Correct!
4. Skin biopsy, Bronchoscopy, ECHO, Rheumatologic panel, High resolution chest CT
Skin and renal biopsies can both aid in the diagnosis of systemic vasculitis. Skin biopsy would be less invasive and would be the appropriate initial approach. If it’s negative, then the more invasive renal biopsy can be considered. High resolution CT of the chest can aid in forming the differential for possible causes of hypoxia in this patient but a bronchoscopy may be more revealing as it can directly sample the pathology. A rheumatologic panel would aid in narrowing the differential with regards to possible auto-immune etiology of disease in the patient. ECHO can help in assessing the cardiac function in the patient since initial pro-BNP was elevated so this would be a reasonable investigation given this clinical scenario.
Brain biopsy would not be appropriate in this clinical scenario. Findings in the patient are not concerning for malignancy thus tumor markers would not yield much. Cardiac catheterization, Stress test and CT angiography do not have any definite indication in this patient and would not be diagnostically relevant.
Our patient had a bronchoscopy with bronchoalveolar lavage which yielded a progressively bloody return. The skin biopsy was consistent with changes associated with vasculitis. Rheumatologic work up showed the patient to be positive for c-ANCA (anti-PR3) and rheumatoid factor.
The differential for diffuse alveolar hemorrhage include(s): (Click on the correct answer to proceed to the 5th of 6 panels)