SHM Converge Scientific Abstract ePoster Gallery-Rare Case of Late Presentation of Hydralazine Induced Pulmonary-Renal Syndrome

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A 79-year-old woman with uncontrolled hypertension and stage 3 chronic kidney disease presented after one week of poor oral intake, nausea, vomiting, and chronic dry cough. Exam showed poor skin turgor and bilateral crackles, but stable vital signs. Labs revealed an acute rise in creatinine from a baseline of 2.6 mg/dL to 5.31 mg/dL, along with urinalysis showing 3+ protein and 3+ blood. Renal ultrasound showed no hydronephrosis. Chest CT demonstrated bilateral ground-glass opacities, and echocardiogram showed elevated pulmonary artery systolic pressure (PASP 52 mmHg) with preserved ejection fraction.<br /><br />Initial treatment with isotonic fluids did not improve renal function. Workup for other causes was negative, including SPEP, UPEP, immunofixation, hepatitis panel, and ANA. However, both PR3-ANCA and MPO-ANCA were elevated. Renal biopsy confirmed drug-induced pauci-immune crescentic glomerulonephritis. She was later found to have been previously treated with hydralazine for hypertension, which had been stopped one month before presentation.<br /><br />She was diagnosed with hydralazine-induced ANCA-associated vasculitis causing pulmonary-renal syndrome. Treatment with rituximab and methylprednisolone led to recovery of kidney function back to baseline. Repeat imaging showed resolution of the lung ground-glass opacities and improvement in pulmonary pressures (PASP reduced to 31 mmHg).<br /><br />This case highlights that hydralazine-induced ANCA-associated vasculitis can present late, even after the drug has been discontinued. The condition may cause severe renal injury, including rapidly progressive glomerulonephritis, and pulmonary involvement ranging from interstitial lung disease to alveolar hemorrhage. Early recognition is important because timely treatment can prevent irreversible kidney damage and reduce mortality.

Asset Subtitle

Hasan Baher

Meta Tag

Author List Alaq MA Al-Abayechi, Hasan Baher, Kanapa Kornsawad, Sara Alhaj

Category Clinical Vignettes

Concept Hydralazine

Concept ANCA-Associated Vasculitis

Concept Pulmonary-Renal Syndrome

Concept Drug-Induced Vasculitis

Concept Acute Kidney Injury

Distinguished Non-Finalist

Presenter Organization Department of Medicine, University of Texas Health Science Center, San Antonio, Texas

Presenting Author Hasan Baher

Track Adult

Keywords

hydralazine-induced vasculitis

ANCA-associated vasculitis

pauci-immune crescentic glomerulonephritis

pulmonary-renal syndrome

rapidly progressive glomerulonephritis

acute kidney injury

PR3-ANCA

MPO-ANCA

ground-glass opacities

rituximab and methylprednisolone

Hydralazine

ANCA-Associated Vasculitis

Pulmonary-Renal Syndrome

Drug-Induced Vasculitis

Acute Kidney Injury