• These are actual cases to– Stimulate your reading– Test your knowledge of the material

• Look for the sound icon (usually in the top right portion of the slide)

• 18 year old male• Malaise and purulent nasal

discharge• Increasing dyspnea and

hemoptysis• History otherwise

unremarkable

• Physical exam: vitals signs stable, bibasilar crackles, especially at left base

• Initial Labwork:– Hgb 100– BUN 17– Cr 170– Urinalysis: 3+ red cells

• Q1: Interpret the CXR.• Answer (Q1)

• Q2: How does the CXR help you distinguish amongst the potential causes of hemoptysis?

• Answer (Q2)

• Q3: Based on the clinical, radiologic, and laboratory information presented so far, what are the diagnostic possibilities and your most likely diagnosis?

• Answer (Q3)

• Patient is admitted to hospital• Bronchoscopy - alveolar

hemorrhage without an airway lesion

• cANCA positive (1 / 2560 titer), pANCA and anti-GBM negative

• urine for cytodiagnostics – RBC casts

• Q4: What should you do next and why?a) CT chest to look for areas of

microcavitationb) Repeat bronchoscopy with

transbronchial lung biopsyc) Open lung biopsyd) Renal biopsye) Start empiric treatment with

steroidsf) Follow

• Answer (Q4)

• Renal biopsy - pauci-immune crescentic, necrotizing glomerulonephritis