This correlated with a clinical improvement allowing the patient to be discharged home. Discussion The patient in this case appeared in the first instance to have another flare of her AAV. was changed to mycophenolate. She experienced a further lung relapse in 2014, treated successfully with high dose steroids and rituximab. She was eventually weaned off all treatment in 2017. She was admitted to hospital in 2019 with dry cough, dyspnoea and sinus congestion. She was mentioned to have several purpuric lesions on her limbs. Her CRP was elevated at 123 with a stable eGFR of 77. ANCA display was negative. Chest Xray exposed bilateral consolidation. She was initially treated with six pulses of 500mg of IV methylprednisolone and one C1qtnf5 pulse of rituximab as an inpatient over the course of 2 weeks, with broad spectrum antibiotic cover. Despite this, she continued to deteriorate having a worsening purpuric rash and increasing oxygen requirement. She underwent plasma exchange with little improvement. Metroprolol succinate CT of her chest revealed multiple progressive bilateral cavitating lesions. It was mentioned that her IgG levels were Metroprolol succinate low (3.72) following rituximab, increasing her risk of illness. An atypical illness display was performed and she was found out to have cytomegalovirus (CMV) reactivation with high viral titres of 56889. Metroprolol succinate She underwent bronchoscopic alveolar lavage which was positive for CMV on PCR. CT guided lung biopsy exposed necrotising granulomatous swelling with occasional CMV positive nuclei. She was given valganciclovir and IV immunoglobulin, and her prednisolone dose was reduced to 10mg. This resulted in her viral weight reducing to undetectable levels, her CRP improving to 23 and immunoglobulins normalising. This correlated with a medical improvement allowing the patient to be discharged home. Conversation The patient in this case appeared in the first instance to have another flare of her AAV. However the flare was atypical in that it was Metroprolol succinate not associated with an increase in her cANCA titre and it did not respond quickly to steroids as had been the case on each earlier occasion. This prompted a reassessment of her case and investigation into additional potential causes for her deterioration. CMV is definitely a prolonged herpesvirus which can impact up to 75% of healthy individuals. The primary illness is definitely hardly ever symptomatic but can be associated with significant morbidity and mortality in immunocompromised individuals. Pulmonary CMV disease can mimic pulmonary disease associated with vasculitis. CMV can also directly damage endothelial cells and cause an occlusive vasculitis itself. The patient was immunosuppressed, increasing her risk of acquiring primary CMV illness or developing CMV reactivation. She was given further potent immunosuppression during her admission. Serology is often unreliable in immunosuppressed individuals and in this case her CMV IgG was positive with a negative IgM, Metroprolol succinate indicating past CMV illness only. It is important to send samples for viral PCR to detect and diagnose active illness, and allow treatment to be initiated promptly. The lung biopsy was experienced to be more in keeping with active AAV, although occasional CMV positive nuclei were present. The patient was therefore handled as having CMV reactivation in the context of active AAV. Treatment of viral illness can pose further challenges when trying to manage coexistent active vasculitis as highlighted in this case. Close monitoring of the patient was required, together with a multidisciplinary approach including input from colleagues in infectious diseases and immunology, to allow the patient to be handled securely and efficiently. Prophylactic antiviral therapy may need to be considered if further immunosuppression is required in future. Key learning points CMV reactivation can complicate treatment of ANCA connected vasculitis. Clinicians should have a low threshold to test for CMV in immunocompromised individuals with vasculitis, particularly in instances which are atypical or refractory to standard.

This correlated with a clinical improvement allowing the patient to be discharged home