Pulmonary-renal syndrome: diagnostic challenge

Abstract

Vasculitis presents several diagnostic challenges. Herein, we present a clinical case of a 71- year old woman, observed in our emergency department due to asthenia, vomiting and persistent cough. The patient had a history of progressive renal failure and anaemia over the last years. On physical examinations, fine pulmonary crackles were detected and laboratory test showed haemoglobin 69 g/L, creatinine 4 mg/dL, potassium 6.3 mmol/L, positive antineutrophil cytoplasm antibody (ANCA), with proteins and dimorphic erythrocytes in the urinary sediment. CT analysis of the thorax revealed patchy ground glass haziness, likely due to diffuse alveolar haemorrhage. Pulmonary-renal syndrome was assumed, and induction therapy was initiated. She was discharged after 33 days of hospitalisation. On the following months, ANCA titres remained undetectable, but minor recovery of renal function was observed, requiring haemodialysis. Indeed, the use of aggressive induction therapy at early stage dramatically improve prognosis, maintenance of disease remission may be difficult, as relapse is frequent.

Keywords: acute renal failure; lung function; vasculitis.

Figure 1

(A) Chest radiographs with diffuse bilateral infiltration; (B) Chest radiographs 15 days post-treatment, with marked improvement of the bilateral infiltrates.

Figure 2

(A) Thorax CT analysis with patchy ground glass haziness in a geographic distribution confirming crazy paving, suggesting of diffuse alveolar haemorrhage; (B) thorax CT analysis 1 month post-treatment, showing minor ground glass haziness.