TUESDAY MEDICAL STUDENT/RESIDENT CASE REPORT POSTERS
Tuesday Medical Student/Resident Case Report Posters
SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM
RESPIRATORY SYNCYTIAL VIRUS MASQUERADING AS MICROSCOPIC POLYANGIITIS:
DIAGNOSTIC CHALLENGES IN SMALL VESSEL VASCULITIS
DAVID CHETRIT MD* TANUJA YALAMARTI AND MICHELLE RUMBAUGH
INTRODUCTION: Small vessel vasculitis poses significant diagnostic challenges. For one, many conditions can mimic the
presentation of systemic vasculitis, not limited to infection. Given the potential risks of immunosuppression in the setting
of infection, correctly identifying vasculitis is of utmost importance before initiating therapy[1]. We describe the case of a
patient with respiratory syncytial virus (RSV) who presented with a pattern of organ and tissue involvement consistent
with microscopic polyangiitis (MPA). Empiric treatment unfortunately led to prolonged ventilation and unfavorable
course.
CASE PRESENTATION: A 55-year-old male with presumed ANCA-negative vasculitis presented with a 2-day history of
purpuric rash, dyspnea, and intermittent hemoptysis. He was evaluated at an outside hospital one year prior for a rash over both
legs, accompanied by myalgias, arthralgias, and weight loss. Skin biopsy showed leukocytoclastic vasculitis. Subsequent renal
biopsy showed glomerulonephritis, without evidence of crescents or immune deposits.
On presentation, labs were notable for leukocytosis and elevated creatinine. Further work-up revealed normal inflammatory
markers, as well as negative antineutrophilic cytoplasmic antibodies (ANCA). Though no serological markers were found
to support a definitive diagnosis, chest imaging revealed pulmonary opacities concerning for diffuse alveolar hemorrhage
(DAH). He was thus treated empirically with high-dose corticosteroids for suspected flare of MPA. He subsequently
developed rapidly worsening hypoxia necessitating intubation, with serial imaging showing progressive bilateral alveolar
infiltrates concerning for acute respiratory distress syndrome (ARDS). Bronchoalveolar lavage later showed no evidence of
hemosiderin-laden macrophages, ruling out DAH. Respiratory viral panel would ultimately come back positive for RSV,
suggesting a primary viral process with a superimposed bacterial infection as the cause of his symptoms. He improved with
antibiotics and supportive care.
DISCUSSION: Illness caused by acute viral infections can imitate systemic vasculitis. Leukocytoclastic vasculitis can be triggered
by a variety of causes, including infections. When accompanied by constitutional symptoms, it can be confused for systemic
disease[2]. Though testing for ANCA can support clinical suspicion, the absence of antibodies does not exclude the diagnosis of
ANCA-associated vasculitis, further obscuring a potential diagnosis[1]. High-dose steroids may worsen outcomes in patients with
ARDS caused by infectious processes[3]. As such, it is important to distinguish mimics from true systemic vasculitis in order to
avoid potentially harmful treatment.
CONCLUSIONS: RSV and other viral infections can mimic the presentation of systemic vasculitis. Attempts must be made to
differentiate between the two prior to initiation of treatment, in order to prevent unfavorable outcomes.
Reference #1: Suresh E. Diagnostic approach to patients with suspected vasculitis. Postgrad Med J. 2006 Aug;82(970):483-8.
Reference #2: Moreno Martínez MJ, Palma Sánchez D, Peñas Martínez E, et al. Leukocytoclastic vasculitis and infection. Report
of a case. Reumatol Clin. 2017 Sep - Oct;13(5):297-298. https://doi.org/10.1016/j.reuma.2016.04.002.
Reference #3: Takaki M, Ichikado K, Kawamura K, et al. The negative effect of initial high-dose methylprednisolone and tapering
regimen for acute respiratory distress syndrome: a retrospective propensity matched cohort study. Crit Care. 2017 Jun 8;21(1):135.
https://doi.org/10.1186/s13054-017-1723-0.
DISCLOSURES: No relevant relationships by David Chetrit, source¼Web Response
No relevant relationships by Michelle Rumbaugh, source¼Web Response
No relevant relationships by Tanuja Yalamarti, source¼Web Response
DOI:
http://dx.doi.org/10.1016/j.chest.2019.08.1374
Copyright ª 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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