The Balance Between Autoimmunity and Infection: A Case Report of Concomitant Pathology of Pulmonary Nocardia and Granulomatosis with Polyangiitis at Initial Presentation.

Abstract

Concurrent presentation of pulmonary nocardiosis and granulomatosis with polyangiitis (GPA) is exceptionally rare and diagnostically challenging, given the overlapping clinical and radiological features. We report a 54-year-old female with fever, cough, weight loss, and arthralgia. Chest imaging showed multiple pulmonary nodules; serology revealed positive anti-neutrophil cytoplasmic antibodies -proteinase 3, and lung biopsy demonstrated necrotizing granulomatous inflammation with Nocardia species. This led to a dual diagnosis of pulmonary nocardiosis and limited form GPA. The patient improved with co-trimoxazole however methotrexate is set to be initiated concomitantly with close monitoring as the manifestations of limited form GPA were still present. This case highlights the importance of considering infectious mimics during initial evaluation of suspected vasculitis, the possibility of dual pathology of both entities, and the emphasis of the staged approach of treating such cases in the background of controlling infection followed by initiating immunosuppressive therapy.

Learning points: Pulmonary nocardiosis may clinically and radiologically mimic granulomatosis with polyangiitis, and both conditions can rarely present simultaneously.Histopathological examination is crucial to distinguish infectious mimics from vasculitis in anti-neutrophil cytoplasmic antibodies-positive patients.A stepwise treatment strategy in which controlling infection before initiating immunosuppression can reduce the risk of complications in dual pathology.