Disclosures: Vincent M. Battafarano, MD: No financial relationships or conflicts of interest

Case Diagnosis: 56-year-old male with multi-focal brain infarcts

Case Description: A 56-year-old male with hypertension, hyperlipidemia, tobacco use disorder, anemia, and recurrent pneumonia acutely develops right leg weakness, dysarthria, and confusion. Magnetic resonance imaging of the brain revealed multiple lacunar infarcts in the white matter of both cerebral hemispheres, temporal lobes, right thalamus, and right brain stem. Computed tomography (CT) of the chest showed bilateral basilar infiltrates consistent with abscesses on biopsy. Infarcts were attributed to septic emboli from cryptogenic organizing pneumonia. He completed acute inpatient stroke rehab and was discharged on a steroid taper. Following completion of the steroid taper, he had worsening malaise, fever, and cough. Recurrent pneumonias and new onset renal failure prompted further evaluation.

Setting: Inpatient hospitalAssessment/

Results: CTA of the chest revealed significant increase in soft tissue nodularity and mass-like consolidation. Due to persistent respiratory failure, fevers, and renal failure despite broad spectrum antibiotics, autoimmune etiology was suspected. Serology was positive for c-ANCA. Renal biopsy showed diffuse necrotizing, crescentic glomerulonephritis, pauci-immune type consistent with granulomatosis with polyangiitis (GPA). Cellcept (mycophenolic acid) and steroids improved his symptoms.

Discussion: Hypertension, diabetes, smoking, dyslipidemia, and arrhythmias are important modifiable risk factors for stroke and are part of routine stroke evaluation. Vasculitides are a less common risk factor. The Chapel Hill Consensus Conference defines GPA as a necrotizing vasculitis, with few to no immune deposits, affecting small to medium vessels predominantly in the respiratory and renal systems and often associated with c-ANCA. The clinical presentation (typically affects older, white adults) includes fever, malaise, unexplained weight loss, pulmonary, and renal involvement but can manifest with neurological symptoms.

Conclusion: This case supports evidence that GPA can present atypically with neurological symptoms. Strokes associated with GPA, while uncommon, can imitate other stroke etiologies but should be considered in older, white patients with pulmonary and renal end organ damage.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/granulomatosis-with-polyangiitis-presenting-as-stroke-a-case-report/