An unusual non-immunological cause of renal pulmonary syndrome

A 38-year-old Caucasian male presented with a 4-week history of nose bleeds, gross hematuria and blurred vision. He was a smoker, who had used cannabis and cocaine previously. At presentation, he had features of malignant hypertension (blood pressure 220/120 mmHg), was hypoxic on room air, with no signs of fluid overload or heart failure. He had acute renal failure with radiological evidence of alveolar hemorrhage. Renal biopsy showed extensive ischemic collapse of glomeruli and severe fibrointimal thickening of the arteries with fibrinoid deposits in the wall. Auto-immune screen was negative. Serum creatinine peaked at 749 micromol/l. Adequate control of blood pressure and supportive oxygen therapy lead to a complete clinical and radiological resolution of the pulmonary hemorrhage and he did not need dialysis. Eighteen months on, his serum creatinine is stable at 279 micromol/l with good blood pressure control. Malignant hypertension is not a recognized cause of the renal-pulmonary syndrome and physicians should be aware of the possibility, if only to avoid inappropriate treatments like plasmapheresis and immunosuppression. History of cocaine use is important in the setting of an acute vascular event.