28353556 Visualization

A 33 Age - year Age - old Age Moroccan Personal_background man Sex with a 5 Duration - month Duration history of recurring Detailed_description sinusitis Disease_disorder presented with temperature Sign_symptom , myalgia Sign_symptom , cough Sign_symptom , and hemoptysis Sign_symptom .
Thoracic Biological_structure physical Diagnostic_procedure examination Diagnostic_procedure revealed reduced Lab_value vesicular Diagnostic_procedure murmur Diagnostic_procedure , and chest Biological_structure X Diagnostic_procedure - ray Diagnostic_procedure showed bilateral Detailed_description diffuse Detailed_description alveolar Biological_structure infiltrates Sign_symptom .
Laboratory Diagnostic_procedure analyses Diagnostic_procedure showed elevation Lab_value of acute Diagnostic_procedure - phase Diagnostic_procedure proteins Diagnostic_procedure ( CRP Diagnostic_procedure 26 Lab_value   mg/dL Lab_value ) and creatinine Diagnostic_procedure ( 1.2 Lab_value   mg/dL Lab_value ) with nonnephrotic Detailed_description proteinuria Sign_symptom and microscopic Detailed_description glomerular Detailed_description hematuria Sign_symptom .
An antibiotic Medication therapy Medication for community Detailed_description acquired Detailed_description and atypical Detailed_description pneumoniae Disease_disorder with levofloxacin Medication 500 Dosage   mg Dosage daily Dosage iv Administration was established, but on the 3rd Date day Date from admission the patient developed respiratory Disease_disorder failure Disease_disorder unresponsive to noninvasive Detailed_description ventilation Therapeutic_procedure and had to be intubated Therapeutic_procedure .
White Color lung Biological_structure with consolidations Sign_symptom and ground Sign_symptom glass Sign_symptom areas Sign_symptom at computed Diagnostic_procedure tomography Diagnostic_procedure scan (Fig.1), diffuse Detailed_description airways Biological_structure bleeding Sign_symptom at fiberoptic Detailed_description bronchoscopy Diagnostic_procedure , mild Severity normocytic Detailed_description anemia Diagnostic_procedure ( 9 Lab_value   g/dL Lab_value ), and ANCA Diagnostic_procedure - PR3 Diagnostic_procedure positivity Lab_value ( 18.9 Lab_value   U/mL Lab_value ) were consistent with the diagnosis of GPA Disease_disorder .
Despite maximal Detailed_description ventilatory Therapeutic_procedure support Therapeutic_procedure , gas Diagnostic_procedure exchange Diagnostic_procedure did Lab_value not Lab_value improve Lab_value ( pH Diagnostic_procedure 7.33 Lab_value , PaO2 Diagnostic_procedure 71 Lab_value   mm Lab_value   Hg Lab_value , PaCO2 Diagnostic_procedure 51 Lab_value   mm Lab_value   Hg Lab_value , HCO3 Diagnostic_procedure – 25 Lab_value   mmol/L Lab_value , SaO2 Diagnostic_procedure 94% Lab_value ) requiring extracorporeal Therapeutic_procedure membrane Therapeutic_procedure oxygenation Therapeutic_procedure ( ECMO Therapeutic_procedure ).
Treatment with high Dosage - dose Dosage methylprednisolone Medication ( 1 Dosage   g Dosage daily Dosage for 3 Duration days Duration and 1 Dosage   mg/kg Dosage daily Dosage thereafter), cyclophosphamide Medication ( 1.2 Dosage   g/pulse Dosage every Dosage 2 Dosage weeks Dosage for Dosage the Dosage 1st Dosage 3 Dosage pulses Dosage , followed by infusions every Dosage 3 Dosage weeks Dosage for Dosage the Dosage next Dosage 2 Dosage pulses Dosage ), and plasma Therapeutic_procedure exchange Therapeutic_procedure ( PE Therapeutic_procedure ), according to European Detailed_description vasculitis Detailed_description study Detailed_description group Detailed_description recommendations,[4] was immediately started with respiratory Diagnostic_procedure improvement Lab_value that allowed ECMO Therapeutic_procedure and orotracheal Therapeutic_procedure tube Therapeutic_procedure withdrawal and subsequent discharge Clinical_event from intensive Nonbiological_location care Nonbiological_location unit Nonbiological_location .
After Date 9 Date days Date from the beginning of treatment ANCA Diagnostic_procedure - PR3 Diagnostic_procedure levels normalized Lab_value ( 3 Lab_value   U/mL Lab_value ).
Two Date months Date later Date , after the 5th Detailed_description bolus Detailed_description of cyclophosphamide Medication and with prednisone Medication 0.3 Dosage   mg/kg/day Dosage , the patient complained arthromyalgia Sign_symptom and testicular Biological_structure pain Sign_symptom with edema Sign_symptom , cough Sign_symptom , and shortness Sign_symptom of Sign_symptom breath Sign_symptom : laboratory Diagnostic_procedure data Diagnostic_procedure showed worsening Lab_value of renal Diagnostic_procedure function Diagnostic_procedure , mild Severity anemia Sign_symptom , and hypoxemia Sign_symptom ( PaO2 Diagnostic_procedure 61 Lab_value   mm Lab_value   Hg Lab_value ).
Epididymitis Disease_disorder was confirmed by ultrasound Diagnostic_procedure .
Because of rapidly Detailed_description progressive Detailed_description renal Disease_disorder failure Disease_disorder (estimated glomerular Diagnostic_procedure filtration Diagnostic_procedure rate Diagnostic_procedure 35 Lab_value   mL/min Lab_value ) renal Biological_structure biopsy Diagnostic_procedure was performed and showed prominent Severity intracapillary Biological_structure and extracapillary Biological_structure proliferation Sign_symptom , with the formation of some fibrocellular Sign_symptom crescents Sign_symptom and focal Detailed_description capillary Biological_structure necrosis Sign_symptom (Fig.2).
Lung Biological_structure computed Diagnostic_procedure tomography Diagnostic_procedure -scan and fiberoptic Detailed_description bronchoscopy Diagnostic_procedure also confirmed alveolar Biological_structure hemorrhage Sign_symptom relapse Detailed_description .
Treatment with high Dosage - dose Dosage methylprednisolone Medication ( 1 Dosage   g Dosage daily Dosage for 3 Duration consecutive Duration days Duration ) and rituximab Medication ( 375 Dosage   mg/m2 Dosage weekly Dosage for 4 Duration weeks Duration ) was started with rapid resolution of urologic Biological_structure and pulmonary Biological_structure involvement Sign_symptom but delayed Detailed_description and partial Lab_value improvement Lab_value of renal Diagnostic_procedure function Diagnostic_procedure .
At a 1 Date - year Date follow Clinical_event - up Clinical_event , the patient is alive Sign_symptom and under treatment with azathioprine Medication ( 150 Dosage   mg Dosage daily Dosage ) and prednisone Medication ( 15 Dosage   mg Dosage daily Dosage ).
Renal Diagnostic_procedure function Diagnostic_procedure has markedly Lab_value improved Lab_value (estimated glomerular Diagnostic_procedure filtration Diagnostic_procedure rate Diagnostic_procedure 94 Lab_value   mL/min Lab_value ) same as gas Diagnostic_procedure - exchange Diagnostic_procedure ( pH Diagnostic_procedure 7.42 Lab_value , PaO2 Diagnostic_procedure 86 Lab_value   mm Lab_value   Hg Lab_value , PaCO2 Diagnostic_procedure 36 Lab_value   mm Lab_value   Hg Lab_value , HCO3 Diagnostic_procedure – 23 Lab_value   mmol/L Lab_value , SaO2 Diagnostic_procedure 95% Lab_value ).
The patient signed institutional informed consent form at the time of admission to hospitalization.
An approval by ethics committee was not necessary because of the routine health care.