Acute Pulmonary-Renal Syndromes

¹ Department of Medicine, Walter Reed Hospital, Walter Reed Army Medical Center

Cases were selected to emphasize the differential diagnosis of the patient who initially and predominantly manifests acute pulmonary and renal involvement. In renal vein thrombosis, pulmonary emboli commonly occur and their recognition in an individual with recent flank pain and rapidly developing nephrosis should suggest this diagnosis. Goodpasture's syndrome is seen in young men and is characterized by recurrent hemoptysis, dyspnea, transitory diffuse lung mottling on chest x-ray films, and an anemia of iron-deficiency type. Renal involvement with uremia soon follows. At necropsy, the lung shows extensive hemorrhage, hemosiderosis, and mild interstitial fibrosis. Vasculitis is not present. The glomeruli are involved with an exudative and proliferative reaction. Unlike post-streptococcal glomerulonephritis in which the involvement is diffuse and uniform, the glomerular changes vary from normal to complete obliteration. The renal picture similar in Wegener's granulomatosis; however, this variant of polyarteritis is seen in both sexes and at any age. The upper respiratory tract is more commonly involved with a necrotizing granulomatous reaction of the nasal or sinus mucosa. When the lung is affected, single to multiple nodular lesions appear which have a tendency to cavitate. A diffuse angiitis is also present. Acute glomerulonephritis may follow beta hemolyticstreptococcal pneumonia. Usually, a mild upper respiratory tract illness is interrupted by high fever, toxicity, dyspnea, severe pleuritic chest pain, and rapidly appearing extensive pleural effusion. The acute phase is slowly controlled with penicillin, and lowgrade fever and pleural pain persist for several days. Renal disease occasionally follows pneumococcal or staphylococcal pneumonia. Overwhelming sepsis with shock is usually present and tubular necrosis results. Exceptionally acute glomerulonephriti may occur.