forgotten aetiology of haemoptysis and rapidly progressive glomerulonephritis

A 76 year old white woman died from massive pulmonary haemorrhage nine days after she was admitted to Parkland Memorial Hospital for evaluation of haemoptysis and rapidly progressive glomerulonephritis. The differential diagnosis of haemoptysis with rapidly progressive glomerulonephritis is presented with particular emphasis on Wegener's granulomatosis and microscopic polyarteritis. Necropsy showed a small vessel necrotising vasculitis associated with a focal segmental necrotising glomerulonephritis consistent with microscopic polyarteritis. University of Texas Southwestern Medical Center, Dallas, Texas S Zashin Parkland Memorial Hospital, Dallas, Texas R Fattor D Fortin Correspondence to: Dr Scott Zashin, Department of Rheumatology, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-9030, USA. Accepted for publication 28 February 1989 Case report A 76 year old white woman was admitted to the hospital for evaluation of fevers, patchy pulmonary infiltrates, and worsening renal function; she expired on the ninth hospital day. She had been well until two months before admission to a hospital in Beaumont, Texas with fevers to 38-9°C, haemoptysis, oral ulcers, epistaxis, nasal congestion, and dyspnoea. The admission chest x ray showed a right upper lobe posterior segment cavitary infiltrate. Treatment was started with cefuroxime and she was treated parenterally for 10 days. Her sputum culture grew Klebsiella pneumoniae. The following evaluation was made: white blood cells 16 9-25 0x 109/1 with 12-15% eosinophils, packed cell volume 0-3, platelets 613 x 109/1, urine analysissp gr 1-005, pH 6-5, no protein, 2+ blood with two to seven red blood cells/high powered field, creatinine 53-133 1imol/l, protein 71 gll, albumin 35 g/l, serum aspartate transaminase 38 IU/1, aLkaline phosphatase 275 IU/1, CH50 normal, antinuclear antibody titre 1/80, thyroid function tests normal, erythrocyte sedimentation rate 115 mm/h. A chest computed tomographic scan was performed showing patchy ill defined confluent infiltrative changes in both mid and