An elderly woman w/ history of IDA, aortic aneurysm + AI, and monoclonal gammopathy presents with SOB, found to have rapidly progressive anemia, AKI, and R>L pulmonary infiltrate concerning for a pulmonary-renal syndrome. She was ultimately diagnosed with ANCA vasculitis with +MPO, possibly related to hydralazine use and with some SLE overlap. Despite steroids and cytoxan, her renal failure progressed quickly requiring dialysis, and she ultimately transitioned to comfort care several months after the initial diagnosis.
*Ddx for pulmonary-renal syndrome – 3 buckets of disease plus one mimicker:
-ANCA vasculitis (microscopic polyangiitis versus granulomatosis w/ polyangiiitis)
-Anti-GBM disease (aka Goodpasture’s)
-Vasculitis from other cause (lupus, HSP, IgA, infective endocarditis)
-Mimicker: Other acute GN (like poststrep GN) can lead to volume overload w/ resultant pulmonary edema and hemoptysis but not true DAH (can distinguish on BAL)
Kaiser SF Internal Medicine Residency Blog 