The Utility of Bronchoscopy in Hydralazine-Induced ANCA-Associated Vasculitis

Abstract

Hydralazine is a vasodilator used for the management of hypertension, heart failure, and hypertensive emergencies in pregnancy. It has been implicated in the causation of drug-induced lupus erythematosus (DLE) and rarely with ANCA-associated vasculitis (AAV), which may present as a pulmonary-renal syndrome and be rapidly fatal. Herein, we describe a case of hydralazine-associated AAV presenting as acute kidney injury with the use of early bronchoalveolar lavage (BAL) with serial aliquots to aid with diagnosis. Our case highlights how, in the correct clinical setting, BAL can act as a rapid diagnostic test to help guide quicker treatment to allow for better patient outcomes.

Figure 1

Admission noncontrast chest CT demonstrating diffuse confluent ground-glass opacities in all five lobes with prominent subpleural sparing.

Figure 2

Bronchoalveolar lavage serial aliquots. Aspirate marked 1 correlates with the first aliquot with ascending numbers denoting sequentially taken aliquots. Findings demonstrate progressive blood-tinged fluid consistent with alveolar hemorrhage.

Figure 3

A glomerulus is involved by fibrocellular crescent (black arrow) occupying most of the Bowman space of the glomerulus. The glomerular capillary loops are collapsed and corrugated (Periodic Acid-Schiff, original magnification ×40).

Figure 4

Another glomerulus showing a segmental fibrinoid necrosis (black arrow) causing obliteration and break of capillary loops (Methenamine silver stain, original magnification ×40).