Myocardial Infarction and Three-Vessel Coronary Artery Disease as Presenting Features of Granulomatosis with Polyangiitis: A Case Report with Review of Literature

Abstract

Granulomatosis with Polyangiitis (GPA) is a systemic, autoimmune disorder characterized by inflammatory insult and granulomatous processes in small and medium-sized vessels leading to various clinical presentations from underlying vasculitis. Underlying such inflammatory cascade is the overactivity of Antineutrophil Cytoplasmic Antibodies (c-ANCA) targeting serum Proteinase 3 (PR3), whose aberrant targeting classically modulates molecular signaling pathways leading to clinical manifestations of the Ear, Nose and Throat (ENT), in addition to renal impairment. Peripheral vessel involvement (i.e. limb vasculature) is not generally associated with GPA. With the exception of seldom reports in the literature, it is rare for GPA to present with coronary artery involvement. Moreover, reports of multi-vessel disease (e.g. triple-vessel disease) with GPA warranting Coronary Artery Bypass Graft (CABG) are lacking in such accounts. The latter with preceding iliac artery claudication makes such a presentation of GPA exceptionally novel and warrants contextual commentary regarding inflammation and Coronary Artery Disease (CAD). We report the case of a 55-year-old Caucasian male presenting with a 2 years history of right-sided groin cramping and an acute one-week history of claudication in the same area. After advised to follow up as an outpatient, this patient returned shortly thereafter to an acute care setting with hemoptysis and myocardial infarction worked up for GPA and triple-vessel disease. The patient was subsequently treated with immunosuppressive pharmacotherapy prior to CABG. We conducted a review of the literature underpinned in clinical and translational biology with a focus on the salient inflammatory pathways featured in both coronary artery disease and GPA.