ENTERORRHAGIA PRESENTING IN PATIENT WITH GRANULOMATOSIS WITH POLYANGITIS- A CASE REPORT

Objectives: ANCA-associated vasculitis(AAV) as a term includes: microscopic polyangiitis(MPA), granulomatosis with polyangiitis(GPA) and eosinophilic granulomatosis with polyangiitis(EGPA).GPA is characterised by formation of granulomas and inflammation of small and medium-sized vessels leading to organ dysfunction,with a predilection for respiratory tract and kidneys.Gastrointestinal(GI) involvement happens rarely in GPA but when affected,has a poor prognosis. Methods: Case report:We report a case of 50-year-old male with GPA who presented with pulmonary renal syndrome and enterorrhagia due to GI vasculitis.The patient was treated with: hemodialysis,pulse methylprednisolone,cyclophosphamide and plasmapheresis.Our systematic review of the literature found only a few case reports where gastrointestinal symptoms were one of the first signs of GPA,however,this entity might be more frequent if physicians would think of this possibility more often. Results: From the examinations:Biopsy of hard and soft palate showed granuloma.Pseudomonas aeruginosa was isolated from the urine,the blood culture remained sterile.PCR test for Sars CoV2 infection,serological findings for infectious agents:anti Treponema pallidum IgG and IgM,Lowenstein culture,Fluorescent microscopy of sputum and Genexpert MTB/RF sputum: remained negative. Immunohematological analyses: IAT,DAT, Enzyme test, Cold autoagglutinins, Cold isoagglutinins, Coombs autoagglutinins and Isoagglutinins with Coombs: remained negative. The antinuclear factor (ANA) was negative and cytoplasmic anti-neutrophilic cytoplasmic antibody (c-ANCA) was 3+ positive. Routine urine examination showed trace of proteins,8- 10 erythrocytes,plenty of leucocytes.Ultrasonography revealed that both kidneys were normal in size and slightly increased echogenicity. Gastroscopy was performed and upper digestive bleeding was excluded. Digital rectal examination showed that it was not melena but enterorrhagia.CT scan of the lungs was performed in addition to nodules and alveolar hemorrhage.Due to enterorrhagia CT angiography of the abdomen was done to localize the site of bleed,arterial phase of scans showed: hyperdense linear zone in part of the wall of the distal ileum with increased density compared to the native series,suspicious for hemorrhage. Conclusions: In cases with high clinical suspicion of GI involvement in GPA,early aggressive immunosuppressive therapy and eventual surgical intervention remains the cornerstone of the manage