The patient, a 59-year-old man, presented with fever, conjunctival injection, and sensorineural hearing loss in 2022. Laboratory evaluation revealed microscopic hematuria and a high-titer proteinase 3-antineutrophil cytoplasmic antibody >200 RU/mL. He was diagnosed with granulomatosis with polyangiitis (GPA).1 Despite initial response to glucocorticoids and intravenous cyclophosphamide (cumulative dose 4.8 g), he developed a clinical relapse in 2023. Thoracic computed tomography (CT) demonstrated the recurrence of multiple bilateral pulmonary nodules and masses (panel A). CT-guided biopsy revealed necrotic and degenerated tissue, consistent with GPA. Induction therapy was switched to rituximab (1,000 mg × 2 doses) and high-dose prednisolone (60 mg daily),2 resulting in rapid symptomatic remission. Longitudinal imaging documented the structural evolution of the lesions: a follow-up CT in 2024 showed excavation of the nodules into thick-walled cavities with air-fluid levels (panel B). By 2025, under maintenance rituximab therapy, these cavities collapsed and regressed, leaving only residual parenchymal scarring (panel C). Uniquely, this case documents the complete chronological transition from solid granuloma to necrotic excavation and finally to structural collapse, offering a novel perspective on the radiographic resolution process. This evolution highlights the efficacy of B cell–depleting therapy in refractory disease. Disclosure Form: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Zhang et al. (Sun,) studied this question.
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