Tongue Ulcer and Hemorrhagic Paronychia as Presenting Manifestations of Granulomatosis with Polyangiitis
A 77-year-old male patient presented to the ENT outpatient department due to a 1-week history of symptoms of odynophagia and hoarseness. Several small ulcerations could be seen in the region of the larynx as well as a painful ulcer on the left edge of the tongue (Figure a). Hemorrhagic paronychia was visible on the fingers and toes. A biopsy of the tongue ulcer revealed nonspecific granulocytic infiltration. To rule out a paraneoplastic etiology, computed tomography imaging was performed, identifying isolated pulmonary nodules (Figure b). Due to concomitant elevated C-reactive protein (206 mg/L), antibiotic therapy was initiated but produced no significant improvement in the findings. In the further course, an elevated titer for c-ANCA/anti-PR3 antibodies was determined, and acute renal failure (Acute Kidney Injury Network stage 3) with a nephritic sediment developed. Histology revealed a segmental necrotizing and proliferative extracapillary pauci-immune glomerulonephritis. Overall, the findings were consistent with granulomatosis (GPA) with polyangiitis. The skin and mucosal lesions, as well as renal function, improved with immunosuppressive therapy comprising glucocorticoids and rituximab. The pulmonary nodules remained unchanged in the long term.
Lotte Dahmen, Klinik für Innere Medizin, Nephrologie und Internistische Intensivmedizin, Philipps-Universität Marburg, email@example.com
Prof. Dr. med. Ronald Wolf, Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg
PD Dr. med. Christian S. Haas, Klinik für Innere Medizin, Nephrologie und Internistische Intensivmedizin, Philipps-Universität Marburg
Conflict of interest statement: The authors declare that no conflict of interests exists.
Translated from the original German by Christine Rye.
Cite this as: Dahmen L, Wolf R, Haas CS: Tongue ulcer and hemorrhagic paronychia as presenting manifestations of granulomatosis with polyangiitis. Dtsch Arztebl Int 2021; 118: 65. DOI: 10.3238/arztebl.m2021.0092