Granulomatosis with polyangiitis: Rheumatoid arthritis overlap syndrome: A case report

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) may rarely be associated with other immune-mediated diseases. Knowledge of these overlap syndromes is important in early recognition of potential complications and differences in clinical courses and management pathways. In this paper we describe the case of a male Egyptian patient, 52 years old, with hypertension and rheumatoid arthritis on disease-modifying antirheumatic drugs, with a recent history of ocular and renal manifestations suggesting vasculitis, who presented to our Emergency Department with acute interstitial pneumonitis, which was successfully treated with high-dose steroids. His clinical course had deteriorated because of self-stoppage of the maintenance dose of steroid and appearance of bilateral nodular infiltrates in the lungs on the chest radiographs. His cytoplasmic c-ANCA autoantibodies were positive, in addition to the histopathological examination of open lung biopsy, which was consistent with granulomatosis with polyangiitis. He was successfully treated with high-dose steroids and cyclophosphamide. We reported a new case of granulomatosis with polyangiitis developing during adalimumab therapy for rheumatoid arthritis. This clinical observation must be considered in all patients treated with antitumor necrosis factor. On the basis of the previously published cases of AAV associated with rheumatoid arthritis as well as our case, the suggestion of a rare form of an AAV autoimmune overlap should be recognized and investigated for rapid initiation of appropriate management.