A 45-year-old male presents to the emergency depament with 2 days of haemoptysis. He repos that he has been coughing up 1-3 tablespoons of blood each day. He does repo mild chest pain, low-grade fevers, and weight loss. He has had about 1 year of severe upper respiratory symptoms including frequent epistaxis and purulent discharge treated with several courses of antibiotics. His only medications are daily aspirin and lovastatin. On examination, he has normal vital signs, and upper airway is notable for saddle nose deformity and clear lungs. A CT scan of the chest shows multiple cavitating nodules, and urinalysis shows RBCs . Which of the following tests offers the highest diagnostic yield to make the appropriate diagnosis?
High-Yield Explanation
The patient presents with classic symptoms for granulomatosis with polyangiitis. C/F: Vasculitis of 1. U= Epistaxis (Oral cavity Strawberry gingivitis) 2. L= Haemoptysis (Cavity formation in lungs) 3. Kidney = Haematuria The average age of diagnosis is 40 years. Male predominance. The diagnosis is made by demonstration of necrotizing granulomatous vasculitis on biopsy. Pulmonary tissue offers the highest yield. Biopsy of the upper airway usually shows the granulomatous inflammation but infrequently shows vasculitis. Renal biopsy may show the presence of pauci-immune glomerulonephritis.