“Coughing Up Blood” part 3

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
    • Diffuse alveolar damage
      • Sarcoidosis, pulmonary embolism, bone marrow transplant, infection, malignancy
  • 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

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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