A Rare Case of Hydralazine-Induced Diffuse Alveolar Hemorrhage.
anti-neutrophil cytoplasmic antibody (anca)-associated vasculitis (aav)
diffuse alveolar hemorrhage
hydralazine
pauci-immune crescentic glomerulonephritis
pulmonary renal syndrome
Journal
Cureus
ISSN: 2168-8184
Titre abrégé: Cureus
Pays: United States
ID NLM: 101596737
Informations de publication
Date de publication:
Oct 2023
Oct 2023
Historique:
accepted:
20
10
2023
medline:
29
11
2023
pubmed:
29
11
2023
entrez:
29
11
2023
Statut:
epublish
Résumé
Hydralazine-induced anti-neutrophil cytoplasmic antibody (ANCA) vasculitis may occur any time after hydralazine initiation. General internists should recognize diffuse alveolar hemorrhage (DAH) as a rare complication of this condition, as early treatment reduces the associated high risk of mortality. We describe the case of an 82-year-old female with diastolic heart failure who presented with a one-month history of worsening dyspnea on exertion and a one-week history of scant hemoptysis and fatigue. Her medications included aspirin and hydralazine. She was hypoxic with bilateral expiratory wheezes on exam. Labs showed new anemia, elevated creatinine, proteinuria, and hematuria. Chest computed tomography showed asymmetric bilateral upper lobe ground-glass attenuation superimposed on interlobular septal thickening and intralobular lines. Further testing showed anti-nuclear antibody, positive ANCA, perinuclear ANCA (p-ANCA), and anti-myeloperoxidase ANCA (anti-MPO-ANCA). Renal biopsy revealed MPO-ANCA, pauci-immune, necrotizing, and crescentic glomerulonephritis. She was diagnosed with DAH secondary to hydralazine-induced ANCA-associated vasculitis (AAV). Hydralazine is an anti-hypertensive medication with known potential for autoimmune reactions. Of these, AAV is a rare sequela mediated by anti-MPO and most commonly affects the kidneys. In rare circumstances, patients with AAV can develop pulmonary-renal syndrome, resulting in both glomerulonephritis and DAH with an associated high risk of mortality. Diagnosis requires a high index of suspicion in patients with acute kidney injury of unclear etiology. Early diagnosis through immune work-up and kidney biopsy should be pursued, as prompt recognition of the vasculitis, cessation of hydralazine, immunosuppression, and early plasma exchange are essential to an improved prognosis.
Identifiants
pubmed: 38022102
doi: 10.7759/cureus.47591
pmc: PMC10665773
doi:
Types de publication
Case Reports
Langues
eng
Pagination
e47591Informations de copyright
Copyright © 2023, Xue et al.
Déclaration de conflit d'intérêts
The authors have declared that no competing interests exist.
Références
Tuberc Respir Dis (Seoul). 2013 Apr;74(4):151-62
pubmed: 23678356
Curr Cardiol Rev. 2021;17(2):182-187
pubmed: 32418528
Curr Opin Rheumatol. 2014 Jan;26(1):42-9
pubmed: 24276086
J Am Soc Hypertens. 2011 Nov-Dec;5(6):473-7
pubmed: 21890447
N Engl J Med. 2010 Jul 15;363(3):211-20
pubmed: 20647198
JACC Heart Fail. 2017 Sep;5(9):632-639
pubmed: 28711446
Cureus. 2023 Feb 22;15(2):e35306
pubmed: 36994251
J Cardiovasc Pharmacol Ther. 2016 Jan;21(1):3-19
pubmed: 26033778
BMJ Case Rep. 2018 Nov 8;2018:
pubmed: 30413463
Oncol Rep. 2011 Feb;25(2):399-407
pubmed: 21152880
Semin Arthritis Rheum. 2018 Oct;48(2):283-287
pubmed: 29519741
J Clin Invest. 2010 Sep;120(9):3209-19
pubmed: 20714105
J Am Soc Nephrol. 1996 Jan;7(1):23-32
pubmed: 8808106
Mod Rheumatol. 2009;19(3):338-47
pubmed: 19424772
Kidney Int. 2021 Aug;100(2):440-446
pubmed: 33857570
Clin J Am Soc Nephrol. 2015 Jul 7;10(7):1300-10
pubmed: 26092827