0
Critical Care |

Monocytic Alveolitis in Microscopic Polyangiitis

Omar Farrukh, MD; Jean Keddissi, MD; Stanley Lightfoot, MD; Houssein Youness, MD
Author and Funding Information

OUHSC - Internal Medicine, Oklahoma City, OK


Chest. 2013;144(4_MeetingAbstracts):353A. doi:10.1378/chest.1703300
Text Size: A A A
Published online

Abstract

SESSION TITLE: Critical Care Student/Resident Case Report Posters IV

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Microscopic polyangiitis (MPA) is one of the ANCA associated vasculitis that affects small vessels. Systemic manifestations of MPA are more common than pulmonary manifestation, with reported glomerulonephritis in 97% and diffuse alveolar hemorrhage (DAH) in 30% of the cases (1). Lung biopsies typically show pulmonary hemorrhage, hemosiderin laden macrophages in alveolar spaces and neutrophilic capillaritis (2).

CASE PRESENTATION: 56 year old white man presented with progressive dyspnea, without cough, hemoptysis or fever. His medical history was positive for obesity, diabetes mellitus, coronary artery disease, hepatitis C and chronic kidney disease. Physical examination was remarkable for hypoxemia, diffuse crackles, and 1+ lower extremities edema. Chest-X-ray and CT scan (Figure 1) revealed significant bilateral consolidations, primarily on the left, with subpleural sparing. Laboratory workup revealed a WBC count of 8500/cm3 (85% neutrophils, 10% lymphocytes, 0.7 % eosinophil). Hemoglobin level was 6.6g/dl (down from a baseline of 10g/dl) . Creatinine was at baseline of 2.1 mg/dl. Urine analysis revealed no red blood cell cast. Due to increased oxygen requirement, the patient was placed on mechanical ventilation. Bronchoscopy revealed increasingly hemorrhagic fluid on sequential bronchoalveolar lavage. Serology workup revealed high C-ANCA (175 U/ml, normal <15 U/ml), P-ANCA of 4U/ml (normal< 15 U/ml), with normal anti-GBM ANA and cryoglobulins. The patient was started on pulse dose steroids and plasmapheresis. Despite therapy, the patient’s respiratory failure continued to worsen and the family decided to withdraw care. Autopsy revealed diffuse pulmonary hemorrhage secondary to microscopic polyangiitis, with no extrapulmonary involvement and no granulomatous inflammation. There was predominant mononuclear cellular infiltration of the alveolar septa with absence of the classical neutrophilic capillaritis (Figure 2).

DISCUSSION: This case demonstrates a deviation from the classical manifestation of microscopic polyangiitis. It was limited to the lungs with no renal or systemic involvement, and was associated with a C-ANCA serology, which is more commonly found in Wegener’s granulomatosis. Another atypical feature was the monocytic predominance in the alveoli, rather than the classical neutrophilic capillaritis.

CONCLUSIONS: Our case describes a variant of MPA that is limited to the lung with monocytic alveolar wall infiltration. Further studies are needed to confirm similar pattern.

Reference #1: 1- Jennette J et al: small-vessel vasculitis. N Engl J Med 1997; 337:1512-1523

Reference #2: 2- Gaudin PB et al: The pathologic spectrum of pulmonary lesions in patients with anti-neutrophil cytoplasmic autoantibodies specific for anti-proteinase 3 and anti-myeloperoxidase. Am J Clin Pathol. 1995 Jul;104(1):7-16.

DISCLOSURE: The following authors have nothing to disclose: Omar Farrukh, Jean Keddissi, Stanley Lightfoot, HOussein Youness

No Product/Research Disclosure Information


Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543