This patient has two separate problems: Hemoptysis (with likely Diffuse Alveolar Hemorrhage) and Acute Kidney Injury (with likely glomerulonephritis as evidenced by urinalysis findings) in the setting of elevated inflammatory markers.
Diffuse Alveolar Hemorrhage
- Diagnosed by bronchoscopic alveolar lavage (BAL) obtaining sequential 5mL aliquots that show increasing RBCs
- Differential Diagnosis:
- Pulmonary capillaritis
- Vasculitis
- Anti-GBM disease
- Medications
- Bland pulmonary hemorrhage
- Coagulation disorders (see Coagulation)
- Heart Failure
- Diffuse alveolar damage
- Sarcoidosis, pulmonary embolism, bone marrow transplant, infection, malignancy
- Pulmonary capillaritis
- Additional workup via bronchoalveolar lavage includes:
- Negative Gram stain (cultures also remained negative) and AFB stain
- Negative ADA, galactomannan, and beta-D-glucan
- Cytology negative for malignant cells
- Additional imaging
- CTA negative for PE
- Additional labs
- PT/INR, PTT within normal range
- Vasculitis testing as below
Glomerulonephritis
- C3/C4 within normal limits
- ANA negative
- Anti-GBM negative
- ANCA positive for perinuclear staining (see small-vessel vasculitis, Nephritic Syndrome)
- Renal Biopsy: Crescenteric glomerulonephritis
Diagnosis
- Microscopic Polyangiitis
Treatment
- Prednisone and Cyclophosphamide
- Patient eventually recovered renal function and pulmonary bleeding stopped and she was successfully extubated. Discharged on prednisone and cyclophosphamide with rheumatology, pulmonology, and nephrology follow-up
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