Today, we had an interesting case of an older lady who presented with vague fatigue and mouth sores, found to have AKI, RBCs in urine, and bilateral patchy opacities which progressed to frank hemoptysis and hypoxemia. Ultimately she was diagnosed with granulomatosis with polyangiitis!


Learning Points: Today we focused a lot on DDx...

  1. DDx oral ulcers -- Infections (HSV, VZV, HIV, coxsackie, syphilis), autoimmune diseases (SLE, Behcet's, vasculitis, bullous pemphigoid, pemphigus vulgaris), drugs.
  2. DDx hemoptysis -- Airway diseases (bronchitis, mets, foreign body), pulmonary parenchymal diseases (infections like TB, rheumatic disease), pulmonary vascular diseases (CHD, PE, HF, MS, endocarditis), disorders of coagulation (DIC, ITP/TTP/HUS, von Willebrand, platelet dysfunction), iatrogenic injuries, drugs/toxins.
  3. Ultimately, our patient was diagnosed with presumed diffuse alveolar hemmorhage secondary to GPA. We discussed options for diagnosis of DAH including bronch with BAL with lavage aliquots showing progressively more hemorrhage as well as hemosiderin-laden macrophages on Prussian blue staining. Our patient had such classic findings of GPA coupled with hypoxia, bilateral patchy infiltrates and hemoptysis that no further diagnostics were explored before starting treatment.