An 81-year-old male patient with symmetrical polyarthritis of the hands was initially classified as seronegative arthritis. Years later, she presented with burning pain and paresthesia of the lower limbs.
The study was repeated, and given MPO (+) and sural nerve biopsy compatible with small vessel vasculitis, the diagnosis of ANCA-associated vasculitis (MPO (+)) was established, with axial tomography (Us of unknown etiology).
Also, with a history of coronary heart disease, heart failure FC I-II and stage 3 chronic kidney disease (CKD).
From the cardiological point of view, the patient had presented an acute coronary syndrome in 2012, whose coronary angiography showed occlusion of the marginal branch and non-significant stenosis of the main vessels.
Echocardiogram showed left ventricular hypertrophy and mild pulmonary artery hypertension.
At the time of diagnosis, oral cyclophosphamide was used; however, the patient developed severe pancreatitis, so it was discontinued.
Patient was treated conservatively for 4 years with prednisone 5 mg/day and azathioprine 50 mg/day.
Stable and asymptomatic.
The weeks prior to the last visit, reactivation of vasculitis was diagnosed, characterized by resumption of pain and paresthesia in the lower limbs, intenseicularis, and progressive increase in ESR and CPR with lived remission induction biopsy.
Pre-procedure tests: Hemoglobin 13.9 g/dL, white blood cells 12.300/mm3, ESR 64 mm/h, creatinine 1.39 mg/dL, total bilirubin 0.5 mg/dL, albumin 101 mg/dL
The patient was hospitalized for administration of methylprednisolone (125 mg), which was uneventful and sent home.
However, approximately 24 h after infusion, the patient developed fever up to 39.8 °C, respiratory distress, cough with mucopurulent expectoration and marked compromise of the general state.
The patient was admitted to the emergency department with fever (38.3 °C), hypotensive (MAP 49 mmHg), desaturating 89% environmental and polypnea (FR 29x’).
Physical examination revealed poor perfusion and the use of accessory muscles.
Laboratory tests: Hemoglobin 14.4 g/dL, leukocytes 5200/mm3, C-reactive protein 177 mg/L, arterial gases: pH 7.49, troponin PO2 53 mmHg, HCO3 19 mEq/L
Chest radiography: cardiomegaly, findings secondary to PIU, with no evident signs of condensation, congestion or pleural effusion.
Electrocardiogram showed normal sinus rhythm.
He returned vigorously, persisting hypotensive, so he was admitted to the ICU for management.
Blood cultures were taken and antimicrobial treatment with moxifloxacin (complete 10 days) and oseltamivir (complete 5 days) was initiated empirically.
Additionally, vasoactive drugs and corticosteroids were started at stress doses.
Pathway with norepinephrine requirements up to 0.1 mcg/kg/min, which were suspended at 12 h.
Samples were obtained for viral panel and viral PCR (-), hemocultive (-), urocultive (-) and absence of leukocytosis in serial measurements.
Chest CT showed no foci of condensation or associated pleural effusion.
1.
Associated with lower complexity, remission was observed in all symptoms and less than 48 hours after admission.
