PMC3806712_01
Time course of pulmonary lesions in our patient. a In a kidney biopsy performed in December 1996, interstitial changes of the lungs and pleural thickening (arrowheads) were the principal findings. b Chest CT from September 2001 shows little change. c Chest CT from October 2010 shows infiltrative shadows (arrows) in bilateral inferior lobes, simultaneously with hemoptysis. d Chest CT 2 days later in October 2010 shows disappearance of the hemorrhagic shadows shortly after initiation of steroid therapy.
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F1
Also, chest computed tomography (CT) delineated interstitial changes accompanied by cystic lesions in the lung and pleural thickening (fig. 1a), along with chest X-ray abnormalities that had been noted in a past medical checkup. An annual CT checkup had shown little change (fig. 1b), and elevation of serum KL-6 had not been documented. Chest CT showed infiltrative shadows in the bilateral lung fields (fig. 1c). A preventive dose of 100 mg isoniazid per day was also prescribed. As expected, the hemorrhagic shadows almost disappeared as early as 2 days after hospitalization (fig. 1d), and the serum MPO-ANCA titer subsequently fell to normal (fig. 2b).
a Course of serum Cr levels and MPO-ANCA titers from the time of renal biopsy until initiation of HD. Arrows indicate plasma exchange therapy; inverted triangle indicates granulocytapheresis. b Normalization of circulating MPO-ANCA following steroid therapy against alveolar hemorrhage. m-PSL = 3-day infusion of 500 mg methylprednisolone.
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F2
Cyclosporine A (CsA) was administered at doses of 50-100 mg per day under therapeutic drug monitoring (the trough level was usually around 50 ng/ml) in lieu of steroid therapy to reduce the risk of excessive immunosuppression, but the serum creatinine (Cr) level showed a rapid elevation in 2000, at approximately 3 years after biopsy (fig. 2a). In contrast, circulating MPO-ANCA had ranged from 10.5 to 32.5 U/ml, even in the dialysis period, indicating possible AAV (fig. 2b).