You’ve Got to Be “Kidney”, Don’t Be Rash About the Infiltrates

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The differential diagnosis of hypoxia and diffuse pulmonary infiltrates, in a seemingly healthy young man is broad. Infection (due to typical, opportunistic, viral, and fungal sources) or pulmonary edema (cardiogenic and non-cardiogenic) are common etiologies, but when clinical evidence for these conditions fails to accumulate, unusual causes should be entertained. This is a case of a patient whose pulmonary diagnosis was revealed through his kidneys. CASE PRESENTATION: A 21-year-old African American male with a history of Hashimoto’s thyroiditis presented with a one-week history of malaise, non-productive cough, shortness of breath, chest pain; on review of systems he admitted to months of polyarthralgia, rash, and endorsed foamy urine for weeks. His mother had a nonspecific rheumatologic disorder. His exam was significant for fever, hypoxic respiratory distress, sinus tachycardia, rales worse in the lung bases, and a purpuric rash of the left hand dorsum. CT chest revealed multilobar consolidations and bilateral ground-glass opacities (Fig. 1). Lab results revealed anemia, nephrotic range proteinuria, RBC’s and WBC’s in the urine, but no casts; ESR was 106; C3 and C4 were low. ANA, anti-DS DNA, ENA RNP, ENA Smith, Anti-chromatin IgG were all elevated. An infectious work-up was negative. With these findings, the patient was started on high dose methylprednisolone. A renal biopsy revealed interstitial fibrosis (Fig. 2a), segmental endocapillary proliferation, closure of capillary loops and thickened arterioles (Fig. 2b), most consistent with lupus nephritis. Steroids were tapered and he was started on mycophenolate and hydroxychloroquine. The patient improved with this treatment. DISCUSSION: Systemic lupus erythematosus (SLE), an autoimmune disease with a predilection for females of non-European descent, affects 20 to 150 patients per 100,000. It frequently presents with arthritis, serositis, skin, renal, and hematologic involvement1. Pulmonary manifestations may be the presenting symptom in 4-5% of patients2. The clinical presentation of acute lupus pneumonitis is nonspecific, usually with cough, dyspnea, pleuritic pain, hypoxia, patchy alveolar infiltrates on radiography, and absence of clinical and laboratory evidence of infection2. CONCLUSIONS: Pulmonary disease is not uncommon in SLE, but is infrequently the initial manifestation of disease. Indeed, the patient’s months of polyarthralgia, rash, and proteinuria suggest his respiratory woes were not the first indication of SLE. This condition should be considered in the differentia diagnosis of young patients presenting with hypoxemic respiratory failure and imaging features suggestive of pneumonia. Reference #1: Keane, M. P., and Joseph P. Lynch, III. “Rare Diseases Bullet 7: Pleuropulmonary Manifestations of Systemic Lupus Erythematosus.” Thorax 55.2 (2000): 159-66. Reference #2: Torre, Olga, and Sergio Harari. “Pleural and Pulmonary Involvement in Systemic Lupus Erythematosus.” La Presse Médicale 40.1 (2011): E41-51. DISCLOSURE: The following authors have nothing to disclose: Amanda Liggett, Enrique Calvo-Ayala, Dean Troyer No Product/Research Disclosure Information