AB0632B TB OR NOT TB, THAT IS THE VASCULITIC QUESTION
Authors: Salema Khalid, Sarah Bartram
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> It is important to remember that there are many disorders that can mimic the clinical, radiographic and histological features of vasculitis. Tuberculosis (TB) is often referred to as the great imitator and therefore, needs to be considered early in the differential diagnosis of vasculitis. <h3>Objectives:</h3> To emphasize the importance of being aware of noninflammatory mimics of vasculitis to be able to avoid unnecessary and potentially harmful immunosuppression. <h3>Methods:</h3> We report a challenging case of a patient presenting with an inflammatory subglottic lesion. <h3>Results:</h3> A 81-year-old lady initially presented to otorhinolaryngology (ENT) with hoarseness and and restriction of breathing. Nasendoscopy revealed a subglottic lesion with oedema and inflammation. Biopsy showed florid necrotising granulomatous inflammation. Upon questioning, patient revealed one year history of epistaxis and nasal crusting requiring regular nasal douching. She also reported lack of energy, loss of appetite, but denied any rash, weight loss or night sweats. She suffered with a severely dry mouth that was causing difficulty swallowing. She also complained of an occasional cough with small amount of phlegm which she attribute to the difficulty with swallowing. Rheumatology team felt that this could be a possible localised Granulomatosis with polyangiitis and requested aNCA and a vasculitis screen. Interestingly, the patient's chest x-ray showed apical scarring, consistent with healed mycobacterial disease. A CT neck/thorax and abdomen was done which showed diffuse mucosal thickening of the subglottis and reticulonodular changes in the lungs. She was also noted to have deranged liver function test around this time. Gastroenterology advised that there was no clear cause for the transaminitis and an autoimmune screen was requested. Given the chest findings on CT, a sputum sample was sent for microscopy and culture. The patient had been started on dexamethasone on admission by ENT and reported substantial improvement in the hoarseness of voice and shortness of breath. ANCA then came back negative, as did the connective tissue screen. While the rheumatology team was considering how to further manage the possible vasculitis, the sputum smear came back positive for acid fast bacilli and the diagnosis was clinched: our patient was suffering with the extremely rare laryngeal tuberculosis, along with pulmonary TB. She was started on anti-tuberculous medication that have been introduced incrementally given the deranged liver function tests. The patient was doing well on her most recent follow up in the respiratory department. <h3>Conclusion:</h3> Greater awareness of vasculitis mimics like TB and a high index of suspicion are needed when assessing a patient presenting with the protean manifestations of suspected vasculitis. It is therefore prudent to include TB in the differentials, whenever consider vasculitis. <h3>References</h3> [1] Naeem Ullah Khan Seb Wallis and Naeem Siddiqui. Laryngeal tuberculosis: a diagnosis not to be missed BMJ Case Rep. 2009; 2009: bcr11.2008.1228. [2] Jain a, Misra DP, Ramesh a, Basu D, Jain VK, Negi VS. Tuberculosis mimicking primary systemic vasculitis: not to be missed! Trop Doct. 2017Apr;47(2):158-164. [3] Suresh E. Diagnostic approach to patients with suspected vasculitis. Postgrad Med J. 2006Aug; 82(970): 483–488. [4] Khasnis a; Molloy E. Mimics of primary systemic vasculitides. International Journal of Clinical Rheumatology. 4(5):597–609, OCT2009 <h3>Disclosure of interests:</h3> None declared