J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://www.journalmc.org

Case Report

Volume 14, Number 8, August 2023, pages 299-306

A Changing Anti-Neutrophil Cytoplasmic Antibody Profile in a Patient With a Diagnosis of Eosinophilic Granulomatosis With Polyangiitis

Figure 1. Chest radiographs and computed tomography scans. (a) First admission (arrow indicates ground-glass opacity in the lower left lung field. (b) Third admission (■ indicates interlobar thickening in the right middle lung field; ▲ indicates a dull right costophrenic angle; the arrow indicates consolidation in the left middle and lower lung field). (c) First admission. (d) Third admission (• indicates pleural effusion; ▲ indicates ground-glass opacity; arrow indicates thickness between leaflets).

Figure 2. Skin biopsy. (a) Ulcerative lesions, erythema, and purpura were observed on the anterior aspect of the left ankle joint. A biopsy was performed on the ulcerative lesion indicated by the red circle. (b) Pathologic findings (hematoxylin and eosin staining, × 200). The biopsy specimen showed infiltration of lymphocytes and histiocytes with fibrinoid necrosis around blood vessels (indicated by ▲) consistent with vasculitis.

**Table 1.** Summary of Laboratory Findings
	Result	Range
HbA1c: glycated hemoglobin.
Hematology
White blood cells	6,500/µL	4,000 - 10,000
Neutrophils	76%
Lymphocytes	8.6%
Monocytes	8.1%
Eosinophils	6.7%
Basophils	0%
Red blood cells	3.83 × 10⁶/µL	400 - 550
Hemoglobin	11.6 g/dL	13.5 - 17.5
Hematocrit	35.1%	40 - 50
Platelets	25.6 × 10³/µL	15 - 40
Biochemistry
Total protein	6.1 g/dL	6.0 - 8.3
Immunoglobulin G	867 mg/dL	700 - 1,600
Immunoglobulin M	52 mg/dL	40 - 230
Immunoglobulin E	161 mg/dL	3 - 423
Total bilirubin	0.4 mg/dL	0.1 - 1.2
Aspartate aminotransferase	49 IU/L	8 - 40
Alanine aminotransferase	24 IU/L	7 - 56
Lactate dehydrogenase	271 IU/L	135 - 225
Blood urea nitrogen	26.5 mg/dL	8 - 21
Creatinine	1.38 mg/dL	0.6 - 1.3
Sodium	137 mmol/L	135 - 145
Potassium	4.8 mmol/L	3.5 - 5.0
Chloride	101 mmol/L	95 - 105
C-reactive protein	10.95 mg/dL	< 1.0
HbA1c	7%	4 - 5.6
Coagulation test
Prothrombin time	13 s	11.0 - 13.5
Activated partial thromboplastin time	34.9 s	25 - 35
Fibrinogen	618 mg/dL	200 - 400
Fibrin degradation product	6 µg/dL	0 - 5
D-dimer	3.8 µg/dL	0 - 0.5
Urine test	Results
Color	Yellow
Appearance	Clear
pH	6
Specific gravity	1.016
Glucose	Negative
Protein	Negative
Ketones	Negative
Bilirubin	Negative
Urobilinogen	Normal
Nitrite	Negative
Leukocyte esterase	Negative
Microscopic examination	No abnormal cells or casts observed

Table 1. Summary of Laboratory Findings

Result

Range

HbA1c: glycated hemoglobin.

Hematology

White blood cells

6,500/µL

4,000 - 10,000

Neutrophils

76%

Lymphocytes

8.6%

Monocytes

8.1%

Eosinophils

6.7%

Basophils

Red blood cells

3.83 × 10⁶/µL

400 - 550

Hemoglobin

11.6 g/dL

13.5 - 17.5

Hematocrit

35.1%

40 - 50

Platelets

25.6 × 10³/µL

15 - 40

Biochemistry

Total protein

6.1 g/dL

6.0 - 8.3

Immunoglobulin G

867 mg/dL

700 - 1,600

Immunoglobulin M

52 mg/dL

40 - 230

Immunoglobulin E

161 mg/dL

3 - 423

Total bilirubin

0.4 mg/dL

0.1 - 1.2

Aspartate aminotransferase

49 IU/L

8 - 40

Alanine aminotransferase

24 IU/L

7 - 56

Lactate dehydrogenase

271 IU/L

135 - 225

Blood urea nitrogen

26.5 mg/dL

8 - 21

Creatinine

1.38 mg/dL

0.6 - 1.3

Sodium

137 mmol/L

135 - 145

Potassium

4.8 mmol/L

3.5 - 5.0

Chloride

101 mmol/L

95 - 105

C-reactive protein

10.95 mg/dL

< 1.0

HbA1c

4 - 5.6

Coagulation test

Prothrombin time

13 s

11.0 - 13.5

Activated partial thromboplastin time

34.9 s

25 - 35

Fibrinogen

618 mg/dL

200 - 400

Fibrin degradation product

6 µg/dL

0 - 5

D-dimer

3.8 µg/dL

0 - 0.5

Urine test

Results

Color

Yellow

Appearance

Clear

Specific gravity

1.016

Glucose

Negative

Protein

Negative

Ketones

Negative

Bilirubin

Negative

Urobilinogen

Normal

Nitrite

Negative

Leukocyte esterase

Negative

Microscopic examination

No abnormal cells or casts observed

**Table 2.** Clinical Course
	First hospital admission	Second hospital admission	Third hospital admission	After discharge
CT: computed tomography; EGPA: eosinophilic granulomatosis with polyangiitis; GGO: ground-glass opacities; MPO-ANCA: myeloperoxidase antineutrophil cytoplasmic antibody; PR3: proteinase 3 antineutrophil cytoplasmic antibody.
PR3-ANCA	(+)	(+)	(+)	(-)
< 3.5 (U/mL)	56.7	14.7	31.4	1.9
MPO-ANCA	(-)	(+)	(+)	(+)
< 3.5 (U/mL)	1	125.4	140	26.4
Eosinophils	(-)	(-)	(+)	(-)
< 1,000 (cells/µL)	563	436	5,635	0
Diagnosis	Bacterial pneumonia	Heart failure	EGPA, bacterial pneumonia	EGPA
Chest CT	GGO	GGO, infiltration, pleural effusion	GGO, infiltration, pleural effusion	GGO
Treatment	Antibiotics	Diuretics	Corticosteroids, antibiotics	Mepolizumab

Table 2. Clinical Course

First hospital admission

Second hospital admission

Third hospital admission

After discharge

CT: computed tomography; EGPA: eosinophilic granulomatosis with polyangiitis; GGO: ground-glass opacities; MPO-ANCA: myeloperoxidase antineutrophil cytoplasmic antibody; PR3: proteinase 3 antineutrophil cytoplasmic antibody.

PR3-ANCA

(+)

(-)

< 3.5 (U/mL)

56.7

14.7

31.4

1.9

MPO-ANCA

(-)

(+)

< 3.5 (U/mL)

125.4

140

26.4

Eosinophils

(-)

(+)

(-)

< 1,000 (cells/µL)

563

436

5,635

Diagnosis

Bacterial pneumonia

Heart failure

EGPA, bacterial pneumonia

EGPA

Chest CT

GGO

GGO, infiltration, pleural effusion

GGO

Treatment

Antibiotics

Diuretics

Corticosteroids, antibiotics

Mepolizumab