SHM Converge Scientific Abstract ePoster Gallery-If Its Not One Thing Its Another: A Rare Case of Hydralazine Induced Lupus Presenting as Diffuse Alveolar Hemorrhage

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This case describes an 83-year-old man with hypertension who presented with recurrent fever, dyspnea, and hemoptysis after an initial hospitalization for presumed pneumonia. He was taking hydralazine chronically for blood pressure control, along with amlodipine, furosemide, and losartan. His infectious workup was negative, and chest CT showed bilateral ground-glass and consolidative opacities, pleural effusions, and mediastinal/hilar lymphadenopathy without pulmonary embolism.<br /><br />Bronchoscopy revealed mucosal hemorrhage and persistently bloody bronchoalveolar lavage from the left lower lobe, consistent with diffuse alveolar hemorrhage (DAH). Subsequent evaluation supported hydralazine-induced lupus, including positive anti-histone antibodies, lupus nephritis on renal biopsy, and pulmonary capillaritis/vasculitis on lung biopsy. The patient improved rapidly with high-dose steroids after hydralazine was stopped and was discharged with a taper and rheumatology/pulmonary follow-up.<br /><br />Hydralazine is a widely used antihypertensive that can cause drug-induced lupus in 5–10% of users, and less commonly ANCA-associated vasculitis. Symptoms often appear months to years after starting the medication. Typical features include fever, arthralgia, myalgia, and sometimes skin involvement; renal and pulmonary disease are much rarer. DAH is a severe and potentially fatal manifestation characterized by hemoptysis, falling hemoglobin, respiratory compromise, and pulmonary infiltrates, with diagnosis confirmed by bronchoscopy showing progressively bloodier lavage.<br /><br />Despite initial improvement, the patient experienced recurrent DAH each time steroids were tapered and required repeated hospitalizations. He ultimately died from complications. This case highlights the need to recognize hydralazine as a potential cause of lupus and life-threatening pulmonary hemorrhage, especially in patients with unexplained hemoptysis and negative infectious workup.

Asset Subtitle

Vaughn M. Williams

Meta Tag

Author List Elias Jabbour, Vaughn M. Williams

Category Clinical Vignettes

Concept Hydralazine

Concept Minocycline-Induced Lupus

Concept ANCA-Associated Vasculitis

Concept Diffuse Alveolar Hemorrhage

Concept Hydralazine Discontinuation

Distinguished Non-Finalist

Presenter Organization Kent Hospital Internal Medicine Residency

Presenting Author Vaughn M. Williams

Track Adult

Keywords

hydralazine

drug-induced lupus

diffuse alveolar hemorrhage

hemoptysis

pulmonary capillaritis

lupus nephritis

ANCA-associated vasculitis

bronchoscopy

ground-glass opacities

high-dose steroids

Hydralazine

Minocycline-Induced Lupus

ANCA-Associated Vasculitis

Diffuse Alveolar Hemorrhage

Hydralazine Discontinuation