What is the most likely diagnosis for a 41‑year‑old male with a 2‑month history of persistent sinus pain, congestion and intermittent epistaxis, a 2‑week history of productive cough with brown sputum, a dark purplish rash on the lower legs, 20‑lb weight loss, myalgias, arthralgias, intermittent fevers up to 102 °F, elevated erythrocyte sedimentation rate, positive antineutrophil cytoplasmic antibody (ANCA), positive rheumatoid factor, negative antinuclear antibody (ANA), and urinalysis showing proteinuria, hematuria and red‑cell casts?

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Granulomatosis with Polyangiitis (Wegener Granulomatosis)

The correct diagnosis is (b) granulomatosis with polyangiitis (Wegener granulomatosis), based on the classic triad of upper respiratory tract disease (persistent sinusitis with epistaxis), lower respiratory tract involvement (productive cough with brown sputum suggesting pulmonary hemorrhage), and glomerulonephritis (proteinuria, hematuria, and RBC casts), combined with positive ANCA serology. 1

Diagnostic Reasoning

Key Clinical Features Supporting GPA

  • Upper respiratory tract involvement occurs in >90% of GPA patients, and this patient's 2-month history of persistent sinus pain, congestion, and epistaxis is a hallmark presentation 1

  • Lower respiratory tract disease is evident from the productive cough with brown sputum (suggesting alveolar hemorrhage), which occurs in >95% of patients with pulmonary GPA 1

  • Renal involvement manifests as pauci-immune necrotizing crescentic glomerulonephritis, demonstrated here by proteinuria, hematuria, and RBC casts—a pathognomonic finding for GPA 1, 2

  • Systemic manifestations including the purpuric rash on lower legs, constitutional symptoms (20-lb weight loss, fevers, myalgias, arthralgias) are common in GPA and reflect active systemic vasculitis 1

Laboratory Confirmation

  • Positive ANCA is present in 80-90% of GPA cases and is highly specific for this diagnosis, with PR3-ANCA (c-ANCA) being the predominant pattern 1, 2

  • Elevated ESR of 60 mm/hr reflects the active systemic inflammation characteristic of GPA 1

  • Negative ANA effectively excludes systemic lupus erythematosus 2

Excluding Alternative Diagnoses

Why Not Eosinophilic Granulomatosis with Polyangiitis (EGPA)?

  • EGPA requires blood eosinophilia >10% and elevated IgE, which are absent in this case 1

  • Only 35-40% of EGPA patients are ANCA-positive, and when present it is usually p-ANCA/MPO rather than c-ANCA 1

  • EGPA more frequently involves cardiac disease and gastrointestinal symptoms, which are not described here 1

Why Not Polyarteritis Nodosa?

  • PAN is an ANCA-negative medium-vessel vasculitis, making it incompatible with the positive ANCA in this patient 1

  • PAN does not typically cause glomerulonephritis or upper respiratory tract involvement 1

Why Not Rheumatoid Arthritis?

  • While positive rheumatoid factor can occur in approximately 5% of GPA patients, RA does not cause necrotizing glomerulonephritis, severe sinusitis with epistaxis, or pulmonary hemorrhage 1

  • The renal findings (RBC casts, glomerulonephritis) are not features of RA 2

Why Not Systemic Lupus Erythematosus?

  • The negative ANA makes SLE highly unlikely 2

  • While ANCA can rarely be positive in SLE (typically p-ANCA/MPO in 20% of cases), the negative ANA combined with the classic GPA triad makes this diagnosis untenable 3

Clinical Pitfalls to Avoid

  • Do not dismiss the diagnosis based on atypical ANCA patterns—while PR3-ANCA (c-ANCA) is most common in GPA, p-ANCA/MPO positivity can occur in severe cases 4

  • Positive rheumatoid factor should not mislead you toward RA—RF positivity can occur as a non-specific finding in GPA patients with atypical ANCA 1

  • The brown sputum is critical—this suggests pulmonary hemorrhage from alveolar capillaritis, a life-threatening manifestation requiring urgent immunosuppression 1

Immediate Next Steps

  • Obtain tissue confirmation through biopsy of an affected organ (kidney, lung, or nasal mucosa) to demonstrate necrotizing vasculitis and granulomatous inflammation 2

  • Initiate urgent treatment with high-dose glucocorticoids combined with either rituximab or cyclophosphamide, as untreated GPA has a mean survival of only 5 months 2

  • Consider plasma exchange if there is evidence of severe pulmonary hemorrhage or rapidly progressive renal failure 1

References

Guideline

Clinical Presentation and Management of Granulomatosis with Polyangiitis (GPA)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Guideline

Granulomatosis with Polyangiitis Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

Which of the following statements are correct regarding granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA): a) systemic symptoms occur in >50% of cases, mainly in GPA; b) ocular involvement occurs more frequently in EGPA; c) peripheral nervous system involvement occurs less frequently in EGPA; d) sinusitis is more common in EGPA; e) asthma is a main feature of GPA?
Can Antinuclear Antibody (ANA) be positive and Antineutrophil Cytoplasmic Antibody (ANCA) be negative?
What is the relationship between Atherosclerotic Cardiovascular Disease (ASCVD) and granulomatosis with polyangiitis (GPA) in terms of cardiovascular risk and management?
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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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