A 40-year-old man with Wegener's granulomatosis with renal and ocular involvement was admitted with symptoms of fever, malaise and cough not responding to oral antibiotics. On initial assessment, he had patchy consolidation but was also found to have a new cardiac murmur. He was mildly anaemic. Within 2 days of hospital stay his haemoglobin dropped and he became tachypnoeic. High-resolution CT found extensive pulmonary infiltrates, which suggested pulmonary haemorrhage, and blood cultures were negative. He was on antibiotics because of suspected infective endocarditis and this made any immunosuppressive treatment for active Wegener's granulomatosis very difficult. After extensive discussion with tertiary centres he had pulse methylprednisolone for 3 days. His echo detected aortic regurgitation but no vegetations. His antibiotics were stopped and he had cyclophosphomide to control his active Wegener's granulomatosis.
He improved remarkably with immunosuppression and non-invasive ventilation and was discharged. He had a further echo, which confirmed moderate aortic regurgitation. He is awaiting cardiac catheter studies but the fact is acute aortic regurgitation has happened due to active Wegener's granulomatosis along with pulmonary haemorrhage. This is a very rare presentation.