77 year old
man presents with small digital gangrenous skin lesions,
(these lesions were found
to be small vessel vasculitis).
he is hypotensive and mild short of breath. He is not
confused and mental status is good. He has splinter
hemorrhages in the nail beds
(vasculitis sign)
and Cardiologist diagnoses
him as Endocarditis starts him on Intravenous
antibiotics including Penicillin and Gentamycin. (Excellent
choice as initially thought to be Endocarditis treating
with Pen & Gentamycin is standard)
Patient is also noted to be anemic and Hemoglobin
is 9 grams BUN and Creatinine are proportionately
elevated at 30 and 2.4, suggestion
of dehydration versus renal disease with anemia
blood gases show increased A-a
gradient and PO2 of 55 on 50% aerosol mask.
almost any lung disease can
elevate A-a gradient shunt , embolism or COPD
CT chest is done shows infiltrates
with solid mass like sub pleural consolidations
bilaterally. Suspicious for pneumonia and tumor.
this is interesting is this all
due to cancer patient with atypical pneumonia or is it a
rheumatologic disease
ESR was
greater than 115, Hemoglobin 9 gm
this favors rheumatologic disease
Na is 125.Anion gap
was Normal .Is it SIADH or
rheumatologic disease or lung cancer hard to say Pulmonologist
diagnoses him as sepsis syndrome with Gagrenosa pyoderma
and Cefepime with vancomycin is given and patient is
monitored in the ICU. Infectious
cause is Possible Pulmonologist is just playing safe
like the cardiologist
Patient is started on moderate
dose steroids. Pulmonologist is
probably playing safe for rheumatologic condition
associated with the
disease.
Nephrologists starts working up for
vasculitis and Wegner's granulomatosis and aggressively
hydrates the patient. He is right
on the money it is Wagner's granulomatosis.
Rheumatologist starts the work up and
suggests patient be transferred to a tertiary care
Hospital. He wants plasma-pherisis
and kidney biopsy and lung biopsy to be done.
Patient is anticoagulated and on
oxygen face mask and starts having hemoptysis, he is
intubated placed on the ventilator and Bronchoscopy is
done.
Tests done show P-ANCA and C-ANCA
test to be positive.
Bronchoscopy shows alveolar
hemorrhage.
Diagnosis
is Wagner's granulomatosis
Contributors :
A. Acosta MD, R. Kaul MD, P. Wawrzynski MD, Z. Iqbal MD,
M. Islam MD
Lupus information :
Lupus site (SLE)- information on lupus
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