Alhumaidi Abdulrahman Abdullah, Aljohani Eid Mohammed, Althakafi Wajd Ahmed, Alkinani Ohud Mohammed, Albalawi Faisal Abdullah
Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia.
Histopathology Unit, Department of Pathology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia.
Eur J Case Rep Intern Med. 2025 Aug 22;12(9):005756. doi: 10.12890/2025_005756. eCollection 2025.
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.
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.
鉴于临床和放射学特征重叠，肺诺卡菌病与显微镜下多血管炎（GPA）同时出现极为罕见且诊断具有挑战性。我们报告一名54岁女性，有发热、咳嗽、体重减轻和关节痛。胸部影像学显示多个肺结节；血清学显示抗中性粒细胞胞浆抗体-蛋白酶3阳性，肺活检显示诺卡菌属引起的坏死性肉芽肿性炎症。这导致了肺诺卡菌病和局限性GPA的双重诊断。患者使用复方新诺明后病情改善，但由于局限性GPA的表现仍然存在，计划在密切监测的同时开始使用甲氨蝶呤。该病例强调了在疑似血管炎的初始评估中考虑感染性模仿疾病的重要性、两种疾病双重病理的可能性，以及在控制感染后启动免疫抑制治疗的背景下分阶段治疗此类病例的重要性。
肺诺卡菌病在临床和放射学上可能模仿显微镜下多血管炎，且两种疾病很少同时出现。组织病理学检查对于在抗中性粒细胞胞浆抗体阳性患者中区分感染性模仿疾病和血管炎至关重要。在开始免疫抑制之前控制感染的逐步治疗策略可以降低双重病理中并发症的风险。
