DIFFUSE ALVEOLAR HEMORRHAGE DUE TO HYDRALAZINE-INDUCED LUPUS

Abstract

TYPE: Case Report TOPIC: Pulmonary Manifestations of Systemic Disease INTRODUCTION: Hydralazine is a known cause of drug-induced lupus and has been associated with ANCA-associated vasculitis (AAV) primarily involving the kidney, with rare pulmonary complications. We report a case of Hydralazine-induced lupus presenting as diffuse alveolar hemorrhage (DAH) in the absence of renal disease or AAV. CASE PRESENTATION: An 86 year-old female presented to the hospital due to one week of dyspnea and hemoptysis. She was started on Hydralazine 100mg BID five months prior. CTA of the chest revealed extensive bilateral central ground-glass opacities with relative sparing of the peripheral lungs. She had an unrevealing infectious and cardiac workup. Urinalysis showed bland sediment. Bronchoscopy revealed blood throughout the tracheobronchial tree and serial lavage aliquots were consistent with DAH. Autoimmune studies noted a positive ANA titer of ≥1:1280, and positive anti-histone IgG of 163AU/mL. The remaining studies were normal, including complement, anti-dsDNA, anti-Smith, anti-GBM, ANCA titers, PR3 and MPO antibodies, rheumatoid factor, anti-CCP, anti-RNP, and anti-SSA/SSB. Hydralazine was discontinued and the patient was started on systemic corticosteroids with complete resolution. DISCUSSION: Few cases of DAH attributed to Hydralazine have been reported in the literature. This case is unique in that there was no nephritis or AAV based on the antibody biomarker distribution. CONCLUSIONS: We report a case of DAH as a result of Hydralazine-induced lupus in the absence of renal involvement or AAV. Discontinuation of the offending agent, early bronchoscopy, autoimmune workup, and systemic corticosteroids are paramount to successful patient outcomes. Further investigation is necessary, as there currently exist no randomized trials to guide therapy. DISCLOSURE: Nothing to declare. KEYWORD: diffuse alveolar hemorrhage