lung lesions, who has been diagnosed with GPA since August 2019. A written informed consent was obtained from the patient.He presented early clinical symptoms including a mild fever (37.5 C), cough, and bloody sputum (hemoptysis). Following a computed tomography (CT) scan, a big pulmonary mass was observed in the right lung [Figure 1]. The patient also had high values of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Moreover, the negative results of tuberculosis (TB), interferon gamma release assay (IGRA), and acid-fast Bacillus tests and the positive results for the PR3-ANCA (cANCA) test (more than three times the normal value) led to the rejection of TB and the diagnosis of GPA. Therefore, as the induction therapy, the patient was immediately treated with 500 mg/day of rituximab (total cumulative dose = 2 g) and methylprednisolone 500 mg pulse (1 g/day) for 3 days. Moreover, the patient also took other medications including prednisolone (1.25 mg/day), cotrimoxazole 400/80 mg (400/80 mg/12 h), and iron-folic acid 1 mg (1 mg/day). After disappearing the early symptoms (remission phase), the patient was scheduled to receive rituximab (500 mg) every 6 months for six consecutive periods. The patient also suffered from cardiovascular disease before being diagnosed with GPA and used carvedilol 6.25 mg (6.25 mg/day), losartan 25 mg (1 tablet/day), and atorvastatin 20 mg (1 tablet/day) to treat it.
Treatment with prednisolone (1.25 mg/day) continued until on April 4, 2020 when the patient visited the doctor for only brief symptoms of shortness of breath. According to the chest X-ray results [Figure 2], increasing the amounts of cANCA (145 U/mL), and CRP (58.9 mg/L), he was diagnosed with a pulmonary abscess due to GPA. Therefore, the dose of prednisolone increased up to 15 mg/day, and he was also prescribed hydroxychloroquine sulfate 200 mg (200 mg/day) and azithromycin 250 mg (500 mg [2 tablets] on the 1st day and 250 mg/day from the 2nd day to the 5th day), which quickly improved his clinical conditions.
Two weeks later (April 20, 2020) that coincided with an increase in the prevalence of COVID-19, the patient went to a hospital with symptoms including body aches, a nonproductive cough, shortness of breath, sore throat, loss of appetite, nausea and vomiting, fatigue, and severe weakness. A reverse transcription (RT)-polymerase chain reaction (PCR) test and lung CT scan [Figure 3] were performed to check the possibility of COVID-19. The RT-PCR test was positive for COVID-19, and the result of the CT scan showed the signs of bilateral multiple ground-glass opacity that were indistinguishable from the recurrence of GPA. The patient was immediately hospitalized, and his vital signs including O2 Sat (87%), PR, (89) temperature (36.8 C), and blood pressure (BP) (137/98 mm Hg) were recorded. He was treated with hydroxychloroquine sulfate 200 mg (200 mg/6 h), azithromycin 500 mg (500 mg/8 h), prednisolone 5 mg TDS (5 mg/8 h), and cotrimoxazole 400/80 mg BD (400/80 mg/12 h), while he was receiving folic acid 1 mg (1 tablet/day), chlorphenamine 4 mg (1 tablet/day), carvedilol 6.25 mg (6.25 mg/day), losartan 25 mg (25 mg/day), atorvastatin 20 mg (20 mg/day). During his hospitalization, the COVID-19 symptoms were mild. A week later of the hospitalization, with the disappearance of the initial symptoms, a negative result of RT-PCR and appropriate vital signs including O2 Sat (92%), PR (79), temperature (36.5 C), and BP (100/6 mm Hg), the patient was allowed to leave the hospital and undergo the home quarantine. All treatments for COVID-19 were applied before the second period of rituximab infusions.
The results of computed tomography scan of the lung with granulomatosis with polyangiitis (a and b). There is a big pulmonary mass in the right lung indicated by arrows.