MEDizzy - A 49 year old male presents with deafness, shortness of

Feed Library Learning Discuss Leaderboard Journal

Nephrology and urology

A 49 year old male presents with deafness, shortness of breath, haemoptysis, reduced urinary output and ankle swelling. On examination: BP is 170/100 mmHg; JVP is 4 cm above the sternal angle, there are bibasal crepitations in the lungs and he has bilateral leg swelling to the mid-calves. Initial investigations reveal: haemoglobin 92 g/L, white cell count 9×109 /L; platelet count 460×109 /L; sodium 142 mmol/L; potassium 6.8 mmol/L; urea 45 mmol/L (270 mg/dL); creatinine 1260 μmol/L (14.25 mg/dL); albumin 32 g/L. Chest X-ray: bi-basal air space shadowing; ultrasound: normal-sized kidneys, no evidence of hydronephrosis. No urine is available for urinalysis. What is the most appropriate initial investigation from the list below?

ExplanationThe presence of haemoptysis and kidney injury indicates a pulmonary renal syndrome, most commonly due to granulomatosis with polyangiitis (previously known as Wegener’s granulomatosis), anti-glomerular basement membrane disease or lupus. Pulmonary embolus may cause haemoptysis, but it would not explain the renal failure in the context of hypertension. While Alport’s disease can cause deafness, it does not account for the haemoptysis, nor the acute nature of the process. Renal biopsy is likely to be required, but the risk of bleeding is very high at this point due to hypertension and uraemia. Serological testing should be performed urgently given the high risk of one of the above causes of pulmonary renal syndrome (most likely granulomatosis with polyangiitis given the deafness).