Head examination was normocephalic and atraumatic with pupils equal, round, and sluggish to light and conjunctival pallor. His neck was supple with no jugular venous distension. Lung examination revealed coarse crackles at bilateral bases but no focal consolidation. His cardiac auscultation showed normal S1 and S2 without murmurs, rubs, or gallops,

and the abdomen was soft with normoactive bowel sounds and no organomegaly. No skin lesions, rashes, or edema were present. Chest X-ray showed appropriately placed endotracheal tube with extensive diffuse interstitial and alveolar infiltrates bilaterally (see Figure 1). Image 1. Chest X-ray showing appropriately Inhibitors,research,lifescience,medical placed endotracheal tube with extensive diffuse interstitial and alveolar infiltrates bilaterally. Laboratory findings included complete blood count, with WBC 10,260 per uL, Hgb 10.3 g/dL, Hct 30.6%, platelets of 167,000 per uL, and MCV 92.4 fL. Complete metabolic panel showed Na 150 mEq/L, K 4.3 mEq/L, Cl 99 mEq/L, CO2 29

mEq/L, BUN 95 mg/dL, Cr 13.8 mg/dL, Inhibitors,research,lifescience,medical glucose 184 mg/dL, calcium 8.9 mg/dL, magnesium 2.1 mg/dL, phosphorus 11.9 mg/dL, total protein 7.8 g/dL, albumin 4.0 g/dL, total bilirubin 0.5 md/dL, direct bilirubin 0.4 mg/dL, ALT 12 units/L, AST 42 units/L, and alkaline phosphatase 71 units/L. Lactic acid was 1.3 mmol/L and urine drug Inhibitors,research,lifescience,medical screen was negative. Urinalysis was grossly red and hazy in appearance, with 2+ protein, large blood and leukocyte esterase, 71 WBC/HPF, more than 200 RBC/HPF, gram stain negative, and no culture growth. Urine eosinophils were negative. Additional laboratory studies included negative ANA, DNA antibody, p-ANCA and c-ANCA, anti-GBM, Inhibitors,research,lifescience,medical and HIV. Complement levels were normal. IgG was elevated at 1570 mg/dL with low levels of IgA (37 mg/dL)

and IgM (27 mg/dL). Bronchoscopy was performed with BAL cell count of 0.155m/mL, 44% PAMS, 2% lymphocytes, 54% PMNS, and negative gram stain. Bronchoalveolar http://www.selleckchem.com/products/Verteporfin(Visudyne).html lavage was negative Inhibitors,research,lifescience,medical for malignancy and GMS stain. However, the lavage aspirate was noted to be progressively bloodier, consistent and characteristic of diffuse alveolar hemorrhage. Renal ultrasound showed relatively normal-sized kidneys with right measuring 10.8 by 6.0 by 5.4 cm and left crotamiton measuring 10.0 by 5.8 by 4.9 cm. No renal mass, calculi, or hydronephrosis was seen. Subsequent renal biopsy revealed acute tubular injury with intertubular and peritubular neutrophilic inflammation secondary to obstructing tubular casts. Renal sample electron microscopy was unremarkable, specifically without any focal areas of complement deposition. Given the patient’s presentation of pulmonary hemorrhage and renal failure, pulmonary renal syndrome was suspected. The patient was therefore started on high-dose steroids and cyclophosphamide and hemodialysis for suspected systemic vasculitis and anticipated start of plasma exchange.