55 year old man presented to hospital with acute onset shortness of breath, cough and a multiple episodes of small volume haemoptysis. The patient reported several months of rhinitis, sinusitis, arthralgia, myalgia, fever and weight loss. Past medical history includes hypertension for which ramipril is taken.
On examination the patient is coughing up fresh red clots, respiratory rate is 30 breaths/min, SpO2 90% on 15L/min O2 through a non -rebreathe mask and there are bilateral crackles to the mid zones. He is peripherally cold to touch, capillary refill time is 3 seconds, heart rate is 100 beats/min and blood pressure is 96/50. A palpable purpuric rash on his legs and conjunctivitis are also noted.
Investigation findings include:
- Arterial blood gas: pH 7.31, P02 7.5kPa, PC02 4.6kPa, HCO3 20 mmol/L, BE -4
- CXR: diffuse perihilar airspace shadowing with sparing of the apices
- Venous bloods: Hb 85g/L, WCC 25 x109/L, Platelets 304 x109/L, CRP 150mg/l, ESR > 100 mm/h, Urea 15.5 mmol/L, Creatinine 322 µmol/L, Na+ 134 mmol/L, K+ 5.8 mmol/L. Liver function tests and coagulation are normal.
