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anti-proteinase 3&#8239;&#62;&#8239;90 U&#47;mL &#91;reference values&#58; &#60; 5 U&#47;mL&#93;&#41;&#46; Other viral serologies were negative&#44; and the markers of inflammatory tests were very high&#58; ESR 64&#8239;mm and CRP 19&#8239;mg&#47;L&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathological examination of the skin revealed leukocytoclastic vasculitis&#44; and direct immunofluorescence was negative with anti-IgM&#44; anti-IgG&#44; and anti-IgA antibodies&#46; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Pulmonary histopathology showed a granulomatous inflammatory process with central caseation&#46; The bronchoalveolar lavage revealed three alcohol-acid fast bacilli &#40;AAFB&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Small vessel vasculitis secondary to tuberculosis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Granulomatosis with polyangiitis &#40;Wegener&#39;s granulomatosis &#91;WG&#93;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Atypical mycobacteriosis with embolization</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Association of tuberculosis with Wegener&#39;s granulomatosis</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The most common manifestation of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infection is pulmonary&#59; 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especially the c-ANCA pattern&#44; increasing the possibility of diagnostic confusion with WG&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7&#44;9&#44;10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M&#46; tuberculosis</span> can stimulate the release of oxygen metabolites from activated neutrophils&#44; which would release lysosomal enzymes in the early stages of infection&#44; with the potential to induce autoantibodies against these components&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In this case&#44; the patient met diagnostic criteria for WG&#44; and had high levels of c-ANCA&#44; generating diagnostic doubt about the possibility of concomitant diseases&#46; The absence of previous sinusopathy&#44; asymmetry of pulmonary involvement&#44; and lack of involvement of medium size vessels &#40;livedo&#44; ulcers&#44; or necrosis of extremities&#41;&#44; indicated an atypical form of TB&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The patient was submitted to an antituberculous regimen &#40;RIPE&#41; and corticosteroid therapy 1&#8239;mg&#47;kg&#47;day&#44; with remission of the condition after one month of treatment&#44; and normalization of c-ANCA after six months&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In countries with a high prevalence of TB&#44; the presence of autoantibodies in a patient with vasculitis&#44; fever&#44; and pulmonary cavitation requires the investigation of infectious causes&#44; especially tuberculosis&#44; before admitting the diagnosis of WG&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contribution</span><p id="par0090" class="elsevierStylePara elsevierViewall">Luana Moraes Campos&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Mariana Righetto de R&#233;&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Priscila Neri Lacerda&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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What is your diagnosis?
Case for diagnosis. Cutaneous small vessel vasculitis (anti-proteinase 3 positive), fever, hemoptysis, and lung cavitation in an adult
Luana Moraes Campos, Mariana Righetto de Ré, Priscila Neri Lacerda, Hélio Amante Miot
Corresponding author
heliomiot@gmail.com

Corresponding author.
Department of Dermatology and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">47-year-old male&#44; smoker&#44; reported the appearance of petechiae&#44; palpable purpura&#44; and hemorrhagic blisters&#44; on the soles and palms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; a week before&#44; progressing to the lower and upper abdomen&#44; and face &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#59; he also reported bleeding in the eyes&#44; nose&#44; hemoptysis&#44; and fever&#46; Chest tomography revealed cavitation&#44; with thick walls in the right upper lobe&#44; and with sparse consolidations in other pulmonary areas &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The laboratory tests demonstrated high levels of classic anti-neutrophil cytoplasmic antibody &#40;c-ANCA&#58; anti-proteinase 3&#8239;&#62;&#8239;90 U&#47;mL &#91;reference values&#58; &#60; 5 U&#47;mL&#93;&#41;&#46; Other viral serologies were negative&#44; and the markers of inflammatory tests were very high&#58; ESR 64&#8239;mm and CRP 19&#8239;mg&#47;L&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathological examination of the skin revealed leukocytoclastic vasculitis&#44; and direct immunofluorescence was negative with anti-IgM&#44; anti-IgG&#44; and anti-IgA antibodies&#46; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Pulmonary histopathology showed a granulomatous inflammatory process with central caseation&#46; The bronchoalveolar lavage revealed three alcohol-acid fast bacilli &#40;AAFB&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Small vessel vasculitis secondary to tuberculosis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Granulomatosis with polyangiitis &#40;Wegener&#39;s granulomatosis &#91;WG&#93;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Atypical mycobacteriosis with embolization</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Association of tuberculosis with Wegener&#39;s granulomatosis</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The most common manifestation of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infection is pulmonary&#59; however&#44; more than 10&#37; of cases have an extrapulmonary presentation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> As the incidence of tuberculosis &#40;TB&#41; has been increasing worldwide&#44; this affects the occurrence of atypical forms&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Skin lesions associated with TB are highly polymorphic&#44; and can occur by direct action of bacilli&#44; by inoculation&#44; hematogenous propagation&#44; deposition of immune complexes on the walls of small vessels &#40;hypersensitivity vasculitis&#41;&#44; or by the formation of antibodies against antigens in the host&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> Small vessel vasculitis secondary to TB is uncommon&#44; with less than 20 cases reported in the literature&#46; Three forms have been described&#58; Henoch-Sch&#246;nlein purpura&#44; vasculitis secondary to rifampicin&#44; and cutaneous leukocytoclastic vasculitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">TB can occur associated with other autoimmune diseases&#44; such as WG&#44; sharing similar clinical findings and histopathology&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a> Necrotic lung lesions in WG are radiologically similar to those observed in TB&#46; It is worth mentioning that the literature presents two case reports in which these two diseases coexisted&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although ANCAs are considered to be markers of systemic vasculitis and are associated with WG and other autoimmune disorders&#44; ANCA positivity has been demonstrated in infectious diseases such as TB&#44; especially the c-ANCA pattern&#44; increasing the possibility of diagnostic confusion with WG&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7&#44;9&#44;10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M&#46; tuberculosis</span> can stimulate the release of oxygen metabolites from activated neutrophils&#44; which would release lysosomal enzymes in the early stages of infection&#44; with the potential to induce autoantibodies against these components&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In this case&#44; the patient met diagnostic criteria for WG&#44; and had high levels of c-ANCA&#44; generating diagnostic doubt about the possibility of concomitant diseases&#46; The absence of previous sinusopathy&#44; asymmetry of pulmonary involvement&#44; and lack of involvement of medium size vessels &#40;livedo&#44; ulcers&#44; or necrosis of extremities&#41;&#44; indicated an atypical form of TB&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The patient was submitted to an antituberculous regimen &#40;RIPE&#41; and corticosteroid therapy 1&#8239;mg&#47;kg&#47;day&#44; with remission of the condition after one month of treatment&#44; and normalization of c-ANCA after six months&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In countries with a high prevalence of TB&#44; the presence of autoantibodies in a patient with vasculitis&#44; fever&#44; and pulmonary cavitation requires the investigation of infectious causes&#44; especially tuberculosis&#44; before admitting the diagnosis of WG&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contribution</span><p id="par0090" class="elsevierStylePara elsevierViewall">Luana Moraes Campos&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Mariana Righetto de R&#233;&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Priscila Neri Lacerda&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Approval of the manuscript&#59; drafting of the manuscript&#59; effective participation in research orientation&#59; effective participation in propaedeutics&#59; literature review&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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2024 May 90 62 152
2024 April 106 82 188
2024 March 108 70 178
2024 February 114 75 189
2024 January 87 50 137
2023 December 67 55 122
2023 November 89 81 170
2023 October 70 86 156
2023 September 62 71 133
2023 August 72 33 105
2023 July 88 51 139
2023 June 66 46 112
2023 May 70 24 94
2023 April 70 14 84
2023 March 89 50 139
2023 February 64 35 99
2023 January 55 39 94
2022 December 55 34 89
2022 November 72 56 128
2022 October 121 65 186
2022 September 52 70 122
2022 August 63 50 113
2022 July 57 63 120
2022 June 56 51 107
2022 May 51 91 142
2022 April 57 66 123
2022 March 53 74 127
2022 February 44 44 88
2022 January 63 99 162
2021 December 43 64 107
2021 November 51 72 123
2021 October 97 96 193
2021 September 51 68 119
2021 August 74 57 131
2021 July 50 52 102
2021 June 107 68 175
2021 May 181 117 298
2021 April 482 291 773
2021 March 83 48 131
2021 February 15 16 31
2021 January 1 2 3
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