A previously healthy 42-year-old man presented with nasal obstruction, headache and cough resistant to topical intranasal corticosteroid treatment. Cough increased and he became slightly dyspnoeic. Chest X-ray showed one large cavitating lesion (Fig. la, white arrow) and numerous smaller nodules (Fig. la, black arrows). Computed tomography confirmed these and showed no evidence of an interstitial infiltrate. Bronchoscopy revealed subglottic and bilateral bronchial ulcers. Anti-neutrophil cytoplasmic antibodies were strongly positive with a cytoplasmic pattern (C-ANCA) and anti-proteinase 3 (PR3) specificity.
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