El FIGURE 1. Plain chest radiograph at the time of the second hos- pital admission, with predominantly right-sided bilateral alveolar infiltrate. *From the Nephrology Service, Hospital Universitario San Car- los, Madrid, Spain. Reprint requests: Dr. Torralbo, c/Seville 1-3 14003 Cordoba, Spain 1590 Alveolar Hemorrhage in Rheumatoid Arthritis (TorraI& et a!) Alveolar Hemorrhage Associated With Antineutrophil Cytoplasmic Antibodies in Rheumatoid Arthritis* Antonio Torralbo, M.D.; Jos#{233} A. Herrero, M.D.; Jose Portol#{232}s,M.D.; and Alberto Barrientos, M.D. A 65-year-old woman with previously known rheuma- toid arthritis and chronic renal failure of possible glomerular origin was admitted to the hospital because of hemoptysis and respiratory insufficiency. Antineutro- phil cytoplasmic antibodies (ANCAs) with antimyelo- peroxidase activity were detected in her serum. The lung biopsy specimen evidenced alveolar hemorrhage. Under immunosuppressive therapy with steroids and cyclo- phosphamide, the patient’s condition improved both clinically and radiologically, and the ANCA became negative after 6 months’ therapy. (Chest 1994; 105:1590-92) Allalveolarhemorrhage;ANCAantineutrophilcytoplas- mic antibody; MPOmyeloperoxidase; RArheumatoid arthritis T he pulmonary manifestations of rheumatoid arthritis (RA) include pleural effusion, diffuse interstitial fi- brosis and pneumonitis, necrobiotic nodules, Caplan’s syndrome, pulmonary hypertension out of proportion to interstitial lung disease (pulmonary vascular disease), up- per lobe fibrobullous disease, bronchiolitis, and bron- chogenic carcinoma.’ Renal disease and alveolar hemor- rhage (AH) have been infrequently described in RA.2-3 In three previously reported cases, no autoantibodies other than rheumatoid factor were detected, though antineu- trophil cytoplasmic antibodies (ANCAs) were not tested for. We describe a patient with RA and AH associated with serum ANCA. CASE REPORT A 65-year-old woman had been diagnosed as having seropos- itive RA at another hospital in 1988. No data are available regarding her renal function over the 2 ensuing years. In 1990, she was admitted to our hospital’s Nephrology Service because of asthenia, vomiting, and limb cramps. The clinical ex- amination disclosed arterial hypertension (170/100 mm Hg), mucocutaneous pallor, ulnar deviation at the metacarpopha- langeal joints in both hands with distal interphalangeal nodules, and absence of lower limb edema. The relevant laboratory results were as follows: hematocrit, 23.8 percent; creatinine, 1087.3 mol/L (12.3 mg/dl); albumin, 27 g/L (2.7 g/dl), globulins, 35 g/L (3.5 g/dl); and proteinuria, 2.5 g/24 h. The rheumatoid fac- tor was positive (153 UI/mi, nephelometry), antinuclear anti- bodies and cryoglobulins were negative, and the complement levels were within normal ranges. The plain chest radiograph showed moderate cardiomegaly and the radiographic study of the hands disclosed ulnar deviation, reduced metacarpophalangeal joint space, erosions in the metacarpal epiphyses, and increased soft-tissue shadows. The abdominal ultrasound revealed small kidneys bilaterally. A diagnosis of end-stage chronic renal failure was established, and the patient was entered in the periodic he- modialysis program. In May 1992, the patient was again admitted to the hospital because of dyspnea and hemoptysis. The hematocrit at this time was 21 percent and gasometric values (breathing 28 percent ox- ygen) were PaO of 55 mm Hg, PaCO2 of 33 mm Hg, pH of 7.46 and CO3H of 25 mmol/L. The plain chest radiograph evidenced a bilateral alveolar infiltrate pattern, most noticeable in the right field (Fig 1). At bronchoscopy, traces of blood were seen in the trachea and the right main bronchus, issuing from the right ha- solateral segment. Under arteriographic control, embolization of the segmental arteries was performed and control of the hemoptysis was achieved. The patient received a transfusion of concentrated RBCs, but again developed anemia over the ensuing hours. The ANCAs were detected in serum 48 h after hospital admission, with a perinuclear indirect immunofluorescence pat- tern and antimveloperoxidase (anti-MPO) activity by enzyme- linked immunosorbent assay. The rheumatoid factor was positive (73 UI/mi); other autoantibodies, including antinuclear, anti- DNA, antihistone, and anti-basal membrane antibodies, were negative. Cryoglobulins and circulating immuole complexes were negative, and the complement was normal. . :.: -.-.. : .. I ‘ F1;URE 2. Photomicrograph showing an area of lung paren- chyma with the alveolar spaces occupied h RBCs, fibrin, and hemosiderin pigment within the macrophages (hematoxylin- eosin, original magnification X125). Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21694/ on 06/25/2017