肼屈嗪诱导的抗中性粒细胞胞浆抗体(ANCA)血管炎可能在肼屈嗪开始后的任何时间发生。一般内科医生应认识到弥漫性肺泡出血(DAH)是这种情况的罕见并发症,因为早期治疗降低了相关的高死亡风险。我们描述了一名82岁的女性舒张性心力衰竭的病例,该患者有一个月的劳累性呼吸困难恶化史和一周的咯血和疲劳史。她的药物包括阿司匹林和肼屈嗪。她在检查时缺氧伴有双侧呼气性喘息。实验室显示新的贫血,肌酐升高,蛋白尿,还有血尿.胸部计算机断层扫描显示不对称的双侧上叶磨玻璃衰减叠加在小叶间隔增厚和小叶内线上。进一步检测显示抗核抗体,ANCA阳性,核周ANCA(p-ANCA),和抗髓过氧化物酶ANCA(抗MPO-ANCA)。肾活检显示MPO-ANCA,Pauci免疫,坏死,和新月体肾小球肾炎。她被诊断为继发于肼屈嗪诱导的ANCA相关性血管炎(AAV)的DAH。肼屈嗪是一种抗高血压药物,具有已知的自身免疫反应潜力。其中,AAV是由抗MPO介导的罕见后遗症,并且最常见地影响肾脏。在极少数情况下,AAV患者可以发展为肺肾综合征,导致肾小球肾炎和DAH与相关的高死亡风险。对于病因不明的急性肾损伤患者,诊断需要高度怀疑。应通过免疫检查和肾脏活检进行早期诊断,迅速识别血管炎,停止肼屈嗪,免疫抑制,早期血浆置换对改善预后至关重要.
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.