Letter to the Editor
Pulmonary haemorrhage in a patient with IgA nefropathy
Hemorragia pulmonar en paciente con nefropatía IgA
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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carlos" "apellidos" => "Fernández-Díaz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] ] ] 2 => array:3 [ "nombre" => "Natalia" "apellidos" => "Palmou Fontana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Emilio" "apellidos" => "Rodrigo Calabia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Luis" "apellidos" => "Martin Penagos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Manuel" "apellidos" => "Arias Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Gema" "apellidos" => "Fernández Fresnedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia pulmonar en paciente con nefropatía IgA" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 525 "Ancho" => 638 "Tamanyo" => 43474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Alveolar-interstitial infiltrates secondary to intrapulmonary haemorrhage and haematoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Henoch-Schönlein purpura (HSP) is a leukocytoclastic vasculitis affecting small-vessels that is rarely seen in adults. Lung involvement is extremely rare, with an unpredictable clinical evolution and high rates of mortality.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 69-year-old male patient with IgA nephropathy and a bilateral alveolar haemorrhage in the context of HSP. As for his personal history, he suffered from hypertension and atrial fibrillation, wore a mechanical prosthesis and was undergoing treatment with oral anticoagulants. The patient was admitted due to fever, dyspnoea, oedemas, coughing and expectoration. On admission, a deterioration of kidney function was observed (Cr 1.67<span class="elsevierStyleHsp" style=""></span>mg/dl; GFR 41<span class="elsevierStyleHsp" style=""></span>ml/min) as well as leukocytosis with a left shift. Following diuretic and antibiotic treatment, an improvement in kidney function occurred (Cr 0.9<span class="elsevierStyleHsp" style=""></span>mg/dl, GFR 82<span class="elsevierStyleHsp" style=""></span>ml/min) and the leukocytosis decreased. A few days later, the patient presented again deterioration of kidney function (Cr 2.1<span class="elsevierStyleHsp" style=""></span>mg/dl), anaemia (Hb 7.5<span class="elsevierStyleHsp" style=""></span>g/dl) along with purpuric lesions of the lower limbs. The tests performed showed: normal albumin, cholesterol and lactate dehydrogenase; an ESR of 52<span class="elsevierStyleHsp" style=""></span>mm, urine element and sediment with +++proteins, ++++Hb, >100 red blood cells/field, 24-hour urine protein of 1870<span class="elsevierStyleHsp" style=""></span>mg; IgA 437.00<span class="elsevierStyleHsp" style=""></span>mg/dl, normal remaining immunoglobulins and complement, antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane antibodies and negative viral serology testing. Haptoglobins < 25, blood smear without schistocytes, positive direct Coombs test. Urological ultrasound with no pathological findings.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In light of suspected vasculitis, treatment was initiated with three boli of methylprednisolone 500<span class="elsevierStyleHsp" style=""></span>mg on consecutive days, followed by prednisone at 1<span class="elsevierStyleHsp" style=""></span>mg/kg every 24 hours. 72 hours later, symptoms of haemoptysis and anaemia appeared; a chest X-ray and chest CT scan were performed, showing findings suggestive of a bilateral alveolar haemorrhage and the presence of intraparenchymal pulmonary haematoma (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Treatment was initiated with a bolus of 500<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> cyclophosphamide and immunoglobulins at 2<span class="elsevierStyleHsp" style=""></span>g/kg, spread across five doses. Five days later, frank haemoptysis, anaemia and significant respiratory effort occurred, prompting a transfer to ICU, where orotracheal intubation and mechanical ventilation were performed. The patient also required aspiration due to massive bleeding.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">During the patient's stay in the ICU, six sessions of plasmapheresis were performed on alternate days, and treatment with corticosteroids was maintained. A clinical and analytical improvement was seen over the subsequent days and extubation was performed 13 days later, with normalised kidney function and no new bleeding episodes. Finally, a kidney biopsy was performed in which 15 glomeruli were observed, four of which were sclerosed while the others showed the presence of diffuse segmental lesions in the form of endocapillary and mesangial proliferation and glomerular necrotic lesions. Interstitium with mild fibrosis and patchy inflammatory infiltrate. Positive immunofluorescence in the face of granular mesangial IgA (++), IgM (++) and C3 (++). After three months in hospital, the patient was discharged on a monthly immunoglobulin treatment and a decreasing corticosteroid regimen. Due to the risk of superinfection, combined treatment with other immunosuppressants was postponed until the pulmonary haematoma had resolved.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the last hospital visit, from a clinical point of view the patient presented without dyspnoea, and clear improvements were seen in his lung X-ray and laboratory tests: creatinine 1.2<span class="elsevierStyleHsp" style=""></span>mg/dl, GFR 61<span class="elsevierStyleHsp" style=""></span>ml/min, urine with minimal microscopic haematuria (15–20 red blood cells/field) with a urine protein:creatinine ratio of 238.6<span class="elsevierStyleHsp" style=""></span>mg/g, and no anaemia or leukocytosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">HSP is a form of leukocytoclastic vasculitis that affects the small vessels and, on rare occasions, the medium vessels. Its symptoms are characterised by non-thrombocytopenic palpable purpura (100% of cases), arthralgia in the lower limbs (82%), gastrointestinal involvement (50–75%) and renal involvement (20–50%). Musculoskeletal, neurological, pulmonary, cardiac and ocular conditions have been described less frequently.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> The incidence in adults is around 1.3 cases per 100,000.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The EULAR/PRINTO/PRES diagnostic criteria (2008) for HSP include, as a mandatory criterion, the existence of non-thrombocytopenic palpable purpura, predominantly in the lower limbs and, in case of atypical distribution, proven IgA deposition in the biopsy. In addition, at least one of the following characteristics is required: diffuse abdominal pain, biopsy with IgA deposition, arthritis or arthralgia and renal involvement (haematuria or proteinuria).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Renal involvement usually manifests in the form of mild glomerulonephritis, with microscopic haematuria and proteinuria, and a biopsy showing IgA nephropathy.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Lung involvement in HSP is extremely rare and includes, above all, haemorrhage or interstitial disease. Diffuse alveolar haemorrhage, which may present immediately following the HSP diagnosis, or even several years later, has an unpredictable clinical evolution and is associated with high rates of mortality.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Chest X-rays are usually non-specific and computed tomography is required to confirm the findings. The severity of the situation warrants the use of intensive immunosuppressive therapy<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a>; treatment combined with glucocorticoids and cyclophosphamide, azathioprine, methotrexate or rituximab is common. Plasmapheresis has also been noted as a therapeutic option.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The most common aetiologies that coexist with alveolar haemorrhage and glomerulonephritis are anti-neutrophil cytoplasmic antibody-associated vasculitis and anti-glomerular basement membrane antibody disease. Although uncommon, HSP should be considered among the differential diagnoses in a patient with pulmonary haemorrhage and renal involvement.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Belmar Vega L, Fernández-Díaz C, Palmou Fontana N, Rodrigo Calabia E, Martin Penagos L, Arias Rodríguez M, et al. Hemorragia pulmonar en paciente con nefropatía IgA. Nefrologia. 2017;37:347–349.</p>" ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The first two authors share authorship.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 525 "Ancho" => 638 "Tamanyo" => 43474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Alveolar-interstitial infiltrates secondary to intrapulmonary haemorrhage and haematoma.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 525 "Ancho" => 525 "Tamanyo" => 55542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intrapulmonary haematoma, areas with ground-glass opacity and crazy-paving pattern due to pulmonary haemorrhage.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Henoch-Schönlein purpura in children. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 8 | 19 |
| 2024 October | 50 | 52 | 102 |
| 2024 September | 70 | 35 | 105 |
| 2024 August | 65 | 64 | 129 |
| 2024 July | 50 | 30 | 80 |
| 2024 June | 66 | 36 | 102 |
| 2024 May | 72 | 41 | 113 |
| 2024 April | 67 | 38 | 105 |
| 2024 March | 46 | 37 | 83 |
| 2024 February | 42 | 33 | 75 |
| 2024 January | 46 | 34 | 80 |
| 2023 December | 47 | 25 | 72 |
| 2023 November | 58 | 40 | 98 |
| 2023 October | 50 | 33 | 83 |
| 2023 September | 71 | 30 | 101 |
| 2023 August | 47 | 19 | 66 |
| 2023 July | 64 | 25 | 89 |
| 2023 June | 49 | 27 | 76 |
| 2023 May | 66 | 26 | 92 |
| 2023 April | 61 | 23 | 84 |
| 2023 March | 111 | 25 | 136 |
| 2023 February | 61 | 17 | 78 |
| 2023 January | 79 | 33 | 112 |
| 2022 December | 63 | 38 | 101 |
| 2022 November | 107 | 33 | 140 |
| 2022 October | 67 | 43 | 110 |
| 2022 September | 52 | 44 | 96 |
| 2022 August | 61 | 48 | 109 |
| 2022 July | 41 | 42 | 83 |
| 2022 June | 50 | 45 | 95 |
| 2022 May | 46 | 30 | 76 |
| 2022 April | 56 | 68 | 124 |
| 2022 March | 66 | 54 | 120 |
| 2022 February | 97 | 52 | 149 |
| 2022 January | 64 | 42 | 106 |
| 2021 December | 79 | 45 | 124 |
| 2021 November | 59 | 42 | 101 |
| 2021 October | 63 | 44 | 107 |
| 2021 September | 39 | 39 | 78 |
| 2021 August | 42 | 44 | 86 |
| 2021 July | 61 | 37 | 98 |
| 2021 June | 47 | 29 | 76 |
| 2021 May | 74 | 56 | 130 |
| 2021 April | 114 | 84 | 198 |
| 2021 March | 79 | 48 | 127 |
| 2021 February | 71 | 41 | 112 |
| 2021 January | 35 | 23 | 58 |
| 2020 December | 50 | 17 | 67 |
| 2020 November | 33 | 14 | 47 |
| 2020 October | 29 | 23 | 52 |
| 2020 September | 40 | 13 | 53 |
| 2020 August | 46 | 13 | 59 |
| 2020 July | 32 | 17 | 49 |
| 2020 June | 60 | 13 | 73 |
| 2020 May | 41 | 15 | 56 |
| 2020 April | 37 | 17 | 54 |
| 2020 March | 54 | 17 | 71 |
| 2020 February | 53 | 24 | 77 |
| 2020 January | 54 | 23 | 77 |
| 2019 December | 63 | 23 | 86 |
| 2019 November | 41 | 19 | 60 |
| 2019 October | 38 | 17 | 55 |
| 2019 September | 51 | 19 | 70 |
| 2019 August | 41 | 14 | 55 |
| 2019 July | 58 | 25 | 83 |
| 2019 June | 36 | 17 | 53 |
| 2019 May | 43 | 20 | 63 |
| 2019 April | 79 | 34 | 113 |
| 2019 March | 46 | 23 | 69 |
| 2019 February | 26 | 14 | 40 |
| 2019 January | 35 | 17 | 52 |
| 2018 December | 160 | 46 | 206 |
| 2018 November | 203 | 17 | 220 |
| 2018 October | 155 | 19 | 174 |
| 2018 September | 109 | 23 | 132 |
| 2018 August | 61 | 15 | 76 |
| 2018 July | 56 | 13 | 69 |
| 2018 June | 68 | 13 | 81 |
| 2018 May | 80 | 15 | 95 |
| 2018 April | 118 | 12 | 130 |
| 2018 March | 91 | 8 | 99 |
| 2018 February | 50 | 8 | 58 |
| 2018 January | 77 | 5 | 82 |
| 2017 December | 67 | 4 | 71 |
| 2017 November | 59 | 10 | 69 |
| 2017 October | 40 | 6 | 46 |
| 2017 September | 53 | 7 | 60 |
| 2017 August | 47 | 2 | 49 |
| 2017 July | 47 | 12 | 59 |
| 2017 June | 17 | 3 | 20 |
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