title: Delayed development of pulmonary hemorrhage in a patient with positive circulating anti-neutrophil cytoplasmic antibody: a clinical dilemma.
abstract: Detection of circulating anti-neutrophil cytoplasmic antibody (ANCA) provides a powerful clue in the diagnosis of vasculitis, but the clinical interpretation of the results is difficult in some cases. Here, we describe the case of a 65-year-old man who underwent hemodialysis due to focal segmental glomerulosclerosis and abruptly developed hemoptysis 14 years after a renal biopsy. At the time of the biopsy, computed tomography (CT) showed interstitial shadows in the lungs and pleural thickening, indicating pneumoconiosis that was accompanied by tuberculosis. Circulating myeloperoxidase-ANCA (10.5-32.5 U/ml) was subsequently noted, but the significance of this observation was unclear due to the preexisting disorders in the lungs and kidneys. Potent immunosuppressive therapies were avoided because of the pulmonary lesions and decreased renal function. There were few changes noted on follow-up CT, but infiltrative shadows emerged in the bilateral lungs, consistent with hemoptysis. The hemorrhagic shadows completely disappeared shortly after initiation of steroid therapy, with normalization of the serum ANCA level. Herein, we report this case, with an emphasis on the clinical dilemma faced in deciding the appropriate treatment. The findings in the case provide deep insights into clinical management of ANCA-positive patients.
authors.affiliation: Department of Internal Medicine, Oyama Municipal Hospital, Oyama, Jichi Medical University, Shimotsuke, Japan ; Dialysis Center, Oyama Municipal Hospital, Oyama, Jichi Medical University, Shimotsuke, Japan ; Divison of Nephrology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.
authors.forename: Toshimi
authors.initials: T
authors.lastname: Imai
authors.forename: Shin-Ichi
authors.initials: S
authors.lastname: Takeda
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kawaguchi
authors.forename: Yuko
authors.initials: Y
authors.lastname: Chaki
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Morishita
authors.forename: Tetsu
authors.initials: T
authors.lastname: Akimoto
authors.forename: Shigeaki
authors.initials: S
authors.lastname: Muto
authors.forename: Eiji
authors.initials: E
authors.lastname: Kusano
keywords: ANCA-related nephritis and vasculitis; Focal and segmental glomerulosclerosis; Pulmonary hemorrhage; Tuberculosis