Diffuse alveolar hemorrhage

Extracorporeal life support for a 5-week-old infant with idiopathic pulmonary hemosiderosis

Idiopathic pulmonary hemosiderosis is a rare disease defined by the triad of iron deficiency anemia, hemoptysis, and diffuse pulmonary infiltrates on chest radiograph. Idiopathic pulmonary hemosiderosis is known to cause dyspnea and, in some cases, acute onset of massive pulmonary hemorrhage which is traditionally treated with conventional mechanical ventilation or high-frequency oscillation in conjunction with immunosuppressive therapy. In this case report, we describe a 5-week-old infant presenting with hemoptysis, massive pulmonary hemorrhage, and significant hypercapnic respiratory failure. The patient failed conventional ventilation but responded well to extracorporeal life support that was initiated early in his course. Idiopathic pulmonary hemosiderosis was suspected in light of his response to high-dose steroids and was confirmed by subsequent lung biopsies.

CONCLUSION

Patients with severe pulmonary hemorrhage secondary to idiopathic pulmonary hemosiderosis can be safely supported with extracorporeal life support when conventional therapies have been exhausted.

Looking beyond the obvious: an unusual cause of iron deficiency anaemia

Iron deficiency anaemia (IDA) is the most common haematological disorder seen in childhood. While poor intake of iron is the most common cause of IDA, a diligent search must be made to exclude other causes. We present a 5 year old girl who had recurrent hospital admissions for chest infection, radiographic evidence of bilateral pulmonary infiltrates and severe IDA. When she failed to respond to repeated courses of antibiotics, anti tubercular and parenteral and oral iron therapy, a lung biopsy was done which revealed blood and hemosiderophages within the alveoli. Further investigations were suggestive of SLE (dsDNA positivity). A diagnosis of SLE induced alveolar haemorrhage was made and therapy with glucocorticoids was initiated. She has responded well to therapy.

Treatment of diffuse alveolar hemorrhage in systemic lupus erythematosus patient with local pulmonary administration of factor VIIa (rFVIIa): a case report

Diffuse alveolar hemorrhage (DAH) is a rare serious life-threatening complication in systemic lupus erythematosus (SLE) associated with a high mortality rate. The old standard treatment options include high-dose corticosteroids, cyclophosphamide, and plasmapheresis, which are unspecific, treating the underlying disease rather than the complication itself, and not effective. We report a case of DAH complicating SLE flare-up in a female patient treated with recombinant activated factor VII (rFVIIa) administered via the bronchoscope that showed clinical and radiological improvement. No toxicity or adverse events were observed with rFVII treatment. rFVII may be an effective treatment option for DAH in SLE patient.

A case of diffuse alveolar hemorrhage associated with hyaluronic acid dermal fillers

Patient: Male, 25

Final Diagnosis: Diffuse alveolar hemorrhage

Symptoms: Cough dry • short of breath

Medication: —

Clinical Procedure: —

Specialty: —

An unexpected cause of diffuse alveolar hemorrhage in a kidney transplant patient

Diffuse alveolar hemorrhage (DAH) is a life-threatening condition requiring urgent treatment. There are many different treatment-relevant causes of DAH, making the diagnostic approach to these patients complex and necessitating a multidisciplinary team. We report the case of a kidney transplant recipient in whom all diagnostic efforts did not reveal the cause of DAH, and only autopsy was able to establish an unexpected diagnosis.

Life-threatening complications of adult-onset Still's disease

Adult-onset Still's Disease (AOSD) since its description in 1971 has proven to be a very complex and challenging disease entity. This rare auto-inflammatory disease is classically described by the "Still's triad" of fever, rash, and arthritis, although the atypical cases frequently outnumber the typical ones. The exact pathogenesis and etiologic factors responsible for the clinical features remain largely obscure, despite recent suggestive cytokine biology findings. Diagnosis is made on clinical grounds, following the exclusion of mimickers of infectious, autoimmune or neoplastic etiology, with the additional consideration of non-specific laboratory abnormalities such as peripheral leukocytosis and elevation of serum ferritin and other acute phase reactants. The disease manifestations are protean and can include diverse complications, affecting multiple organ systems. Moreover, the severity of the organ involvement can vary considerably, representing a wide spectrum from the self-limited to severe. The mainstay of therapy has evolved from the traditional use of corticosteroids and oral immunosupressants to the newer targeted treatments with biologic agents. The scope of this review is to alert the clinician to the existence of life-threatening AOSD complications, namely the macrophage activation syndrome, disseminated intravascular coagulopathy, thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, and pulmonary arterial hypertension. Such knowledge may lead in earlier recognition, prompt treatment, and, ideally, improved patient outcomes.

Diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a life-threatening and medical emergency that can be caused by numerous disorders and presents with hemoptysis, anemia, and diffuse alveolar infiltrates. Early bronchoscopy with bronchoalveolar lavage is usually required to confirm the diagnosis and rule out infection. Most cases of DAH are caused by capillaritis associated with systemic autoimmune diseases such as anti-neutrophil cytoplasmic antibody-associated vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus, but DAH may also result from coagulation disorders, drugs, inhaled toxins, or transplantation. The diagnosis of DAH relies on clinical suspicion combined with laboratory, radiologic, and pathologic findings. Early recognition is crucial, because prompt diagnosis and treatment is necessary for survival. Corticosteroids and immunosuppressive agents remain the gold standard. In patients with DAH, biopsy of involved sites can help to identify the cause and to direct therapy. This article aims to provide a general review of the causes and clinical presentation of DAH and to recommend a diagnostic approach and a management plan for the most common causes.

KL-6, a Human MUC1 Mucin, as a prognostic marker for diffuse alveolar hemorrhage syndrome

Background

Diffuse alveolar hemorrhage syndrome is a life threatening condition with diverse etiologies. Sensitive prognostic markers for diffuse alveolar hemorrhage have not been well investigated. Serum KL-6 is a biomarker for various interstitial lung disease associated with disease activity and prognosis. The purpose of the present study was to evaluate the clinical utility of serum KL-6 level as a prognostic marker for diffuse alveolar hemorrhage.

Methods

We retrospectively collected 41 consecutive patients clinically diagnosed as having diffuse alveolar hemorrhage who were admitted to the Intensive Care Unit of Hiroshima University Hospital between 2004 and 2011. Correlation between prognosis and age, sex, laboratory findings including serum KL-6, radiological findings, ventilatory modes or therapeutic regimens were evaluated.

Results

Baseline and peak serum KL-6 levels were significantly higher in non-survivors compared with survivors. An increase in KL-6 levels during the initial week was associated with a subsequent deterioration of the oxygenation index. Higher baseline KL-6 levels and higher peak KL-6 levels were strongly correlated with death. With a cut-off level of 700 U/mL for peak KL-6, the sensitivity, specificity and accuracy for non-survival were 75%, 85% and 78%, respectively. In the multivariate analysis, only the peak KL-6 level ≥700 U/ml was an independent poor prognostic factor for diffuse alveolar hemorrhage.

Conclusions

Peak serum KL-6 level ≥700 U/ml may become a clinically useful marker of poor prognosis for diffuse alveolar hemorrhage.

Platelets in pulmonary vascular physiology and pathology

Almost a trillion platelets pass through the pulmonary circulation every minute, yet little is known about how they support pulmonary physiology or contribute to the pathogenesis of lung diseases. When considering this conundrum, three questions jump out: Does platelet production in the lungs occur? Why does severe thrombocytopenia—which undercuts the principal physiological role of platelets to effect hemostasis—not lead to pulmonary hemorrhage? Why does atherothrombosis—which platelets initiate, maintain, and trigger is other critically important arterial beds—not develop in the pulmonary artery? The purpose of this review is to explore these and derivative questions by providing data within a conceptual framework that begins to organize a subject that is largely unassembled.

Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients: a state-of-the-art review

Diffuse alveolar hemorrhage (DAH) represents a syndrome that can complicate many clinical conditions and may be life-threatening, requiring prompt treatment. It is recognized by the signs of acute- or subacute-onset cough, hemoptysis, diffuse radiographic pulmonary infiltrates, anemia, and hypoxemic respiratory distress. DAH is characterized by the accumulation of intra-alveolar red blood cells originating most frequently from the alveolar capillaries. It must be distinguished from localized pulmonary hemorrhage, which is most commonly due to chronic bronchitis, bronchiectasis, tumor, or localized infection. Hemoptysis, the major sign of DAH, may develop suddenly or over a period of days to weeks; this sign may also be initially absent, in which case diagnostic suspicion is established after sequential bronchoalveolar lavage reveals worsening red blood cell counts. The causes of DAH can be divided into infectious and noninfectious, the latter of which may affect immunocompetent or immunodeficient patients. Pulmonary infections are rarely reported in association with DAH, but they should be considered in the diagnostic workup because of the obvious therapeutic implications. In immunocompromised patients, the main infectious diseases that cause DAH are cytomegalovirus, adenovirus, invasive aspergillosis, Mycoplasma, Legionella, and Strongyloides. In immunocompetent patients, the infectious diseases that most frequently cause DAH are influenza A (H1N1), dengue, leptospirosis, malaria, and Staphylococcus aureus infection. Based on a search of the PubMed and Scopus databases, we review the infectious diseases that may cause DAH in immunocompetent patients.

Idiopathic pulmonary hemosiderosis in adults: a case report and review of the literature

Idiopathic pulmonary hemosiderosis is a very rare condition rarely affecting adults and causing recurrent episodes of diffuse alveolar haemorrhage that may lead to lung fibrosis. Due to lack of pathognomonic findings, IPH diagnosis is established upon exclusion of all other possible causes of DAH in combination with specific pathologic findings revealing bland alveolar haemorrhage with absence of vasculitis and/or accumulation of immune complexes within lung parenchyma. Here we describe a rare case of idiopathic pulmonary hemosiderosis in an otherwise healthy 27-year-old Greek male patient with relapsing episodes of fever accompanied by general fatigue and discomfort. He was at this time point a light smoker and had been hospitalised once in the past for similar symptoms. His iron deficiency anemia coupled with chest high-resolution computed tomography and bronchoalveolar lavage revealed findings compatible with diffuse alveolar hemorrhage. After excluding all other sources of bleeding through extensive gastrointestinal workup and thorough immunologic profile, video-assisted thoracic lung biopsy was performed and the diagnosis of Idiopathic Pulmonary Hemosiderosis was established. Patient was treated with high doses of oral corticosteroids, leading to clinical response. We highlight the need for vigilance by the respiratory physician for the presence of DAH, a challenging, acute condition requiring early recognition along with identification of the underlying syndrome and appropriate treatment to achieve optimal results.

Diffuse alveolar hemorrhage in immunocompetent patients: etiologies and prognosis revisited

BACKGROUND

Diffuse alveolar hemorrhage (DAH) represents a diagnostic challenge of acute respiratory failure. Prompt identification of the underlying cause of DAH and initiation of appropriate treatment are required in order to prevent acute respiratory failure and irreversible loss of renal function. More than 100 causes of DAH have been reported. However, the relative frequency and the differential presentation of those causes have been poorly documented, as well as their respective prognosis.

METHODS

We retrospectively reviewed the charts of 112 consecutive patients hospitalized for DAH in a tertiary referral center over a 30-year period.

RESULTS

Twenty-four causes of DAH were classified into four etiologic groups: immune (n = 39), congestive heart failure (CHF; n = 33), miscellaneous (n = 26), and idiopathic DAH (n = 14). Based on this classification, clinical and laboratory features of DAH differed on hospital admission. Patients with immune DAH had more frequent pulmonary-renal syndrome (p < 0.001), extra-pulmonary symptoms (p < 0.01), and lower blood hemoglobin level than others (p < 0.001). Patients with CHF-related DAH were older and received more anticoagulant treatments than others (p < 0.05). Those with miscellaneous causes of DAH exhibited a shorter prodromal phase (p < 0.001) and had more frequent hemoptysis >200 mL (p < 0.05). Patients with idiopathic DAH had more bronchoalveolar lavage siderophages (p < 0.01). In-hospital mortality was 24.1%, ranging from 7.1% in patients with idiopathic DAH to 36.4% in those with CHF.

CONCLUSIONS

Arbitrary classification of DAH in four etiologic groups gives the opportunity to underline distinct presentations and outcomes of various causes of DAH.

Histological spectrum of pulmonary manifestations in kidney transplant recipients on sirolimus inclusive immunosuppressive regimens

Background

After the introduction of novel effective immunosuppressive therapies, kidney transplantation became the treatment of choice for end stage renal disease. While these new therapies lead to better graft survival, they can also cause a variety of complications. Only small series or case reports describe pulmonary pathology in renal allograft recipients on mTOR inhibitor inclusive therapies. The goal of this study was to provide a systematic review of thoracic biopsies in kidney transplant recipients for possible association between a type of immunosuppressive regimen and pulmonary complications.

Methods

A laboratory database search revealed 28 of 2140 renal allograft recipients (18 males and 10 females, 25 to 77 years old, mean age 53 years) who required a biopsy for respiratory symptoms. The histological features were correlated with clinical findings including immunosuppressive medications.

Results

The incidence of neoplasia on lung biopsy was 0.4% (9 cases), which included 3 squamous cell carcinomas, 2 adenocarcinomas, 1 diffuse large B-cell lymphoma, 1 lymphomatoid granulomatosis, and 2 post transplant B-cell lymphoproliferative disorders. Diffuse parenchymal lung disease was identified in 0.4% (9 cases), and included 5 cases of pulmonary hemorrhage, 3 cases of organizing pneumonia and 1 case of pulmonary alveolar proteinosis. Five (0.2%) cases showed histological features indicative of a localized infectious process. Patients on sirolimus had neoplasia less frequently than patients on other immunosuppressive combinations (12.5% vs. 58.3%, p = 0.03). Lung biopsies in 4 of 5 patients with clinically suspected sirolimus toxicity revealed pulmonary hemorrhage as the sole histological finding or in combination with other patterns.

Conclusions

Our study documents a spectrum of neoplastic and non-neoplastic lesions in renal allograft recipients on current immunosuppressive therapies. Sirolimus inclusive regimens are associated with increased risk of pulmonary toxicity but may be beneficial in cases of posttransplant neoplasia.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/3320012126569395.

Immunological insights into the pathogenesis of active CMV infection in non-immunosuppressed critically ill patients

Dissociation of cytomegalovirus (CMV) DNA loads between the lower respiratory tract and blood, with high levels in the former compartment and low or undetectable levels in the latter, commonly occurs during active CMV infection in critically ill patients despite the presence of high frequencies of CMV-specific IFN-γ-producing CD8(+) and CD4(+) T cells in blood. Data presented in this case report suggest that inter-compartmental differences in interleukin-10 (IL-10) levels may, in part, explain the pathobiology of this phenomenon. In the absence of ganciclovir treatment, a significant correlation was observed between IL-10 levels and CMV DNA loads in lower respiratory tract specimens (P = 0.016), but not in plasma samples (P = 0.46). Comparable data were obtained during the course of active CMV infection episodes that developed in six CMV-seropositive critically ill patients with no canonical immunosuppression. The presence of higher levels of IL-10 in the lower respiratory tract than in plasma may result in increased impairment of CMV-specific T-cell effector responses in the lung compared to the systemic compartment, facilitating local CMV replication.

Pulmonary-renal syndromes: an update for respiratory physicians

Pulmonary-renal syndromes are a group of disorders characterised by necrotising glomerulonephritis and pulmonary haemorrhage. Small vessel systemic vasculitis is the most common cause of pulmonary-renal syndromes presenting to respiratory physicians. Rarer causes include systemic lupus erythematosus and connective tissue diseases though severe pneumonia or cardiac failure may mimic their presentation. Some forms of small vessel vasculitides have a predilection for the pulmonary and renal vascular beds and if left untreated can result in fulminant organ failure. Whilst the aetiology of these syndromes remains unclear, much is known about the disease mechanisms including the pathogenic role of autoantibodies, immune-complex mediated inflammation and microangiopathic in-situ thrombosis. Despite established treatments achieving successful remission induction, patient tolerability and side effect profiles have limited their use which has led to searches for more targeted treatments. Consequently newer biological therapies have gained wider acceptance despite little being known about their long term safety and efficacy. The European Vasculitis Study Group (EUVAS) have recently formulated guidelines to provide consensus on diagnosis and management in this area and work to define survival rates in these conditions with longer term follow-up studies is ongoing. This review summarises the current aetiopathogenesis thought to underlie these complex diseases, the diagnostic definitions and classification criteria currently in use and the evidence base for modern therapies. Though unusual for respiratory specialists to coordinate overall management of these patients, an update on their current management is regarded as important to their practice given the recently changing trends in treatments.

Diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder characterized clinically by the presence of hemoptysis, falling hematocrit, diffuse pulmonary infiltrates and hypoxemic respiratory failure. It refers to bleeding that originates in the pulmonary microvasculature instead of the parenchyma or bronchial circulation. DAH should be considered a medical emergency due to the morbidity and mortality associated with failure to treat the disorder promptly. Pulmonary renal syndromes, connective tissue disorders and drugs make up the majority of the cases of DAH. The treatment of DAH ranges from supportive care and withdrawal of offending drugs to high-dose steroids, immunosuppresents and plasmapharesis. The following review will discuss the clinical, radiographic and pathologic findings in a variety of disorders that cause DAH. Standard treatment options, as well as new treatment options will also be discussed.

[Diffuse alveolar hemorrhage: Causes and outcomes in a referral center]

OBJECTIVE

To identify the most common causes of diffuse alveolar hemorrhage (DAH) and the evolution of cases during hospitalization.

PATIENTS AND METHODS

A review of cases diagnosed with DAH; the diagnoses were classified according to existing criteria and the progression of the cases was determined.

RESULTS

We identified 17 cases of DAH, with the leading cause being ANCA associated vasculitis (41% of cases), followed by cases secondary to drugs (18%). In 35% of the cases, there was a failure in identifying an etiology. Six patients died (35%), the only factor associated with mortality was male gender 5/6 vs 3/11, p=0.05.

CONCLUSIONS

The most frequent cause of alveolar hemorrhage was ANCA associated vasculitis. The mortality in DAH is about 35%, males seem to have a worse prognosis.

Pulmonary capillaritis leading to alveolar hemorrhage in a juvenile idiopathic arthritis patient: first description

Juvenile idiopathic arthritis (JIA) is characterized by the typical joint involvement and some patients have extra-articular lesions, such as uveitis and pleuritis. However, until this date, no case of alveolar hemorrhage in JIA has been described. Herein, the authors describe a case of a male patient, 33 years old diagnosed as polyarticular JIA who had a dramatic evolution with alveolar hemorrhage secondary to pulmonary capillaritis. He received intravenous immunoglobulin and pulse therapies with glucocorticoid and cyclophosphamide with a satisfactory outcome. In addition, the authors review this important pulmonary complication in rheumatic diseases.

A case of life-threatening post-operative diffuse alveolar hemorrhage in patient with recent chemotherapy -A case report-

A 53-year-old woman who had undergone total gastrectomy and received adjuvant chemotherapy two months ago underwent adhesiolysis of the small bowel. She presented with sudden desaturation and dyspnea of unknown etiology at postanesthetic care unit. Following ET intubation, the endotracheal tube suction revealed massive hemoptysis. Bilateral lung infiltrated on her chest radiograph and bronchofibroscopic examination disclosed a diffuse hemorrhage on both lung fields without bleeding focus. These findings were consistent with diffuse alveolar hemorrhage (DAH) syndrome. As per our knowledge and search, this is the first reported case of DAH that occurred during the recovery period immediately after general anesthesia. DAH is known to have a high mortality rate and an early detection followed by adequate treatment is essential.

[Efficacy of recombinant activated factor VII in diffuse alveolar haemorrhage]

INTRODUCTION

Alveolar haemorrhage is a serious complication of a range of different pathologies. Published recent literature has reported only cases unresponsive to the usual treatment (steroids, transfusions, immunosuppressors and mechanical ventilation) as well as multiple secondary complications of these kinds of therapies. Recombinant activated factor VII (rF VIIa) is a new class of agent, which appears to be a successful adjunct therapy in the case of failure of conventional treatments.

OBSERVATIONS

We describe two cases of alveolar haemorrhage treated with rF VIIa. The first patient had leukaemia and the second had ANCA-associated granulomatous vasculitis. Both were admitted to the intensive care unit for mechanical ventilation with persistent diffuse alveolar haemorrhage that responded only to a single dose of rF VIIa (90 μg/kg).

DISCUSSION AND CONCLUSION

rF VIIa is a promising treatment for diffuse, persistent alveolar haemorrhage, with only a small dose required to be effective. Future studies are needed in order to establish a clear protocol for the administration of this novel agent.

[Massive alveolar hemorrhage due to cytomegalovirus (CMV) and HIV infection]

Alveolar hemorrhage may be a complication of diseases with local and systemic manifestations. Both share the same pathophysiological concept: damage to the alveolar microcirculation. It is a clinical entity that generates a diagnostic challenge for the physician. Early recognition favors aggressive treatment, which can improve the outcome. Despite the technological advances in its diagnosis and treatment, it is still a condition having high morbidity and mortality. We present the case of a 42-year old woman diagnosed of massive alveolar hemorrhage induced by cytomegalovirus (CMV) and HIV infection. Its presentation is atypical because most reported cases have occurred as a pneumonic process, episodes of massive hemorrhage being uncommon. The diagnosis was documented by bronchoscopy with bronchoalveolar lavage and etiological diagnosis with molecular techniques using reverse transcription polymerase chain reaction.

Diffuse alveolar hemorrhage following itraconazole injection

Diffuse alveolar hemorrhage (DAH) syndrome is potentially fatal. We encountered a nearly fatal case of DAH possibly due to intravenous itraconazole (ITCZ). A 53-year-old man with chronic pulmonary aspergillosis underwent pneumonectomy of the left lung 15 days prior to the onset of DAH, which was confirmed by bronchoalveloar lavage. The battery of diagnostic evaluations performed revealed no other positive etiological factor, leading to the diagnosis of DAH possibly induced by intravenous ITCZ with a positive drug lymphocyte stimulation test. The patient did not respond to pulse methylprednisolone therapy, but responded dramatically to direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX) therapy.

Diffuse alveolar haemorrhage due to 5-nitroimidazole treatment

Diffuse alveolar haemorrhage (DAH) is indicated by the presence of red blood cells, fibrin and haemosiderin deposits in the lung parenchyma. We present a case of DAH in a 25-year-old male following 5-nitroimidazole treatment. The first episode of haemoptysis occurred following metronidazole treatment 10 months previously. The second episode of haemoptysis occurred following ornidazole treatment 10 days before admission. During his first admission, the patients haemoglobin concentration decreased to 40 g/L. The CXR was normal, whereas high resolution CT of the lungs revealed a diffuse acinonodular pattern. Serological tests for connective tissue diseases were negative. The haemorrhagic appearance of the BAL fluid obtained during fibreoptic bronchoscopy was consistent with DAH. Microbiological analysis of the BAL fluid showed no evidence for bacterial or mycobacterial infection. Haemosiderin laden macrophages were detected in BAL fluid and lung biopsy specimens. DAH due to use of 5-nitroimidazole was diagnosed on the basis of the patient's previous history and complete recovery following treatment with corticosteroid. This is the first reported case of DAH due to use of 5-nitroimidazole. Physicians should be aware of this side-effect when prescribing this group of drugs to patients.

Severe respiratory failure due to diffuse alveolar hemorrhage: clinical characteristics and outcome of intensive care

BACKGROUND

The aim of this study was to characterize patients and report outcome of diffuse alveolar hemorrhage (DAH) requiring intensive care unit support.

PATIENTS AND METHODS

Thirty-seven patients were identified. Clinical characteristics and outcome were determined by chart review.

RESULTS

Eighty-nine percent of patients presented with shortness of breath, 23% with cough, and 3% with hemoptysis. In 9% of patients, a diagnosis of DAH was suspected on admission. Diagnosis was confirmed by finding a progressively hemorrhagic bronchoalveolar lavage fluid in 89% and by a positive iron stain in 11% of patients. Vasculitis was causative in 19%, drug toxicity in 11%, thrombocytopenia in 27%, stem-cell transplantation in 5%, sepsis-associated lung injury in 22%, and unknown mechanisms in 16%. Thirty-two patients were mechanically ventilated, 4 received noninvasive ventilation, and 1 received supplemental oxygen therapy. Overall, 18 (49%) of 37 patients survived the intensive care unit stay. Survival was markedly different between patients with an immunologic/unknown etiology (82%) and patients with thrombocytopenia and/or sepsis (22%).

DISCUSSION

Diffuse alveolar hemorrhage should be considered in all patients with persistent pulmonary infiltrates. Both bronchoalveolar lavage fluid and iron stain are mandatory diagnostic means. Patients with an immunologic/idiopathic pathogenetic mechanism have a relatively good prognosis, whereas the outcome in individuals with DAH secondary to cancer therapy or sepsis is poor.

A case of adult-onset Still's disease complicated with diffuse alveolar hemorrhage

Adult-onset Still's disease (AOSD) is an inflammatory disease that presents with a variety of clinical symptoms. Pulmonary involvement is well-known in AOSD and is seen in up to 53% of AOSD cases, with the most common pulmonary diseases being pleural effusion and transient pulmonary infiltrates. We present the first case of chronic AOSD complicated with diffuse alveolar hemorrhage during the acute flare of the disease.

Intrapulmonary hemorrhage in collagen-vascular diseases includes a spectrum of underlying conditions

OBJECTIVE

To elucidate the background and clinical features of intrapulmonary hemorrhage in collagen-vascular diseases (CVD) patients.

PATIENTS AND METHODS

The charts of collagen-vascular diseases patients who were hospitalized and had intrapulmonary hemorrhages between 1981 and 2006 were retrospectively examined for underlying diseases, clinical and laboratory features, and treatments and outcomes.

RESULTS

Of 4,017 patients, 11 females aged 52.1+/-12 had total of 17 episodes of diffuse or non-diffuse intrapulmonary hemorrhage. Fourteen episodes of diffuse alveolar hemorrhage (DAH) developed in 4 microscopic polyangiitis (MPA) patients having a high MPO-ANCA level, 4 systemic lupus erythematosus (SLE) patients having a high SLEDAI score, and 1 SLE/MPA patient having a high MPO-ANCA level. Among the 9 DAH patients, 2 had complicated Goodpasture syndrome, 3 had thrombotic thrombocytopenic purpura (TTP), and 1 had disseminated intravascular coagulation. In DAH the peripheral blood hemoglobin level decreased from 9.3+/-2.2 (n=13) to 6.8+/-1.5 g/dL (n=14, p<0.0001) at 0.5+/-0.7 g/dL/day, and the lymphocyte count decreased from 854+/-424 to 462+/-376 /microL. No patient died of DAH, including 1 who spontaneously remitted. The 3 episodes of non-DAH included 2 pulmonary aneurysm ruptures in 1 SLE patient, and 1 thromboembolism that developed in 1 SLE patient who had anti-phospholipid antibody; their SLEDAI scores were low and these remitted spontaneously.

CONCLUSION

Of intrapulmonary hemorrhage in CVD patients, DAH developed with active MPA or SLE, upon which Goodpasture syndrome or TTP was occasionally superimposed. With DAH, the magnitude of peripheral blood Hb level decrease was approximately 0.5 g/dL/day, and the lymphocyte count decreased. No patient died of DAH.

Diffuse alveolar hemorrhage with acute respiratory distress syndrome associated with phenprocoumon therapy

An 84-year-old woman was admitted to the emergency room with hemoptysis consisting of relevant amounts of fresh blood. She was treated with phenprocoumon for 11 years following mechanical aortic valve replacement without any complication. Laboratory results revealed phenprocoumon over dosage with international normalized ratio over 6. Chest radiograph showed diffuse alveolar infiltrates conformable to diffuse alveolar hemorrhage. Besides the pulmonary complication no other bleeding occurred. She needed noninvasive ventilatory support for 24 h to cope with the symptoms of an acute respiratory failure. After substitution of vitamin K dependent blood clot factors resulting in a normalized coagulation hemoptysis which persisted for another 3 days followed by a slow recovery. Other causes of diffuse alveolar hemorrhage were excluded in our patient. This case report presents a rare case with diffuse alveolar hemorrhage as the leading and sole symptom due to phenprocoumon overdose.

Aetiologies and outcomes of diffuse alveolar haemorrhage presenting as acute respiratory failure of uncertain cause

BACKGROUND AND OBJECTIVE

Connective tissue diseases are the most common disorders causing diffuse alveolar haemorrhage (DAH) confirmed by open lung biopsy. However, it is not known whether these diseases are also the most common causes of DAH in patients presenting with the features of ARDS/acute lung injury (ALI). This study evaluated the frequency of concomitant disease in patients with ARDS/ALI and DAH.

METHODS

The sampling frame comprised all patients in a tertiary referral hospital diagnosed with ARDS/ALI and who underwent BAL between January 2000 and July 2006. The medical records of those patients who had BAL fluid findings compatible with DAH were reviewed.

RESULTS

Of the 97 patients diagnosed with ARDS/ALI and who underwent BAL, 27 had BAL fluid findings compatible with DAH. Sixteen of the 27 patients did not have connective tissue diseases (59%); of these 12 patients had concomitant haematological malignancies or solid tumours. Of the seven patients who presented with DAH and no known underlying disease, only two were subsequently diagnosed with a connective tissue disorder. The in-hospital mortality rate was 55% and 63% for patients with DAH with and without connective tissue diseases, respectively (P = 0.710).

CONCLUSIONS

The majority of patients with DAH presenting with the features of ARDS/ALI did not have underlying connective tissue diseases. Concomitant malignancies were found frequently in these patients. The outcome did not differ between patients with DAH with or without connective tissue diseases.

Idiopathic pulmonary hemosiderosis: favorable response to corticosteroids

A 50-year-old Taiwanese woman had a history of massive hemoptysis occurring every 6 months for the past 4 years. After each bout of hemoptysis, chest roentgenography would show diffuse alveolar infiltration of bilateral lungs, which would usually resolve within 7 days. Transbronchial biopsy revealed diffuse alveolar hemorrhage and hemosiderin-laden macrophage infiltration. Idiopathic pulmonary hemosiderosis was diagnosed by excluding other glomerular, cardiac and immunological disorders. An initial dose of 20 mg prednisolone daily was tapered to 10 mg daily 1 month later. The patient is currently undergoing steroid therapy, and there have been no further episodes of hemoptysis.

Pediatric hemoptysis with pulmonary hemorrhage and respiratory failure

Hemoptysis is a rare complaint in the pediatric population. It is most commonly of infectious etiology and is rarely life threatening. However, there are rare life-threatening causes of pediatric hemoptysis, which should be included in the differential diagnoses of children presenting to the emergency department (ED) with this complaint. This study aims to present a case of pediatric hemoptysis, briefly discuss the differential diagnosis, and present a review of the causes, manifestations, and treatment for hemoptysis secondary to diffuse alveolar hemorrhage (DAH).

Co-occurrence pulmonary haemosiderosis with coeliac disease in child

Idiopathic pulmonary haemosiderosis (IPH) is a rare and serious disorder in children of unknown aetiolopathogeny. Association of IPH and coeliac disease (CD) is even rarer. Immunological origin of IPH is now well accepted. We report the case of an 11-year-old female admitted for evaluation of recurrent streaky haemoptysis that had been evolving over the previous 9 months. Physical examination revealed weight loss with normal weight, but there was cutaneous and mucosal pallor due to severe anaemia (haemoglobin 4.6g/dl). The chest X-rays showed unilateral alveolo-intertitial infiltrate. Broncho-alveolar lavage revealed 70% haemosiderin-laden macrophages. The diagnosis of IPH was made. Since severe anaemia is disproportionate to radiologic findings, searching associated CD was performed and then confirmed by biological and histological examinations. A gluten-free diet was initiated. Evolution was favourable. Looking for especially CD in IPH should be systematic, even in the absence of gastrointestinal symptoms.

Radiological aspects of diffuse alveolar haemorrhage

PURPOSE

This paper describes chest X-ray (CXR) and computed tomography (CT) findings of diffuse alveolar haemorrhage (DAH).

MATERIALS AND METHODS

We retrospectively reviewed 23 episodes of DAH in 20 patients, 17 of known aetiology and three of unknown aetiology. All cases were studied by CXR and 15 also by CT. Parenchymal consolidations and ground-glass opacities were evaluated after dividing each lung into three regions (upper, middle, lower) for a total of six zones.

RESULTS

Consolidations or ground-glass opacities were identified on CXR in 16/20 patients, mainly in the middle fields (73%). In 4/20 patients, all with Wegener's granulomatosis, CXR was negative or demonstrated only nodular opacities; in two of these cases, CT revealed ground-glass opacities. A complete follow-up was available for ten patients: initially, they showed consolidation opacities in 36/60 zones, which persisted in 16/60 after 7 days and in 11/60 after 15 days. Conversely, ground-glass opacities increased after 7 days owing to the partial regression of consolidation opacities, and they markedly diminished after 15 days.

CONCLUSIONS

DAH is radiologically characterised by a nonspecific alveolar-filling pattern. Diagnosis or suspicion of DAH needs to be supported by the evidence of haemoptysis and/or rapid-onset anaemia. CT is superior in detecting ground-glass opacities and is required in cases of suspected DAH with normal CXR findings.

An asthmatic adolescent with hematuria and hemoptysis

When alveolar hemorrhage occurs in association with glomerulonephritis, one of the leading causes is Goodpasture syndrome. We report a case of an adolescent who presented to the emergency department in respiratory distress. Subsequent evaluation was consistent with the diagnosis of Goodpasture syndrome.

Diffuse alveolar hemorrhage and infection-associated alveolar hemorrhage following hematopoietic stem cell transplantation: related and high-risk clinical syndromes

Diffuse alveolar hemorrhage (DAH) is a noninfectious pulmonary complication of hematopoietic stem cell transplantation (HSCT) with unclear pathogenesis and treatment. We reviewed prospectively collected data on 1919 consecutive transplants performed between 1995 and 2004 and compared patients with DAH and infection-associated alveolar hemorrhage (IAH) who presented with similar symptoms of hypoxemia, pulmonary infiltrates, and progressively bloody alveolar lavage but also had microorganisms isolated from blood, bronchoalveolar lavage, or tracheal aspirate within 1 week of alveolar hemorrhage. Overall, 116 patients had alveolar hemorrhage (45 with DAH, 71 with IAH). Older age, allogeneic donor source, myeloablative conditioning regimen, and acute severe graft-versus-host disease (GVHD) were independently predictive of an increased risk of post-HSCT alveolar hemorrhage. The DAH and IAH groups were comparable except for a higher proportion of patients receiving umbilical cord blood as a donor source and total-body irradiation-containing conditioning in the IAH group. The probability of 60-day survival from onset of hemorrhage was 16% (95% CI, 6%-26%) for the DAH and 32% (95% CI, 21%-43%) for the IAH group (P = .08). All except 20 patients were treated with a standard regimen of high-dose corticosteroids. Patients who received corticosteroids had 60-day survival of 26% (95% CI, 18%-34%), compared with 25% (95% CI, 6%-44%) for those who did not (P = .28). The pathogenesis of alveolar hemorrhage after HSCT is multifactorial, and we propose that IAH and DAH in HSCT recipients are related clinical syndromes with similar clinical presentation, risks, and associated high mortality.

Successful treatment of a rare complication of Henoch-Schönlein purpura in advanced age: pulmonary hemorrhage

Henoch-Schönlein purpura (HSP) is a form of systemic vasculitis involving both arterioles and capillaries. HSP frequently is seen in children between the ages of 2 and 11 years, though adults with this disease are occasionally encountered. Although it primarily is a disease of early childhood, it can occur at any age. The clinical manifestations include a classic tetrad: rash, arthralgias, abdominal pain and renal disease. However, it may affect almost any other bodily tissue, such as myocardium, lungs, ureter and nervous system. Pulmonary hemorrhage is a rare complication of HSP, which largely has been observed in adolescents and adults. Pulmonary hemorrhage in HSP is associated with significant morbidity and mortality. We present the successful treatment of a 78-year-old woman with HSP complicated by pulmonary hemorrhage.

Bench-to-bedside review: pulmonary-renal syndromes--an update for the intensivist

The term Pulmonary-renal syndrome refers to the combination of diffuse alveolar haemorrhage and rapidly progressive glomerulonephritis. A variety of mechanisms such as those involving antiglomerular basement membrane antibodies, antineutrophil cytoplasm antibodies or immunocomplexes and thrombotic microangiopathy are implicated in the pathogenesis of this syndrome. The underlying pulmonary pathology is small-vessel vasculitis involving arterioles, venules and, frequently, alveolar capillaries. The underlying renal pathology is a form of focal proliferative glomerulonephritis. Immunofluorescence helps to distinguish between antiglomerular basement membrane disease (linear deposition of IgG), lupus and postinfectious glomerulonephritis (granular deposition of immunoglobulin and complement) and necrotizing vasculitis (pauci-immune glomerulonephritis). Patients may present with severe respiratory and/or renal failure and require admission to the intensive care unit. Since the syndrome is characterized by a fulminant course if left untreated, early diagnosis, exclusion of infection, close monitoring of the patient and timely initiation of treatment are crucial for the patient's outcome. Treatment consists of corticosteroids in high doses, and cytotoxic agents coupled with plasma exchange in certain cases. Renal transplantation is the only alternative in end-stage renal disease. Newer immunomodulatory agents such as those causing TNF blockade, B-cell depletion and mycophenolate mofetil could be used in patients with refractory disease.