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• W4387248906 abstract "SESSION TITLE: Images in Respiratory Failure SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a life threatening condition characterized by hemoptysis, anemia and alveolar opacities on imaging. It is often diagnosed based on progressively bloodier aliquots of bronchoalveolar lavage (BAL) fluid or on cytology showing hemosiderin laden macrophages. Treatment for DAH is largely determined by the underlying etiology. We report the case of a patient who presented with worsening hemoptysis associated with shortness of breath, hypoxia and fatigue, and was diagnosed with DAH from hydralazine-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. CASE PRESENTATION: A 78-year-old female with hypertension presented for progressively worsening nonproductive cough for two weeks with associated generalized fatigue. Hemoptysis started 36 hours prior to presentation. Initially sputum was blood streaked and subsequently she had bloody streaks with clots. She denied any new medications, or being on anticoagulation, antiplatelet agents or nonsteroidal anti-inflammatory agents. Home medications included amlodipine, simvastatin, hydralazine, and metformin. She denied any recent travel, sick contacts or family history of autoimmune conditions. She denied any other systemic symptoms. Patient was noted to be desaturating on presentation requiring three liters of supplemental oxygen. Physical examination was unrevealing except for a small amount of blood in the corner of her mouth. Initial workup revealed anemia and thrombocytopenia. Urine analysis showed microscopic hematuria. Coagulation panel, complete metabolic panel and lactate dehydrogenase were all unremarkable. Computed tomographic (CT) imaging of the chest extensive bilateral ground glass opacities (Figure 1). Patient was started on Ceftriaxone and azithromycin. She underwent a bronchoscopic evaluation which showed evidence of DAH (Figure 2). Cytology confirmed the diagnosis, with findings of hemosiderin laden macrophages (Figure 3). The autoimmune panel was positive for antinuclear antibody (ANA), anti-histone antibodies (AHA), perinuclear-ANCA (P-ANCA), anti-Myeloperoxidase (MPO) antibody, low complement-3 (C3), complement-4 (C4), and low total complement levels. The patient was diagnosed with hydralazine induced ANCA-associated vasculitis causing DAH and was started on pulse dose steroids as well as Rituximab. Hydralazine was discontinued. Patient showed clinical improvement with resolution of hemoptysis. Follow up imaging after four weeks showed complete resolution of previously seen infiltrates and a negative autoimmune panel. DISCUSSION: The potential for hydralazine to cause DAH is not well documented. One of the rare side effects hydralazine is known to cause is ANCA-associated vasculitis. Autoimmune work up typically can show multiple positive antibodies including ANA, AHA, Anti-MPO antibodies, P-ANCA, along with low C3/C4 complement levels, making it a challenging diagnosis to make and distinguish from other forms or causes of vasculitis [1]. Typical treatment for hydralazine induced ANCA-associated vasculitis includes cessation of hydralazine and induction therapy with steroids [2]. If the pulmonary symptoms are severe, additional immunosuppressants like cyclophosphamide and rituximab should be considered [3]. CONCLUSIONS: DAH can be a life-threatening emergency requiring prompt diagnosis. Autoimmune, rheumatologic and infectious workup along with extensive history-taking is of utmost importance to establish underlying etiology. Medication reconciliation is crucial as this could reveal underlying etiology, as in our case. REFERENCE #1: Doughem, K., Battisha, A., Sheikh, O., Konduru, L., Madoukh, B., Al-Sadawi, M., & Shaikh, S. (2021). Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review. Current cardiology reviews, 17(2), 182–187. https://doi.org/10.2174/1573403X16666200518092814 REFERENCE #2: Alawneh, D., & Edrees, A. (2022). Hydralazine-Induced Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Case Report and Literature Review. Cureus, 14(4), e24132. https://doi.org/10.7759/cureus.24132 REFERENCE #3: Tu, W., Fayman, B., Ward, S. C., Mamoon, Y., & Bandagi, S. S. (2021). Hydralazine-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Asymptomatic and Renal-Restricted Presentation. The American journal of case reports, 22, e931263. https://doi.org/10.12659/AJCR.931263 DISCLOSURES: No relevant relationships by Asad Chohan No relevant relationships by Saiara Choudhury No relevant relationships by Jorge Garza No relevant relationships by Austin Makadia No relevant relationships by Vashistha Patel No relevant relationships by Vishesh Persaud No relevant relationships by Abhay Vakil" @default.
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• W4387248906 date "2023-10-01" @default.
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• W4387248906 title "HYDRALAZINE-INDUCED VASCULITIS: A RARE DIFFUSE ALVEOLAR HEMORRHAGE" @default.
• W4387248906 doi "https://doi.org/10.1016/j.chest.2023.07.2618" @default.
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