Combination of granulomatosis with polyangiitis with COVID-19: difficulties in differential diagnosis and treatment

Abstract

The article presents a prospective clinical observation with a fatal outcome in a patient with severe granulomatosis with polyangiitis (GPA) complicated by COVID 19 on the background of immunosuppression. At the onset of the disease, there were difficulties in making a diagnosis; differential diagnosis between eosinophilic granulomatosis with polyangiitis (EGPA) and GPA was carried out. Against the background of combined therapy — the use of high and ultra-high doses of glucocorticoids (GC) and cytostatic drugs, a short-term improvement was noted. However, within a year and a half of treatment, it was not possible to achieve remission of the disease. Taking into account the ineffectiveness of the therapy, by the decision of the medical commission, the patient was prescribed genetically engineered biological therapy rituximab (RTM). There was a decrease in the activity of the disease, the achievement of depletion of B-cells. During the pandemic period, despite observing the isolation regime, the patient fell ill with a coronavirus infection. Immunosuppression contributed to severe infection. After the infection was treated, the activity of vasculitis increased, which required the repeated administration of RTM for health reasons. During the therapy it was short-term stabilization of the condition. But after short period — fever, an increase in respiratory failure, the development of neutropenia. Taking into account the initial lesion of the lungs in the patient, differential diagnostics was carried out between the complications of coronavirus infection and the activity of the underlying disease. Despite anti-inflammatory, anticoagulant, antibacterial therapy, the patient's condition progressively worsened, respiratory failure increased, hemoptysis appeared. Spontaneous pneumothorax on the right was diagnosed, pneumomediastinum. After repeated negative PCR results, the causative agent of SARS COV-2 was again detected in smears. The immediate cause of death, according to clinical observation and autopsy, was severe respiratory failure, thrombosis in small vessels of the lungs in a patient with a new coronavirus infection against the background of immunosuppression for GPA.