INTRODUCTION:
Commonly located in the proximal stomach, Dieulafoy’s lesions are a result of small vessel dilation that can result in GI hemorrhages. Granulomatosis with polyangiitis, a systemic small-vessel vasculitis, usually involves the respiratory tract, kidneys, skin, and joints. Although GI symptoms are uncommon, previous cases have shown an association between Dieulafoy’s lesions and other systemic vasculitides, including Buerger’s disease and HSP. This case suggests a possible link between Dieulafoy’s lesion and granulomatosis with polyangiitis.
CASE DESCRIPTION/METHODS:
A 69-year-old white female with history of nasal vestibulitis, sinusitis, and otitis media presented with generalized weakness and sharp, bilateral chest pain with associated shortness of breath and tachycardia. CTA was negative for pulmonary embolism. Labs revealed normal procalcitonin and lactic acid but elevated ESR, CRP, D-dimer, and WBC. Due to her high oxygen requirement, patient underwent a bronchoscopy that revealed multiple lung nodules. Biopsies revealed caseating granulomatous inflammation. Further workup confirmed the diagnosis of granulomatosis with polyangiitis, and she was started on Rituxan and solumedrol. Her condition was improving until she had acute onset of hematemesis, dropping her hemoglobin by 5 g/dL. She underwent an EGD that revealed hiatal hernia with erosions, a Dieulafoy vessel in the gastric body of the lesser curvature, and a large clot that obscured nearly two-thirds of the stomach. Once hemodynamically stable, EGD was repeated and revealed several small satellite ulcers around a large 1 cm ulcer with visible vessel in the greater curvature that was then cauterized and clipped. Hemoglobin remained stable for the remainder of the hospital course. Biopsies were negative for H. pylori. She was discharged to inpatient rehab, where she continued to receive Protonix, Rituxan, prednisone, Xopenex, and Pulmicort.
DISCUSSION:
Several case reports linking Dieulafoy’s lesions with vasculitides have been reported in recent times. In the case above, this abnormal lesion was found in a patient with active granulomatosis with polyangitis, a diagnosis primarily known to affect the respiratory and renal system. The presence of a Dieulafoy’s lesion can be life-threatening, as in this case. EGD is an important tool for diagnosis and treatment of these lesions in the upper GI tract. Awareness of this potential association can help physicians anticipate and prevent fatal outcomes while inducing remission of this disease.
