A 67-year-old woman with a history of idiopathic pulmonary fibrosis was admitted to the hospital for new onset of cough with blood-streaked sputum, which followed several months of weight loss, anorexia, nausea, vomiting, and abdominal pain. She reported no occurrence of fever, rashes, oral ulcers, Raynaud phenomenon, chest pain, dyspnea on exertion, paresthesia, or joint concerns. On examination, her temperature was 36.9° C, blood pressure was 134/81 mm Hg, pulse was 110/min, and oxygen saturation level was 91% breathing room air. She appeared dyspneic, had no heart murmur, and had diffuse crackles especially at the lung bases and 2+ pitting edema of the legs without jugular venous distension. No rashes, synovitis, or focal neurological deficits were found. Laboratory evaluation showed a hemoglobin level of 7.5 g/dL from a baseline of 10.4 g/dL (reference range, 11.6-15.2 g/dL); a creatinine level of 6.5 mg/dL from a baseline of 1.2 mg/dL (reference range, 0.6-1.2; SI conversion to μmol/L, multiply by 88.4); and normal white blood cell count, platelets, and lactate. Urinalysis showed the presence of red blood cells but no protein. Chest x-ray showed new bilateral opacities. Computed tomographic imaging of the chest showed moderate stable fibrosis with multiple ground-glass opacities in the left lung. Based on these results, additional studies were performed (Table).
Bui VL, Kermani TA. Clinical Significance of a Positive Antineutrophil Cytoplasmic Antibody (ANCA) Test. JAMA. 2016;316(9):984-985. doi:10.1001/jama.2016.8307