PMC10017231_01
Chest radiography findings. Chest radiography on admission revealed multiple nodular shadows as well as a mass shadow in the right lower lung (A), which markedly shrank after treatment with prednisolone and rituximab (B).
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As chest radiography revealed multiple nodular shadows as well as a mass shadow in the right lower lung (Fig. 1A), she was admitted to Hachinohe City Hospital. Her symptoms and imaging findings have improved (Fig. 1B), and the ANCA titer also decreased.
Chest computed tomography on admission. Chest computed tomography on admission showed multiple nodular shadows, including a mass shadow with ground-glass opacities in the right lower lobe.
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Pathological findings of the lung biopsy. Lung pathology showed infiltration of neutrophils, lymphocytes, histiocytes, and multinucleated giant cells around the necrotic area (A) as well as segmental and eccentric vasculitis with a disrupted vascular wall structure (arrows) (B). Elastica-Masson staining revealed disruption of the elastic lamina (arrow heads), suggesting necrotizing granulomatous vasculitis (C). Numerous multinucleated giant cells with intense nuclear chromatin staining (arrowheads) and granulomatous inflammation with neutrophil and lymphocyte accumulation are observed in the surrounding area (D).
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A small area of necrotic tissue was found in some of the tissues, and angiitis with granulomas were detected (Fig. 3).
Pathological findings of the nasal septal mucosal biopsy. The nasal septal mucosal biopsy showed formation of granulation tissue exhibiting a degree of chronic inflammation and neutrophilic infiltration, but necrosis was not evident.
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Since magnetic resonance imaging (MRI) showed thickening of the nasal mucosa, a mucosal biopsy of the nasal septum was performed, which showed chronic inflammation and significant neutrophil infiltration, suggesting GPA (Fig. 4).