A Case of Extranodal NK/T-cell Lymphoma Infiltrating Kidneys, Presenting With Hematuria and Proteinuria With False-Positive Serum Anti-proteinase 3, and Mimicking Granulomatosis With Polyangiitis

We report a case of misdiagnosed extranodal NK/T-cell lymphoma, nasal type, mimicking granulomatosis with polyangiitis (GPA). A 30-year-old male presented with chronic non-resolving right paranasal sinusitis for two years accompanied by multiple generalized cutaneous nodules, and subnephrotic-range proteinuria. Biopsies from skin lesions and paranasal sinuses demonstrated leukocytoclastic vasculitis and necrotizing granulomatous inflammation, respectively. Serum proteinase 3 (PR3)-antineutrophilic cytoplasmic antibody (ANCA) was positive, suggesting the diagnosis of GPA based on the 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for GPA. A kidney biopsy was not pursued due to the cause of glomerulonephritis (GN) being clinically evident, per the KDIGO 2021 GN Clinical Practice Guidelines. Immunosuppression was administered, which led to a transient improvement in clinical symptoms. However, subsequent kidney biopsy and other organ biopsies with cytogenic and molecular tests eventually confirmed extranodal NK/T-cell lymphoma infiltrating kidneys, skin, and paranasal sinuses. Physicians should always consider the possibility of hematologic malignancy in young adults presenting with multiple-organ involvement with vasculitic lesions or pauci-immune crescentic GN, albeit positive ANCA serologies. Kidney biopsy with cytogenic support should be performed to exclude threatening diseases, especially in atypical cases such as in young patients despite a context of compatible manifestations with other syndromes.