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77 year old man presents with small digital gangrenous skin lesions, he is hypotensive and mild short of breath. He is not confused and mental status is good. He has splinter hemorrhages in the nail beds and Cardiologist diagnoses him as Endocarditis starts him on Intravenous antibiotics including Penicillin and Gentamycin. Patient is also noted to be anemic and Hemoglobin is 9 grams BUN and Creatinine are proportionately elevated at 30 and 2.4, blood gases show increased A-a gradient and PO2 of 55 on 50% aerosol mask.

CT chest is done shows infiltrates with solid mass like sub pleural consolidations bilaterally. Suspicious for pneumonia and tumor. ESR was greater than 115, Hemoglobin 9 gm Na is 125.Anion gap was Normal .

Pulmonologist diagnoses him as sepsis syndrome with Gagrenosa pyoderma and Cefepime with vancomycin is given and patient is monitored in the ICU. Patient is started on moderate dose steroids.

Nephrologists starts working up for vasculitis and Wegner's graulomatosis and aggressively hydrates the patient.

Rheumatologist starts the work up and suggests patient be transferred to a tertiary care Hospital.

Patient is anticoagulated and on oxygen face mask and starts having hemoptysis, he is intubated placed on the ventilator and Bronchoscopy is done.

Tests done show P-ANCA and C-ANCA test to be positive.

Bronchoscopy shows alveolar hemorrhage.

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Contributors : A. Acosta MD, R. Kaul MD, P. Wawrzynski MD, Z. Iqbal MD, M. Islam MD

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