A 55-year-old woman who suffered from diabetes mellitus for 25 years at the time of hospitalization had haemoglobin A1c was from 6.9 to 7.2% at a dosage of 2.5 mg/day of Glibenclamide. Her urinalysis was normal. She had severe diabetic retinopathy. She complained of appetite loss, haematuria, and renal impairment on admission. Eight months before her admission, she had chronic coughing and low-grade fever. Blood pressure was 170/100 mmHg.

Investigations: chest X-P showed reticular shadows in both lower lobes of the lungs. She had pretibial oedema and severe diabetic retinopathy (Scott B-II). She had no skin rash. Her urinary examination revealed haematuria and proteinuria. The white blood cell count was 7,190/|jl. The concentration of haemoglobin was 7.3 g/dl, and haematocrit was 23.8%. Platelet count was 470,000/microlitre. In blood biochemistry, the serum creatinine level was 2.2 mg/dl, total protein was 6.5 g/dl, and serum albumin was 3.1 g/dl. No deposits were recognized on both immunofluorescence analysis and electron microscopy. Figure 3 shows her clinical course and treatment.

Treatment &amp; course: She was treated with methylprednisolone pulse therapy and prednisolone at a dosage of 30 mg/day, which was maintained for one month. Later the reticular shadows in chest X-P had disappeared, and her cough had stopped. Her chest CT showed improvement of interstitial pneumonia. But the haematuria and renal impairment did not improve. Cyclophosphamide pulse therapy (500 mg/day) was started, and DFPP. Later the haematuria disappeared, the level of p-ANCA decreased to 35 EU, and the serum creatinine level decreased to 1.8 mg/dl. She was discharged from the hospital with prednisolone treatment at a dosage of 25 mg per day. Her haemoglobin A1c was 7.6% at a dosage of 15 units of Humulin N per day. On October 20, she had no haematuria, and her serum creatinine level had decreased to 1.5 mg/dl. The level of p-ANCA was less than 10 EU.

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