MICROSCOPIC POLYANGIITIS PRESENTING AS DIFFUSE PULMONARY HEMORRHAGE AND ACUTE TYPE-1 RESPIRATORY FAILURE

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Microscopic polyangiitis is one of the causes of pulmonary-renal syndrome, a grave diagnosis with high mortality rate. Pulmonary symptoms include chest pain, dyspnea, and hemoptysis, with imaging showing diffuse pulmonary infiltrates. High degree of suspicion is required for timely diagnosis and management as delay in treatment increases mortality rate. CASE PRESENTATION: 59-year-old white Caucasian male with multiple comorbidities was admitted with acute type one respiratory failure requiring intubation due to diffuse pulmonary hemorrhage. During intubation, copious bloody secretions within the airway were noted, making intubation technically difficult. Patient was not taking any anticoagulant prior to admission and prophylactic anticoagulation was not initiated due to profound anemia on admission and concerns of airway hemorrhage.His clinical course was complicated by hemorrhagic shock, ischemic hepatitis, and worsening acute kidney injury that required dialysis, patient was treated with pulse steroid therapy, erythropoeitin was given in an attempt to improve anemia. Physical examination at presentation showed diffuse bilateral coarse breath sounds on auscultation. Pertinent blood work was hemoglobin of 6.8 gm/dl, Creatinine of 2.1 mg/dl, ALT of 1369 U/L, AST of 1812 U/L, positive MPO antibody with ANCA titer of 1:40, and low C3 complement level, pulmonary-renal syndrome was suspected with hemorrhagic airway and worsening kidney injury. CT scan of chest without contrast showed diffuse bilateral ground-glass opacities. Patient's family refused blood products due to religious beliefs and had continued worsening. Unfortunately, the patient did not respond to treatment and passed away. DISCUSSION: Microscopic polyangiitis (MPA) is an ANCA positive small vessel vasculitis and one of the causes of pulmonary-renal syndrome. MPA is associated with a 90% positive ANCA antibody and causes necrotizing vasculitis of small vessels without granuloma formation. Despite appropriate management, ANCA vasculitis remains a grave diagnosis with a mortality rate of 10% at one year.Intubating a patient with suspected alveolar hemorrhage can be technically difficult, placing a large diameter ETT considered safe, elective intuabtion of non-bleeding lung if bleeding lung can be indetified using bronchoscopy. Double lumen ETT is less preferable and comes with serious consequences of poor positioning and limiting bronchoscopy due to smaller-diameter lumen.Patients who declines blood transfusion can be challenging. Minimizing blood loss, reducing blood draws as well as optimizing RBC cell production along with reducing oxygen demand, improving oxygen delivery and using erythyroipesis stimulating agents have been used to improve anemia in such patients. CONCLUSIONS: Clinicians should be aware of the possibility of pulmonary-renal syndrome in a patient presenting with hemoptysis, hypoxia, and renal impairment. Reference #1: https://www.ncbi.nlm.nih.gov/pubmed/25984050 Reference #2: https://www.ncbi.nlm.nih.gov/pubmed/32185342 Reference #3: https://www.ncbi.nlm.nih.gov/books/NBK554372/ DISCLOSURES: No relevant relationships by Adel El Abbassi, source=Web Response No relevant relationships by Mahmoud El Iskandarani, source=Web Response No relevant relationships by Ibrahim Haddad, source=Web Response No relevant relationships by Sajin Karakattu, source=Web Response No relevant relationships by Lana Makahleh, source=Web Response No relevant relationships by Rasheed Musa, source=Web Response