A 66 yo M with no past medical history presents with hemoptysis. Patient has significant weight loss, fevers, and history of chronic sinusitis.
Questions to Ask
- Onset: gradual vs acute? sick exposures?
- Constitutional: fevers, weight loss, fatigue?
- ENT: sinusitis, septal deformities, epistaxis, hearing loss?
- Nervous: mononeuritis multiplex (foot drop)?
- Cutaneous: purpura, ulcers?
Physical Exam
- Diffuse rales on pulmonary exam
- Vitals stable
- Otherwise normal exam
Diagnostic Workup
Labs
- CBC with Hgb 9 (no prior), CMP with Cr 1.9, UA 2+ blood, RBCs = ~20 per hpf
- ANCA with positive C-ANCA and PR3 antibodies
Further Workup
- Kidney bx: pauci-immune crescentic glomerulonephritis
- Bronch: consistent with DAH
Treatment
- Start pulse steroids
Referrals
- Consult rheumatology for consideration of rituximab vs. cyclophosphamide
A 54 yo F presents with foot drop. Further hx reveals longstanding hx asthma, fatigue, weight loss, otherwise negative.
Questions to Ask
- Onset: gradual vs. acute? sick exposures?
- Constitutional: fevers, weight loss, fatigue?
- Respiratory: shortness of breath?
- ENT: sinusitis?
- Cardiac: new-onset chest pain?
- Cutaneous: history of eczema?
Physical Exam
- Vitals stable
- Neurologic: 2/5 strength left foot dorsiflexion
- Respiratory: lungs clear
Diagnostic Workup
Labs
- ANCA negative
- CBC: absolute eosinophil count 2300 (20% on differential), CMP unremarkable
Further Workup
- Sural nerve bx: Necrotizing vasculitis
Treatment
- Pulse dose steroids for severe eosinophilic granulomatosis with polyangiitis (EGPA) (neurologic involvement)
Referrals
- Consult rheumatology for initiation of cyclophosphamide