case_images: PMC9453098_01
case_images: Ulcer on third and fifth toes (arrows).
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case_images: fig1
case_images: He developed petechial lesions on both feet that progressed to ulcers (Figure 1) on the bilateral lower extremities.
case_images: CT imaging showing multiple irregular pulmonary nodules (arrow) at different levels. The morphology of these nodules favors infectious/inflammatory nodules more than malignancy. Vasculitis can also have this appearance.
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case_images: fig2
case_images: Computed tomography (CT) of the chest showed multiple irregular nodules with suspected infectious versus inflammatory etiology and septic emboli could not be excluded (Figure 2).
case_images: Light microscopy of a renal biopsy with multiple cores of renal tissue, of which approximately 40% is represented by cortex. Eighteen glomeruli are present, none of which are globally sclerotic. In up to four glomeruli, there are segmental cellular crescents, associated with fibrinoid necrosis and rupture of the capillary loops. Intact glomeruli do not show significant endocapillary hypercellularity. The tubulointerstitial compartment is marked by tubular injury, with tubular dilatation and epithelial simplification. There is mild and patchy inflammatory infiltrate, mixed. Multiple red blood cell casts are present throughout the biopsy. Occasional neutrophilic casts are also seen. There are mild interstitial fibrosis and tubular atrophy which comprise approximately 20% of the cortex. Arteries are marked by mild intimal fibrosis. Arterioles do not show significant hyalinosis. Toluidine blue-stained sections contain four intact glomeruli.
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case_images: fig3
case_images: He later had a renal biopsy which showed granulomatosis with polyangiitis and mild interstitial fibrosis with tubular atrophy and a pauci immune crescentic glomerulonephritis (Figures 3 and 4).
case_images: This section is stained for fibrinogen and kappa and lambda light chains. There is focal and segmental staining of glomeruli with fibrinogen, in areas of crescents/fibrinoid necrosis (arrow). Kappa and lambda stain equally throughout the tubulointerstitium.
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case_images: fig4
case_images: He later had a renal biopsy which showed granulomatosis with polyangiitis and mild interstitial fibrosis with tubular atrophy and a pauci immune crescentic glomerulonephritis (Figures 3 and 4).
case_images: Predominantly central patchy and confluent ground-glass and interstitial opacities (arrows). This pattern is nonspecific but, given the patient's history, is favored to represent alveolar hemorrhage secondary to vasculitis.
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case_images: fig5
case_images: Repeat CT chest was ordered and was consistent with diffuse alveolar hemorrhage (Figure 5).