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Ben Mrad I, Ben Mrad M, Oumaya Z, Zairi I, Besbes B, Ouaghlani K, Kamoun S, Mleyhi S, Miri R, Mzoughi K, Kraiem S. Alveolar Hemorrhage Following Thrombolytic Therapy for Acute Myocardial Infarction: Two Case Reports and Literature Review. Open Access Emerg Med 2021; 13:399-405. [PMID: 34475787 PMCID: PMC8407669 DOI: 10.2147/oaem.s324366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022] Open
Abstract
Alveolar hemorrhage (AH) is a heterogeneous clinical syndrome with a high mortality rate, characterized by extensive bleeding into the alveolar spaces. AH secondary to systemic thrombolysis treatment in the setting of acute myocardial infarction is an uncommon complication, but potentially fatal and can lead to acute respiratory failure. This entity is rarely reported in the literature. We report two cases of acute AH after intravenous thrombolysis for acute myocardial infarction, which could contribute to the literature on the subject, and discuss the risk factors as well as the clinical and radiological findings supporting the diagnosis. We overview also the rare previous published case reports in this context, and we contrast our findings with those reported in the literature.
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Affiliation(s)
| | - Melek Ben Mrad
- Cardiovascular Surgery Department, Rabta Hospital, Tunis, Tunisia
| | - Zeineb Oumaya
- Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
| | - Ihsen Zairi
- Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
| | | | | | - Sofien Kamoun
- Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
| | - Sobhi Mleyhi
- Cardiovascular Surgery Department, Rabta Hospital, Tunis, Tunisia
| | - Rim Miri
- Cardiovascular Surgery Department, Rabta Hospital, Tunis, Tunisia
| | - Khadija Mzoughi
- Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
| | - Sondos Kraiem
- Cardiology Department, Habib Thameur Hospital, Tunis, Tunisia
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Prasad K, Singh P, Kanabar K, Vijayvergiya R. Pulmonary haemorrhage following thrombolysis with streptokinase in myocardial infarction. BMJ Case Rep 2020; 13:13/1/e232308. [PMID: 31980474 DOI: 10.1136/bcr-2019-232308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pulmonary haemorrhage is a rare but a life-threatening complication of thrombolytic therapy in patients with acute ST-elevation myocardial infarction (MI). It usually presents with anaemia, massive haemoptysis, acute-onset respiratory distress and diffuse bilateral lung infiltrates on imaging. We hereby describe two patients, who had pulmonary haemorrhage following streptokinase therapy for acute MI. The first patient improved with conservative treatment, while the second patient died due to respiratory failure. Streptokinase, a fibrin non-specific agent, is a widely used thrombolytic in low-income and middle-income countries. Pulmonary haemorrhage should be suspected in patients who develop sudden respiratory compromise after receiving thrombolytics, especially streptokinase. The management issues related to this uncommon life-threatening complication have been discussed in this article.
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Affiliation(s)
- Krishna Prasad
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parminder Singh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kewal Kanabar
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Atmaca MM, Simsek UB, Midi I, Aliev R, Aytac E, Kocaturk M. Diffuse alveolar hemorrhage following intravenous thrombolytic treatment in acute ischemic stroke: a case series. Neurol Sci 2019; 41:233-237. [PMID: 31280387 DOI: 10.1007/s10072-019-03997-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/26/2019] [Indexed: 11/25/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) following fibrinolytic therapy is a rare but a life-threatening complication. In acute ischemic stroke (AIS), DAH as a complication was not reported following intravenous thrombolytic therapy (ITT). The demographic, clinical, radiologic, and prognostic data of 4 patients with AIS who developed DAH after ITT are presented in this case series, along with a literature review.
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Affiliation(s)
- Murat Mert Atmaca
- Department of Neurology, Istanbul Sultan Abdulhamid Han Training and Research Hospital, Selimiye Quarter, Tibbiye Avenue, 34668, Uskudar, Istanbul, Turkey.
| | - Ugur Burak Simsek
- Department of Neurology, Istanbul Sultan Abdulhamid Han Training and Research Hospital, Selimiye Quarter, Tibbiye Avenue, 34668, Uskudar, Istanbul, Turkey
| | - Ipek Midi
- Department of Neurology, Istanbul Pendik Training and Research Hospital, Marmara University, Fevzi Cakmak Quarter, Muhsin Yazicioglu Avenue, No. 10, 34899, Pendik, Istanbul, Turkey
| | - Rustem Aliev
- Department of Neurology, Istanbul Pendik Training and Research Hospital, Marmara University, Fevzi Cakmak Quarter, Muhsin Yazicioglu Avenue, No. 10, 34899, Pendik, Istanbul, Turkey
| | - Emrah Aytac
- Department of Neurology, Firat University Hospital, University Quarter, Yunus Emre Avenue, No. 20, 23200, Elazıg, Turkey
| | - Mehtap Kocaturk
- Department of Neurology, Harran University Research and Application Hospital, Osmanbey Campus, 63300, Sanliurfa, Turkey
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Chen X, Xu G. Intravenous thrombolysis in SLE-related stroke: a case report and literature review. Neurol Sci 2017; 39:155-159. [PMID: 29116545 DOI: 10.1007/s10072-017-3158-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/12/2017] [Indexed: 01/08/2023]
Abstract
Patients with systemic lupus erythematosus (SLE) bear an increased risk of ischemic stroke. However, evidences for treating acute stroke due to artery thrombosis in SLE patients are extremely limited. A 45-year-old woman experienced sudden left hemiplegia. She was transported to the emergency department of our hospital 2 hours after the initial symptom. According to the medical records, the patient was diagnosed with SLE at the age of 28. CT scanned 150 min after the initial symptom showed no evidence of acute changes or hemorrhage. Magnetic resonance angiography (MRA) revealed occlusion of the right proximal middle cerebral artery (MCA). Ischemic stroke was diagnosed and NIHSS scored 11. The occluded MCA was successfully recanalized with intravenous rtPA. Sequent vascular imaging and serological results indicated that the etiology of the occlusion in right MCA was SLE vasculitis. The patient attained a mRS of 3 at the 3-month follow-up. The case is the first one in the literature that acute ischemic stroke related to SLE vasculitis was treated successfully with intravenous rtPA thrombolysis. The feasibility of intravenous thrombolysis for stroke related to SLE warrant further study.
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Affiliation(s)
- Xiaodong Chen
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, 210002, China. .,Department of Neurology, Shuyang People's Hospital, Shuyang, Jiangsu Province, 223600, China.
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, 210002, China
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Narayanan S, Thulaseedharan NK, Subramaniam G, Panarkandy G, Arathi N. Pulmonary alveolar hemorrhage following thrombolytic therapy. Int Med Case Rep J 2017; 10:123-125. [PMID: 28435331 PMCID: PMC5388342 DOI: 10.2147/imcrj.s129087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report a case of a 58-year-old male without any comorbidities who was thrombolysed with streptokinase for acute anterior wall myocardial infarction and developed massive hemoptysis with dyspnea and imaging features showing bilateral alveolar infiltrates. He was diagnosed with pulmonary alveolar hemorrhage and treated conservatively. His condition improved, and follow-up imaging showed resolution. Alveolar hemorrhage is a rare and life-threatening complication of thrombolytic therapy.
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Affiliation(s)
| | | | - Gomathy Subramaniam
- Department of Radiodiagnosis, Government Medical College, Kozhikode, Kerala, India
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Sandur S, Dweik RA, Arroliga AC. Alveolar Hemorrhage. J Intensive Care Med 2016. [DOI: 10.1177/088506669801300603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.
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Affiliation(s)
- Sunder Sandur
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Alejandro C. Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
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Mahjoob MP, Khaheshi I, Paydary K. Diffuse pulmonary hemorrhage after fibrinolytic therapy for acute myocardial infarction in a cocaine abuser patient. Heart Views 2014; 15:83-5. [PMID: 25538823 PMCID: PMC4268617 DOI: 10.4103/1995-705x.144797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a 45-year-old man with antroseptal myocardial infarction who developed bilateral basal alveolar infiltrates after initiating the fibrinolytic therapy. Although thrombolytic therapy with streptokinase is generally used in the course of acute myocardial infarction and has diminished morbidity and mortality, pulmonary hemorrhage is an uncommon, but a potentially life-threatening complication that should be regarded as one of the differential diagnoses of pulmonary infiltrates or dropping hemoglobin with no apparent bleeding site.
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Affiliation(s)
- Mohammad Parsa Mahjoob
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Isa Khaheshi
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koosha Paydary
- Students Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Gallant SC, Fritz MA, Paul BC, Costantino PD. Management of airway compromise following thyroid cyst hemorrhage after thrombolytic therapy. Laryngoscope 2014; 125:604-7. [PMID: 25043767 DOI: 10.1002/lary.24841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 06/10/2014] [Accepted: 06/23/2014] [Indexed: 11/10/2022]
Abstract
The risk of hemorrhage after therapeutic administration of tissue plasminogen activator (tPA) is well known. Cases of postadministration hemorrhage have been reported within many organ systems. We present a case of a 62-year-old female with undiagnosed thyroid goiter who received tPA for acute ischemic stroke and developed acute airway compromise. The surgical airway response team was called due to inability to ventilate or intubate. An incision into the mass during attempted tracheotomy released colloid and blood, decompressing the airway and facilitating ventilation and intubation. Hemithyroidectomy for mass removal was delayed for 3 days to allow normalization of post-tPA coagulopathy.
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Affiliation(s)
- Sara C Gallant
- Department of Otolaryngology, New York University, New York, New York, U.S.A
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Lingual Haematoma due to Tenecteplase in a Patient with Acute Myocardial Infarction. Case Rep Otolaryngol 2013; 2013:239796. [PMID: 23862086 PMCID: PMC3686072 DOI: 10.1155/2013/239796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/04/2013] [Indexed: 11/17/2022] Open
Abstract
The use of intravenous thrombolytic agents has revolutionised the treatment of acute myocardial infarction. However, the improvement in mortality rate achieved with these drugs is tempered by the risk of serious bleeding complications, including intracranial haemorrhage. Tenecteplase is a genetically engineered mutant tissue plasminogen activator. Haemorrhagic complications of tissue plasminogen activator (tPA) are well known. Compared to other tPAs, tenecteplase use leads to lower rates of bleeding complications. Here, we report a case of unusual site of spontaneous bleeding, intralingual haematoma during tenecteplase therapy following acute myocardial infarction, which caused significant upper airway obstruction and required tracheotomy to maintain the patient's airway. Clinical dilemmas related to securing the airway or reversing the effects of tissue plasminogen activator are discussed.
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Iskandar SB, Kasasbeh ES, Mechleb BK, Garcia I, Jackson A, Fahrig S, Albalbissi K, Henry PD. Alveolar Hemorrhage: An Underdiagnosed Complication of Treatment with Glycoprotein IIb/IIIa Inhibitors. J Interv Cardiol 2006; 19:356-63. [PMID: 16881986 DOI: 10.1111/j.1540-8183.2006.00161.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Alveolar hemorrhage (AH) is a rare complication of treatment with GP IIb/IIIa inhibitors. Hemoptysis, a constant sign, lacks in specificity, and may occur in confounding syndromes such as pulmonary edema, pulmonary infarction, and pneumonia. Nonspecific symptoms and signs often delay the diagnosis, thereby allowing serious or even fatal disease progression. Here, we performed a large-scale retrospective analysis to define the incidence and risk factors of AH in the setting of GP IIb/IIIa inhibitors therapy. BACKGROUND Randomized controlled trials demonstrate that treatment with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors may improve the outcome of acute myocardial infarction (AMI) and angioplastic procedures. However, this treatment may rarely lead to severe hemorrhagic complications, in particular AH. Unfortunately, the incidence and risk factors of AH remain poorly defined. METHODS We reviewed for the period extending from August 1998 to January 2005 consecutive histories of AMI patients receiving coronary arteriography and treatment with either eptifibatide or abciximab. Concomitantly admitted AMI patients not treated with GP IIb/IIIa inhibitors were reviewed and served as a control group. The diagnosis of AH required the demonstration of typical symptoms and signs including dyspnea, hemoptysis, arterial hypoxemia, pulmonary radiographic changes, and, when available, bronchoscopic signs for AH. Potential covariates including pulmonary disease, pulmonary hypertension, smoking, and use of other anticoagulant or antiplatelet agents were evaluated. RESULTS Six of 1,810 patients (0.33%) receiving eptifibatide and five of 3,648 patients (0.14%) receiving abciximab exhibited typical symptoms and signs of AH. Contrarily, only one of 4,136 patients (0.025%) receiving no GP IIb/IIIa inhibitors presented with similar symptoms and signs. There was no fatal outcome, though two patients required blood transfusions. Statistically significant differences were found between control patients and patients receiving eptifibatide alone (P = 0.004). There was also a significant difference between untreated patients and those receiving eptifibatide and abciximab (P = 0.017). No differences were found between eptifibatide and abciximab-treated patients (P = 0.19) or between abciximab and untreated control patients (P = 0.105). CONCLUSIONS AH is a rare complication of treatment with GP IIb/IIIa inhibitors. Its incidence ranged from 0.14% in patients treated with abciximab to 0.33% in those receiving eptifibatide. Compared to a control group, patients treated with GP IIb/IIIa inhibitors had a statistically increased risk for AH.
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Affiliation(s)
- Said B Iskandar
- Division of Cardiology, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee 37604, USA.
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Abstract
Diffuse alveolar hemorrhage represents a medical emergency, and clinicians must have an expedient approach to its identification. There are many causes of diffuse alveolar hemorrhage, including vasculitides, immunologic conditions such as Goodpasture's syndrome, collagen vascular disease, and idiopathic conditions. Careful attention to the medical history, physical examination, and targeted laboratory evaluation often suggests the underlying cause. Patients in whom the diagnosis of diffuse alveolar hemorrhage remains uncertain should undergo diagnostic bronchoscopy. In patients with evidence of diffuse alveolar hemorrhage and renal involvement, kidney biopsy should be considered to identify the underlying cause and help direct therapy.
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Affiliation(s)
- Harold R Collard
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C272, Denver, CO 80262, USA.
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Abstract
Current and past drug intake is essential in the evaluation of a patient who has DAH. Simple treatments, such as reversal of a coagulation defect or withdrawal of the drug, can reverse a life-threatening situation. DAO may result in DAH, and depending on the severity of the drug withdrawl, will not be adequate and corticosteroid therapy is recommended.
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Affiliation(s)
- Marvin I Schwarz
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, C272, Denver, CO 80262, USA.
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Shaps HJ, Snyder GE, Sama AE, Rudolph GS. Airway compromise secondary to lingual hematoma complicating administration of tissue plasminogen activator for acute ischemic stroke. Ann Emerg Med 2001; 38:447-9. [PMID: 11574803 DOI: 10.1067/mem.2001.116615] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hemorrhagic complications of tissue plasminogen activator (tPA) are well known. We report a case of a lingual hematoma that developed after tPA administration for an acute ischemic stroke that necessitated orotracheal intubation to maintain the patient's airway. This case demonstrates the need for thorough preadministration physical examination, as well as careful monitoring during infusion and after administration of this potent therapeutic agent.
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Affiliation(s)
- H J Shaps
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA.
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Khanlou H, Tsiodras S, Eiger G, Abousy K, Goldberg S, Nakhjavan F, Yazdanfar S. Fatal alveolar hemorrhage and Abciximab (ReoPro) therapy for acute myocardial infarction. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 44:313-6. [PMID: 9676804 DOI: 10.1002/(sici)1097-0304(199807)44:3<313::aid-ccd14>3.0.co;2-l] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We describe two cases of diffuse alveolar hemorrhage and development of ARDS in patients who underwent percutaneous transluminal coronary angioplasty (PTCA) with stenting in whom Abciximab (ReoPro) was used in combination with other agents interfering with the hemostatic mechanism. The development of pulmonary infiltrates, associated with a fall in hemoglobin after the administration of Abciximab, should strongly suggest the possibility of diffuse alveolar hemorrhage. Physicians should be aware of the possible association between the use of Abciximab and the development of alveolar hemorrhage.
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Affiliation(s)
- H Khanlou
- Department of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA
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