Successful treatment of anti-neutrophil cytoplasmic antibody-associated inflammatory pseudotumour with rituximab: A case report.

RATIONALE: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare autoimmune condition that can involve various organ systems. Ocular involvement, though uncommon, may present as the initial or even sole manifestation. Orbital inflammatory pseudotumor, particularly its sclerosing subtype, can pose significant diagnostic and therapeutic challenges due to its steroid dependence and potential for recurrence.

PATIENT CONCERNS: A 72-year-old Chinese man presented with a 6-month history of recurrent headaches. He later developed bilateral exophthalmos and progressive vision loss despite initial treatment. His past medical history included type 2 diabetes mellitus.

DIAGNOSES: The patient initially tested positive for both p-ANCA and c-ANCA, with markedly elevated anti-myeloperoxidase and proteinase 3 antibody levels. Imaging revealed bilateral orbital masses consistent with orbital inflammatory pseudotumor, and biopsy confirmed sclerosing orbital inflammatory pseudotumor. Despite serological remission, clinical symptoms worsened during steroid tapering, suggesting steroid dependence.

INTERVENTIONS: The patient was initially treated with high-dose corticosteroids and oral cyclophosphamide. Although symptoms improved transiently, relapse occurred upon tapering steroids. Rituximab (RTX; 500 mg weekly for 4 weeks) was then administered as second-line therapy.

OUTCOME: The patient experienced significant improvement following RTX therapy, which allowed successful steroid tapering. No further relapse occurred during short-term follow-up.

LESSONS: This case illustrates the limitations of cyclophosphamide-based regimens in managing steroid-dependent ANCA-associated orbital disease. RTX may be a more effective alternative in relapsing or refractory cases, particularly when ocular symptoms persist despite ANCA seronegativity. Early recognition and individualized immunosuppressive therapy are essential for preserving vision and improving outcomes in ocular ANCA-associated vasculitis.