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. 2015 Jun;19(6):316-25.
doi: 10.4103/0972-5229.158261.

Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit

Srinivas Rajagopala  1 , Baburao Kanthamani Pramod Sagar  1 , Molly Mary Thabah  1 , B H Srinivas  2 , Ramanathan Venkateswaran  1 , Sreejith Parameswaran  3
Affiliations

Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit

Srinivas Rajagopala et al. Indian J Crit Care Med. 2015 Jun.

Abstract

Background: The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported.

Aims: The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS.

Materials and methods: We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics".

Results: We saw 27 patients with "provisional PRS" over the said duration; this included 13 patients with "definite PRS" and 14 with "PRS mimics". The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics".

Conclusion: The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

Keywords: Crescentic glomerulonephritis; diffuse alveolar hemorrhage; pulmonary-renal; rapidly progressive renal failure; systemic lupus erythrematosus.

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Figures

Figure 1
Figure 1
Composite image of the chest radiograph (left) and computed tomography (CT) of the chest (right) of patient 1 with showing bilateral lower lobe consolidation with corresponding asymmetric ground glass opacities and crazy-paving on CT. A clinical diagnosis of alveolar hemorrhage (DAH) was made
Figure 2
Figure 2
Study flow-chart
Figure 3
Figure 3
Composite image of the chest-computed tomography (left) of patient 10 with granulomatosis with polyangiitis showing bilateral lower lobe air-space nodules with ground glass opacities. A thick-walled cavity in the right upper lobe was also present (not shown). Broncho-alveolar lavage showed increasingly hemorrhagic returns diagnostic of alveolar hemorrhage. Surgical biopsy confirmed granulomatosis and polyangiitis
Figure 4
Figure 4
Composite image of percutaneous renal biopsy specimen (left, H and E ×400) of patient 4 with systemic lupus erythrematosus showing endocapillary proliferation with basement membrane thickening and duplication. Immunofluorescence (right, FITC stain, monoclonal antibody for IgG, DAKO, USA, ×20) showed full-house pattern (also positive for IgM, C3, C1q, κ and λ [not shown])
Figure 5
Figure 5
Composite image of percutaneous renal biopsy specimen (left, H and E×400) of patient 2 with systemic lupus erythematosus showing endocapillary proliferation and cellular crescent and postmortem lung biopsy specimen showing alveolar septa expanded by inflammatory infiltrate and diffuse alveolar hemorrhage (right, H and E, ×400). Immunofluorescence of the kidney specimen showed full-house pattern (not shown)
Figure 6
Figure 6
Composite image of percutaneous renal biopsy specimen (left, H and E ×400) of patient 3 with microscopic polyangiitis (MPA) showing a cellular crescent and fibrinoid necrosis within the glomerulus and afferent arteriole. The photomicrograph on the right (H and E ×400, patient 8 with MPA) shows perivascular inflammatory infiltrate with few palisading macrophages and a small focus of fibrinoid necrosis. Immunofluorescence of the kidney specimens showed no staining with IgG, IgM, C3, C1q, κ and λ (pauci-immune, not shown)
Figure 7
Figure 7
Composite image of percutaneous lung biopsy specimen (left, H and E ×200) from a patient with crescentic glomerulonephritis and cavitating nodules showing alveoli filled with neutrophils and collection of hyphal forms. High-power view (right, Gomori-Methanamine Stain ×400) confirms thin septate fungal hyphae with acute angle branching, strongly suggestive of aspergillus species
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