SHM Converge Scientific Abstract ePoster Gallery-Granulomatosis With Polyangiitis Presenting With Diffuse Alveolar Hemorrhage in a Patient With a History Suggestive of Fungal Coccidioides Pneumonia: A Clinical Conundrum

Granulomatosis With Polyangiitis Presenting With Diffuse Alveolar Hemorrhage in a Patient With a History Suggestive of Fungal Coccidioides Pneumonia: A Clinical Conundrum

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This case describes a 42-year-old previously healthy firefighter who presented with hemoptysis, chest pain, dyspnea requiring oxygen, dark urine, migratory joint pain, and constitutional symptoms after working wildfire duty in the California desert. Because he had blood-tinged sputum, poor response to broad-spectrum antibiotics, and imaging concerning for pneumonia, the initial differential included fungal Coccidioides pneumonia as well as autoimmune disease.<br /><br />He was transferred after an outside hospital performed bronchoscopy, BAL, and transbronchial biopsy. On arrival, he had leukocytosis, normocytic anemia, elevated inflammatory markers, and a chest x-ray showing right mid-lung infiltrates. Empiric fluconazole was started for possible coccidioidomycosis while additional infectious and autoimmune testing was pursued.<br /><br />Hospital course clarified the diagnosis: outside BAL showed no fungal organisms, transbronchial biopsy showed acute and chronic inflammation, and serologies returned positive for PR3 and c-ANCA, supporting granulomatosis with polyangiitis (GPA). He then acutely worsened with hypoxemia, bilateral infiltrates, falling hemoglobin, and repeat BAL demonstrating diffuse alveolar hemorrhage (DAH). He was transferred to the ICU, intubated for seven days, and treated with pulse-dose steroids plus cyclophosphamide/mesna induction. His ICU course was complicated by acute kidney injury, bilateral soleal DVTs, and Pseudomonas airway infection requiring antibiotics. After extubation, he was started on avacopan and a steroid taper, with clinical improvement over five days.<br /><br />The key teaching point is that DAH can be the presenting manifestation of GPA and may mimic severe pneumonia, especially in patients with relevant environmental exposures. A broad infectious and autoimmune evaluation is essential in hemoptysis with progressive infiltrates and poor antibiotic response, and ICU-level monitoring should be considered early when respiratory failure is evolving.

Asset Subtitle

Abiha Kazmi

Meta Tag

Author List Abiha Kazmi, Jacob Teperman, Marianna Babadzhanov, Nevada Cox, Sri Nuvvula, Syed E. Ahmad, Wajiha Kazmi

Category Clinical Vignettes

Concept Granulomatosis with Polyangiitis

Concept Diffuse Alveolar Hemorrhage

Concept ANCA-Associated Vasculitis

Concept Proteinase 3 ANCA

Concept Pulse-Dose Steroids

Distinguished Non-Finalist

Presenter Organization SUNY Downstate Health Sciences University

Presenting Author Abiha Kazmi

Track Adult

Keywords

granulomatosis with polyangiitis

diffuse alveolar hemorrhage

hemoptysis

c-ANCA

PR3 antibody

wildfire exposure

respiratory failure

bronchoscopy

cyclophosphamide

avacopan

Granulomatosis with Polyangiitis

Diffuse Alveolar Hemorrhage

ANCA-Associated Vasculitis

Proteinase 3 ANCA

Pulse-Dose Steroids