PMC3914016_01
The patient's clinical course.
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fig1
Antineutrophil cytoplasm antibodies against myeloperoxidase (MPO-ANCA) and antibodies against proteinase 3 (PR3-ANCA) and antiglomerular basement membrane (anti-GBM) antibodies were not identified, although these assays were performed several times during the clinical course (Figure 1).
(a), (b) Chest X-ray and CT on admission showed bilateral central opacities, which are more confluent in the right upper and lower lung zone than elsewhere. There is slight cardiomegaly. (c) The radiograph obtained after intubation on the 10th day showed increased confluence of the opacities. The right hemidiaphragm is partially obscured. (d) Chest CT scan on the 10th day showed bilateral ground-glass opacities corresponding to the central and perihilar opacities and both small pleural effusions. (e) Chest CT scan on the 36th day showed progressed bilateral ground-glass opacities, confluent, and consolidated opacities, and a large quantity of pleural effusions in both lung fields. (f) Chest X-ray on the 92nd day showed the disappearance of infiltrative shadows in both lung fields.
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fig2
However, as alveolar patchy infiltrates gradually expanded after admission (Figures 2(c), 2(d), and 2(e)) and she expectorated bloody sputum on the 3rd day, we evaluated these antibiotic drugs as ineffective and she was treated with a blood transfusion because of worsening of anemia. Chest radiograph and chest CT scan showed a bilateral pulmonary infiltrative shadow that improved on the 64th day and disappeared without lung damage on the 92nd day (Figure 2(f)). 
(a), (b), (c) Light-microscopy examination of renal-biopsy specimens showed proliferative-appearing glomeruli with focal formation of cellular and fibrocellular crescents. The GBM was duplicated. Many glomeruli were globally sclerosed, indicating disease chronicity. (A periodic acid Schiff staining, B periodic acid silver-methenamine staining, C Masson's trichrome staining). (d) Immunofluorescence microscopy showed slightly bright granular staining for C3 in the mesangium area. (e) Immunofluorescence microscopy showed weak staining with IgG in a linear pattern in part of the GBM. GBM: glomerular basement membrane.
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fig3
The linear deposition of IgG was observed in part of the basement membrane by immunofluorescence micrography (see Figure 3).