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

MEK1/2- and ERK1/2-Mediated Lung Endothelial Injury and Altered Hemostasis Promote Diffuse Alveolar Hemorrhage in Murine Lupus

OBJECTIVE

About 3% of patients with lupus develop severe diffuse alveolar hemorrhage (DAH) with pulmonary vasculitis. C57BL/6 (B6) mice with pristane-induced lupus also develop DAH, but BALB/c mice are resistant. DAH is independent of Toll-like receptor signaling and other inflammatory pathways. This study examined the role of the MEK1/2 pathway (MEK1/2-ERK1/2, JNK, p38).

METHODS

B6 and BALB/c mice were treated with pristane with or without inhibitors of MEK1/2 (trametinib/GSK1120212 [GSK]), ERK1/2 (SCH772984 [SCH]), JNK, or p38. Effects on lung hemorrhage and hemostasis were determined.

RESULTS

GSK and SCH abolished DAH, whereas JNK and p38 inhibitors were ineffective. Apoptotic cells were present in lung samples from pristane-treated mice but not in mice receiving pristane and GSK, and endothelial dysfunction was normalized. Expression of the ERK1/2-regulated transcription factor early growth response 1 increased in pristane-treated B6, but not BALB/c, mice and was normalized by GSK. Pristane also increased expression of the anticoagulant genes Tfpi and Thbd in B6 mice. The ratio of Tfpi to tissue factor (F3) to Tfpi increased in B6 (but not BALB/c) mice and was normalized by GSK. Circulating thrombomodulin protein levels increased in B6 mice and returned to normal after GSK treatment. Consistent with augmented endothelial anticoagulant activity, pristane treatment increased tail bleeding in B6 mice.

CONCLUSION

Pristane treatment promotes lung endothelial injury and DAH in B6 mice by activating the MEK1/2-ERK1/2 pathway and impairing hemostasis. The hereditary factors determining susceptibility to lung injury and bleeding in pristane-induced lupus are relevant to the pathophysiology of life-threatening DAH in systemic lupus erythematosus and may help to optimize therapy.

The Wide Spectrum of Presentations of Cytomegalovirus Infection in Immunocompetent Hosts: An Exhaustive Narrative Review

CMV is a ubiquitous DNA virus that establishes infection and results in 40-100% seropositivity. Viral replication occurs following an acquired primary infection (or reinfection) or by the reactivation of life-long latency. In immunocompetent patients, CMV infection is mostly asymptomatic or mild and self-limited. However, an extensive review of the literature published up to April 2024 reveals that despite immunocompetence, CMV can cause a very large variety of clinical syndromes in any part of the gastrointestinal tract (the most common pattern), the central or peripheral nervous system, and the eyes, as well as hematological, pulmonary, cardiac, and cutaneous disease. Not uncommonly, more than one system is involved, and though the disease is often self-limited, treatment with intravenous ganciclovir or oral valganciclovir may be required, and in isolated cases, fatalities may occur. Thus, a potential CMV infection should be considered in the differential of myriad syndromes in non-immunocompromised patients. Associated systemic symptoms (fever, sweats, and weight loss), lymphocytosis, and hepatitis are not uncommon and can be a useful clue. Some populations, such as critically ill patients in intensive care, pregnant women, elderly patients, and those with inflammatory bowel disease, may be more susceptible. Moreover, the potential of past, latent CMV infection (i.e., CMV seropositivity) to be associated with significant cardiovascular morbidity and all-cause mortality years later is intriguing and requires further study. All these data indicate the outstanding importance of developing a vaccine against CMV, which hopefully will become available in the foreseeable future. Meanwhile, a solid diagnosis of active CMV infection can be quickly established (or ruled out) by widely available serology tests and PCR amplification, and clinicians in all disciplines need to be more aware of the diverse guises of CMV infection and remember to consider it in any host, including an immunocompetent one.

Diffuse Alveolar Hemorrhage: A Rare Life-Threatening Cause of Massive Hemoptysis

We present a case report of diffuse alveolar hemorrhage (DAH), which presented with massive hemoptysis and impending airway compromise. A previously healthy 33-year-old female presented to the emergency department with dyspnea, chest pain, and massive hemoptysis. Due to impending respiratory failure, the patient was placed on mechanical ventilation and a bronchoscopy revealed a diagnosis of DAH. Throughout the hospital course, the patient received antibiotics, steroids, fresh frozen plasma (FFP), cryoprecipitate, tranexamic acid (TXA), and multiple blood transfusions. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO), but despite these life-saving measures, the patient died less than 48 hours after her initial presentation. This case serves as a harrowing reminder of DAH's destructive capabilities and the importance of rapid, aggressive management.

MEK1/2 and ERK1/2 mediated lung endothelial injury and altered hemostasis promote diffuse alveolar hemorrhage in murine lupus

Objective

About 3% of lupus patients develop severe diffuse alveolar hemorrhage (DAH) with pulmonary vasculitis. B6 mice with pristane-induced lupus also develop DAH, but BALB/c mice are resistant. DAH is independent of TLR signaling and other inflammatory pathways. This study examined the role of the mitogen-activated protein kinase pathway (MEK1/2-ERK1/2, JNK, p38).

Methods

B6 and BALB/c mice were treated with pristane ± inhibitors of MEK1/2 (trametinib/GSK1120212, "GSK"), ERK1/2 (SCH772984, "SCH"), JNK, or p38. Effects on lung hemorrhage and hemostasis were determined.

Results

GSK and SCH abolished DAH, whereas JNK and p38 inhibitors were ineffective. Apoptotic cells were present in lung from pristane-treated mice, but not mice receiving pristane+GSK and endothelial dysfunction was normalized. Expression of the ERK1/2-regulated transcription factor Egr1 increased in pristane-treated B6, but not BALB/c, mice and was normalized by GSK. Pristane also increased expression of the anticoagulant genes Tfpi (tissue factor pathway inhibitor) and Thbd (thrombomodulin) in B6 mice. The ratio of tissue factor ( F3 ) to Tfpi increased in B6 (but not BALB/c) mice and was normalized by GSK. Circulating Thbd protein increased in B6 mice and returned to normal after GSK treatment. Consistent with augmented endothelial anticoagulant activity, pristane treatment increased tail bleeding in B6 mice.

Conclusion

Pristane treatment promotes lung endothelial injury and DAH in B6 mice by activating the MEK1/2-ERK1/2 pathway and impairing hemostasis. The hereditary factors determining susceptibility to lung injury and bleeding in pristane-induced lupus are relevant to the pathophysiology of life-threatening DAH in SLE and may help to optimize therapy.

Qualitative evaluation of connective tissue disease with cytomegalovirus infection: A meta-analysis of case reports

BACKGROUND

The primary therapies for connective tissue disease include glucocorticoids and immunosuppressants. However, their prolonged usage can precipitate opportunistic infections, such as cytomegalovirus infection. When managing connective tissue disease complicated by cytomegalovirus infection, judicious selection of treatment modalities is crucial. This involves assessing the necessity for antiviral therapy and contemplating the reduction or cessation of glucocorticoids and immunosuppressants.

OBJECTIVE

This investigation sought to methodically review existing literature regarding treating connective tissue disease patients with cytomegalovirus infection.

METHODS

On July 5, 2023, an exhaustive literature search was conducted. Data analysis utilized the Kruskal-Wallis test or one-way analysis of variance, supplemented by Bonferroni post hoc testing.

RESULTS

Our meta-analysis incorporated 88 studies encompassing 146 connective tissue disease patients with CMV infections. The results indicated that patients with connective tissue disease and cytomegalovirus disease benefitted more from antiviral therapy than those not receiving such treatment (P = 0.003, P < 0.005). Furthermore, the strategic reduction of glucocorticoids and/or immunosuppressants was beneficial (P = 0.037, P < 0.05). Poor clinical outcomes with glucocorticoid-immunosuppressant combination therapy compared to other treatment modalities. The findings also suggested that CMV infection patients fare better without Cyclosporine A than using it (P = 0.041, P < 0.05).

CONCLUSION

Antiviral therapy is a viable treatment option in cases of connective tissue disease co-occurring with cytomegalovirus disease. Additionally, when connective tissue disease is stable, there is potential merit in reducing glucocorticoids and/or immunosuppressants, especially avoiding the combination of these drugs. For all cytomegalovirus infection patients, Cyclosporine A may be avoided wherever possible for selecting immunosuppressive agents if its use is not deemed essential in the treatment regimen.

The other great imitator among infectious diseases: Leptospirosis

INTRODUCTION

Leptospirosis is a worldwide zoonosis responsible for highly diverse clinical presentations with a wide range of severity. Variable environment exposures to infected urines of rodents have been described.

OBSERVATION

We report five cases of serologically confirmed leptospirosis leading to hospitalization in an intensive care unit (ICU) of a French center. These patients displayed neurological, respiratory, and abdominal presentation of leptospirosis with variable level of severity. Either professional, leisure related, or daily living exposures have been retrieved.

CONCLUSION

These cases underline the diversity of clinical presentation and environmental exposure of this infectious disease. They highlight the interest of an exhaustive anamnesis with collection of professional activity, environmental exposures, and leisure activities.

Severe dengue in the intensive care unit

Dengue fever is considered the most prolific vector-borne disease in the world, with its transmission rate increasing more than eight times in the last two decades. While most cases present mild to moderate symptoms, 5% of patients can develop severe disease. Although the mechanisms are yet not fully comprehended, immune-mediated activation leading to excessive cytokine expression is suggested as a cause of the two main findings in critical patients: increased vascular permeability that may shock and thrombocytopenia, and coagulopathy that can induce hemorrhage. The risk factors of severe disease include previous infection by a different serotype, specific genotypes associated with more efficient replication, certain genetic polymorphisms, and comorbidities such as diabetes, obesity, and cardiovascular disease. The World Health Organization recommends careful monitoring and prompt hospitalization of patients with warning signs or propensity for severe disease to reduce mortality. This review aims to update the diagnosis and management of patients with severe dengue in the intensive care unit.

Hemoptysis in Cancer Patients

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

Viral anti-inflammatory serpin reduces immuno-coagulopathic pathology in SARS-CoV-2 mouse models of infection

SARS-CoV-2 acute respiratory distress syndrome (ARDS) induces uncontrolled lung inflammation and coagulopathy with high mortality. Anti-viral drugs and monoclonal antibodies reduce early COVID-19 severity, but treatments for late-stage immuno-thrombotic syndromes and long COVID are limited. Serine protease inhibitors (SERPINS) regulate activated proteases. The myxoma virus-derived Serp-1 protein is a secreted immunomodulatory serpin that targets activated thrombotic, thrombolytic, and complement proteases as a self-defense strategy to combat clearance. Serp-1 is effective in multiple animal models of inflammatory lung disease and vasculitis. Here, we describe systemic treatment with purified PEGylated Serp-1 as a therapy for immuno-coagulopathic complications during ARDS. Treatment with PEGSerp-1 in two mouse-adapted SARS-CoV-2 models in C57Bl/6 and BALB/c mice reduced lung and heart inflammation, with improved outcomes. PEGSerp-1 significantly reduced M1 macrophages in the lung and heart by modifying urokinase-type plasminogen activator receptor (uPAR), thrombotic proteases, and complement membrane attack complex (MAC). Sequential changes in gene expression for uPAR and serpins (complement and plasminogen inhibitors) were observed. PEGSerp-1 is a highly effective immune-modulator with therapeutic potential for severe viral ARDS, immuno-coagulopathic responses, and Long COVID.

Pulmonary capillaritis as a cause of lethal diffuse alveolar hemorrhage

Lethal pulmonary hemoptysis is a common finding in forensic medicine. Since hemoptysis does not necessarily occur before death and its previous symptoms are usually unspecific, indicative signs or findings at the site of a corpse may be completely absent. If lethal acute alveolar hemorrhage is found in the post-mortem examination, a differential diagnosis should be made for traumatic, substance-related, infectious, or organic causes. Cocaine-associated pulmonary hemorrhage and drug reactions are in the foreground. For organic causes, autoimmune diseases should be considered in addition to cardiac, haematological, and infectious causes. The following two cases show similarities both in the sudden, unexpected deaths and the anamnesis of the two deceased women. One of the deceased received a Corona vaccination a few months earlier. In each case, the post-mortem examination revealed an acute diffuse pulmonary hemorrhage caused by acute inflammation of the lung capillaries. This case presentation demonstrates the necessity of a complete autopsy including toxicological and histological analyses. The documentation and publication of rare causes of death are essential for medical research and practice in order to critically consider and discuss the possibility of to date unknown associations in similar cases.

[An outline of pulmonary hemorrhage - A pulmonologists perspective]

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

A case of severe leptospirosis with Jarisch-Herxheimer reaction presenting as respiratory failure

Background

Leptospirosis is a widespread zoonotic disease caused by pathogenic Leptospira spp. The treatment of penicillin or tetracycline can cause a Jarisch-Herxheimer reaction (JHR), which can lead to acute respiratory distress syndrome (ARDS) and multi-organ failure in severe cases. The overall course of evolution and imaging features of a JHR exacerbation of leptospirosis have rarely been reported.

Case presentation

We present a case of leptospirosis complicated by pulmonary alveolar hemorrhage and a Jarisch-Herxheimer reaction (JHR) that required respiratory and vasopressor support. This case demonstrates a well-defined course of evolution of JHR and the imaging features.

Conclusions

Leptospirosis is easily misdiagnosed in some sporadic areas, and JHR complicates its management. Early diagnosis and appropriate treatment can reduce the mortality of severe leptospirosis with JHR.

Characteristics of patients with viral infections of the lower respiratory tract: A retrospective study

While the impact of respiratory virus infections has been well researched in some respiratory diseases, no clinical studies have discussed the subject of who would be more likely to develop respiratory virus infections among patients with various respiratory illnesses who come from different backgrounds. This study aimed to identify respiratory diseases that are frequently associated with respiratory virus infections along with the characteristics of patients who develop such infections in clinical settings. Tested specimens were obtained from the lower respiratory tract by bronchoscopy to provide more accurate data. Data of bronchoscopies at Ryukyu University Hospital between August 2012 and September 2016 were reviewed, and patients who underwent multiplex polymerase chain reaction (PCR) tests for detecting respiratory viruses in bronchoscopy specimens were retrospectively recruited for descriptive statistics. Differences among patients' primary pulmonary diseases and backgrounds were compared between the PCR-positive and -negative patients, and multivariate statistical analysis was performed to analyze factors associated with a positive PCR test result. Overall, 756 bronchoscopies were performed during the study period and PCR tests were performed for 177 patients. Of them, 27 tested positive for respiratory viruses, mainly parainfluenza virus and rhinovirus, and out of those, 7 were hospitalized for >1 month. Overall, all patients did not experience typical upper respiratory infection symptoms. In positive patients, 13 and 7 had diagnoses of interstitial lung disease and bacterial pneumonia, respectively. The diagnoses of 3 bacterial pneumonia cases were changed to viral pneumonia after receiving their PCR-positive tests. Respiratory virus infections were confirmed in 14 patients on immunosuppressant therapy and 4 on maintenance dialysis. Multivariate analysis revealed that immunosuppressant therapy and maintenance dialysis were independently associated with respiratory virus infections. Viruses were commonly detected in patients with interstitial lung diseases and bacterial pneumonia, while few patients were diagnosed with pure viral pneumonia. These illnesses were considered to be induced by respiratory infections. Immunosuppressant therapy and maintenance dialysis were associated with respiratory virus infections. Multiplex PCR testing is an essential diagnostic tool for respiratory virus infections in immunocompromised patients.

HEROES V-A-HEmoRrhagic cOmplications in veno-arterial Extracorporeal life Support-Development and internal validation of a multivariable prediction model in adult patients

BACKGROUND

Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS.

METHODS

Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model.

RESULTS

In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66.

CONCLUSION

The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.

The Spectrum of Autoantibodies in Adult Patients With Idiopathic Pulmonary Hemosiderosis: A Brief Review of the Literature

While autoimmune antibodies or autoantibodies have been reported sporadically in adult patients with idiopathic pulmonary hemosiderosis (IPH), their true prevalence is unknown. The question as to whether any difference exists between antibody-positive and negative patients has not been explored. The primary objective of this paper was to assess the spectrum of autoantibody testing and its positivity rate. The other objectives included a comparative analysis of demographics, symptom onset, clinical manifestations, and differences in clinical outcomes between antibody-positive (cohort A) and negative (cohort B) patients. To that end, we conducted a retrospective review of the relevant published literature. Multiple databases were searched to retrieve studies published between 1990 and 2022.

A total of 35 studies, involving 38 patients, were identified. Five of these patients had a positive autoantibody. Patients in cohort A were older and more likely to be male. The frequencies of testing for these antibodies were as follows: antineutrophil cytoplasmic antibody (ANCA): 37/38 (97.4%), antinuclear antibody (ANA): 31/38 (81.6%), and anti-glomerular basement membrane antibody (anti-GBM): 30/38 (78.9%); 5/38 (13.2%) patients tested positive for an autoantibody, and two of these patients were positive for ANA, two for antithyroid antibody, and one patient tested positive for ANCA, rheumatoid factor (RF), and granulocyte monocyte-colony stimulating factor (GM-CSF) antibody. There was no difference between the cohorts regarding their clinical presentations, recurrence risks, and survival.

The occurrence of autoantibodies is uncommon in adult IPH patients. This is in contrast with the pediatric IPH patient population, where the prevalence is much higher (26.4% vs. 13.2%), and the antibodies are more diverse. Unlike pediatric patients, adult patients with autoantibodies do not necessarily have worse outcomes.

Severe pediatric Mycoplasma pneumonia as the cause of diffuse alveolar hemorrhage requiring veno-venous extracorporeal membrane oxygenation: A case report

BACKGROUND

Diffuse alveolar hemorrhage (DAH) is an acute life-threatening disease often associated with immunocompromised patients and systemic disorders, such as infections, vasculitis, and toxins. Mycoplasma pneumoniae is one of the most common causes of community-acquired pneumonia in children, which rarely causes respiratory failure and fulminant disease; However, a rapid progression may occur in some patients. Mycoplasma pneumonia-associated DAH is rare.

CASE PRESENTATION

We report a case of severe pediatric mycoplasma pneumonia in an immuno-competent child. This patient's condition progressed rapidly, with severe lung lesions associated with pleural effusion, coagulopathy, diffuse alveolar haemorrhage and severe respiratory distress requiring ventilator and intravenous extracorporeal membrane oxygenation (VV-ECMO) support. She was discharged upon successful treatment.

CONCLUSION

Diffuse alveolar hemorrhage associated with Mycoplasma pneumoniae in children is very rare, and clinicians should be aware of the potential rapid onset of the disease. Early detection and diagnosis are very important. The main treatment measures include anti-infection and supportive measures such as mechanical ventilation, but as in our case, success with both prone positioning for more than 10 h per day and VV-ECMO was life-saving.

HEROES V-V-HEmorRhagic cOmplications in Veno-Venous Extracorporeal life Support-Development and internal validation of multivariable prediction model in adult patients

BACKGROUND

During extracorporeal life support (ECLS), bleeding is one of the most frequent complications, associated with high morbidity and increased mortality, despite continuous improvements in devices and patient care. Risk factors for bleeding complications in veno-venous (V-V) ECLS applied for respiratory support have been poorly investigated. We aim to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving V-V ECLS support.

METHODS

Data from adult patients reported to the extracorporeal life support organization (ELSO) registry between the years 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-V ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the predictive model. The performance of the model was tested by discriminative ability and calibration with receiver operating characteristic curves and visual inspection of the calibration plot.

RESULTS

In total, 18 658 adult patients were included, of which 3 933 (21.1%) developed bleeding complications. The prediction model showed a prediction of bleeding complications with an AUC of 0.63. Pre-ECLS arrest, surgical cannulation, lactate, pO₂ , HCO₃ , ventilation rate, mean airway pressure, pre-ECLS cardiopulmonary bypass or renal replacement therapy, pre-ECLS surgical interventions, and different types of diagnosis were included in the prediction model.

CONCLUSIONS

The model is based on the largest cohort of V-V ECLS patients and reveals the most favorable predictive value addressing bleeding events given the predictors that are feasible and when compared to the current literature. This model will help identify patients at risk of bleeding complications, and decision making in terms of anticoagulation and hemostatic management.

Metagenomic next-generation sequencing in the diagnosis of leptospirosis presenting as severe diffuse alveolar hemorrhage: a case report and literature review

BACKGROUND

Leptospirosis is a common infectious disease in tropical and semitropical regions, and it is typically neglected. Leptospirosis-associated acute diffuse alveolar hemorrhage is one of its fatal complications. The use of bronchoalveolar lavage fluid (BALF) metagenomic next-generation sequencing in the diagnosis of Leptospira interrogans infection has rarely been reported.

CASE PRESENTATION

We present the case of a 62-year-old female who was transferred to our hospital with dyspnea, and severe hemoptysis and was supported by a tracheal intubation ventilator. Bronchoalveolar lavage fluid (BALF) metagenomic next-generation sequencing (mNGS) reported Leptospira interrogans. A diagnosis of diffuse alveolar hemorrhage caused by leptospirosis was made. After immediately receiving antibiotics and hormone therapy, the patient achieved a complete recovery upon discharge.

CONCLUSION

Leptospirosis presenting as severe diffuse alveolar hemorrhage is rare but should be considered in the differential diagnosis. mNGS can help identify pathogens and treat them early, which can improve prognosis.

Diffuse Alveolar Hemorrhage Associated With Severe Acute Respiratory Syndrome Coronavirus 2

Diffuse alveolar hemorrhage (DAH) is a rare syndrome resulting from the accumulation of intra-alveolar red blood cells originating most often from the alveolar capillaries and, less frequently, from precapillary arterioles or postcapillary venules. The causes of DAH can be divided into infectious and noninfectious. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has not been previously identified in humans, and it is responsible for coronavirus disease-19 (COVID-19) infection. Here, we present a case of DAH that is believed to be a consequence of COVID-19 infection in a female patient with no known past medical history. The patient was found to be positive for perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA) and anti-glomerular basement membrane antibodies. The patient was diagnosed with ANCA-associated vasculitis with glomerulonephritis and was treated successfully with methylprednisolone 500 mg intravenous (IV) daily for three days, followed by rituximab 375 mg/m² IV once weekly for four weeks. The long-term complications of COVID-19 are not entirely known and are still being investigated. The association between COVID-19 infection and DAH is not fully known. However, the inflammatory process of COVID-19 infection may have a role in vasculitis, leading to DAH.

Association of bleeding symptoms during influenza infection and administered drugs

On March 1, 2019, the Ministry of Health, Labour and Welfare added bleeding symptoms to adverse reaction package inserts as a possible adverse event for a new anti-influenza drug, baloxavir marboxil, because 13 patients with bleeding symptoms were identified among influenza patients taking the drug. Nevertheless, aspects of the epidemiology of bleeding symptoms among influenza patients remain unclear. This study elucidated bleeding symptoms among influenza patients and hospitalized patients as severe cases. A survey was administered to all physicians in Japan during the 2019-2020 season for reporting of bleeding symptoms in influenza patients. The survey elicited information about outcomes, assuming associated underlying diseases and drugs in addition to administered drugs including acetaminophen and anti-influenza (antiviral) drugs. We received reports of 63 cases with bleeding symptoms, including 5 cases of hospitalized patients. Among all patients, 54% had been administered oseltamivir; 10% had been administered baloxavir marboxil. Among hospitalized patients, all had been administered acetaminophen; 40% of them had been administered oseltamivir, and one patient had been administered baloxavir marboxil. Accumulation of bleeding symptom cases is expected to be necessary to evaluate the association.

The etiology, clinical profile, and outcome of diffuse alveolar hemorrhage in children: a ten-year single-center experience

BACKGROUND

Diffuse alveolar hemorrhage (DAH) is a life-threatening syndrome that may be caused by numerous disorders. There is scant data on the etiology and characteristics of DAH in children.

METHODS

We retrospectively reviewed the clinical records of patients admitted to a tertiary pediatric hospital with DAH over a 10-year period. The syndrome was classified into five groups according to different etiologies, and the characteristics and outcomes of patients were compared.

RESULTS

A total of 74 children were included in the study. Idiopathic pulmonary hemosiderosis (IPH) was the most frequent cause (64.9%), followed by miscellaneous causes (infection and other conditions) (16.2%), immune-mediated disorders (9.5%), liver dysfunction (5.4%), and cardiovascular disorders (4.1%). The median age of the patients was 3.5 years (ranging from 1.5 to 7 years), and no difference was found in the proportion of fever, crackles, and pulmonary infiltrates among the five etiological groups. There was no difference in the proportion of blood transfusions among the groups. Cardiac catheterization was performed on 31 patients for whom the diagnostic workup was negative and were suspected of having IPH, and abnormal signs were observed and bronchial artery embolization (BAE) was performed in all those patients. The patients with IPH had the lowest mortality, while those with DAH secondary to liver failure had the highest mortality. Patients in BAE group had a shorter duration of corticosteroids and a lower relapse rate than non-BAE group.

CONCLUSIONS

Idiopathic pulmonary hemosiderosis is a common etiology of DAH and has a good prognosis in children. Vascular abnormalities were observed in the patients with IPH. Further studies are needed to clarify the role of vascular malformations in IPH.

Diffuse alveolar haemorrhage secondary to haemophilus influenzae in a vaping patient

Diffuse alveolar haemorrhage (DAH) is known to occur from several infectious and non-infectious aetiologies. Among the infectious aetiologies, Haemophilus influenzae, an organism known to cause community-acquired pneumonia, has not been reported in association with DAH prior to this case. On the other hand, vaping, an evolving epidemic concern, has been linked to various types of lung injury, including DAH. However, DAH related to vaping is only limited to several case reports. Our case describes H. influenzae pneumonia with DAH in a patient known to have vaped until the night prior to elective lobectomy for lung cancer and developed DAH within 24 hours of hospitalisation. He subsequently recovered with treatment. DAH requires immediate recognition, and healthcare providers need to be aware that neither haemoptysis nor decrease in haemoglobin level is necessarily associated. Prior to diagnosis, empirical treatment with intravenous steroids and antibiotics can be life-saving.

A rare case of diffuse alveolar hemorrhage caused by acute mycoplasma pneumoniae pneumonia

Mycoplasma pneumoniae is a common bacterial pathogen that causes atypical community-acquired pneumonia. Illness onset can be gradual and progressive over weeks. Patients typically have cough, pharyngitis, malaise, and tracheobronchitis. Although symptoms are frequently mild, the initial presentation can be severe with numerous complications. We present a case of a 28-year-old male who presented with 1 day of significant hemoptysis. He was intubated for airway protection and underwent bronchoscopy, which showed multiple blood clots in several lung lobes, consistent with diffuse alveolar hemorrhage (DAH). His workup was negative for pulmonary embolism, coagulopathy, and vasculitis. He tested positive for rhinovirus and mycoplasma pneumoniae IgM (negative IgG). He was ultimately discharged home with oral doxycycline to complete a 10-day course. DAH is a rare presentation and life-threatening complication of mycoplasma pneumonia. Although there is a reported association between DAH and rhinovirus, our patient improved with antibiotics making mycoplasma pneumoniae the likely culprit. When encountering hemoptysis or alveolar bleeding, clinicians should have low suspicion for atypical infections and start appropriate antibiotics early in the clinical course.

Acute ANCA Vasculitis and Asymptomatic COVID-19

We describe the presentation and diagnosis of a child with newly diagnosed antineutrophil cytoplasmic antibody-associated vasculitis and associated diffuse alveolar hemorrhage who was positive for coronavirus disease 2019 immunoglobulin G antibodies, indicative of a previous asymptomatic infection. Results of multiple polymerase chain reaction tests coinciding with the start of symptoms were negative, indicating that acute infection was not the cause of the patient's symptoms. Coronavirus disease 2019-induced autoimmune diseases have been described in adults, but this case report represents the first case described in a pediatric patient.

Pulmonary angiosarcoma presenting with diffuse alveolar hemorrhage: a case report

This study aimed to analyze the diagnosis and treatment of one case of pulmonary angiosarcoma (PPA) retrospectively. The main manifestation of this female patient was cough, hemoptysis and dyspnea. Computed tomography (CT) of the chest revealed multiple small nodules and ground-glass patches in both lungs suggesting of diffuse alveolar hemorrhage (DAH). Laboratory examination revealed decreased hemoglobin and platelet counting, normal coagulation function. Results of rheumatic markers testing including antinuclear antibody (ANA), anti-extractable nuclear antigen antibody (ENA), vasculitis marker, and antiphospholipid antibody were negative. Tumor markers were negative. Sputum smear, sputum culture, and alveolar lavage fluid culture showed negative results. The bone marrow smear was essentially normal. The patient received methylprednisolone pulse therapy (250 mg daily × 5 days) and immunoglobin (20 d daily × 7 days) treatment, but her hemoptysis persisted. Bilateral pleural effusion drainage found a large amount of bloody effusion, but cytology of the pleural fluid showed negative results. The clinical symptoms, laboratory results, imaging findings, and pathological features of the patient were summarized, and problems in diagnosis and treatment were discussed. A thoracoscopic lung biopsy was performed and the diagnosis of PPA was confirmed by pathology and immunohistochemistry (IHC) staining. This case suggested that the possibility of PPA should be considered in patients with DAH, but with negative findings in routine examinations, lung biopsy is usually required.

Haemoptysis as the first presentation of COVID-19: a case report

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an ongoing pandemic that profoundly challenges healthcare systems all over the world. Fever, cough and fatigue are the most commonly reported clinical symptoms.

CASE PRESENTATION

A 58-year-old man presented at the emergency department with acute onset haemoptysis. On the fifth day after admission, he developed massive haemoptysis. Computed tomography (CT) angiography of the chest revealed alveolar haemorrhage, more prominent in the left lung. Flexible bronchoscopy confirmed bleeding from the left upper lobe, confirmed by a bronchial arteriography, which was successfully embolized. Nasopharyngeal swabs (NPS) tested for SARS-CoV-2 using real-time polymerase chain reaction (RT-PCR) repeatedly returned negative. Surprisingly, SARS-CoV-2 was eventually detected in bronchoalveolar lavage (BAL) fluid.

CONCLUSIONS

Life-threatening haemoptysis is an unusual presentation of COVID-19, reflecting alveolar bleeding as a rare but possible complication. This case emphasises the added value of bronchoscopy with BAL in the diagnostic work-up in case of high clinical suspicion and negative serial NPS in patients presenting with severe symptoms.

Understanding immunopathology of severe dengue: lessons learnt from sepsis

Endothelial dysfunction leading to vascular permeability and plasma leakage are characteristic features of severe dengue and sepsis. However, the mechanisms underlying these immune-pathologies remain unclear. The risk of severe dengue and sepsis development depend on patient-related and pathogen-related factors. Additionally, comorbidities increase the risk of severe disease and their incidence hampers correct diagnosis and treatments. To date, there is no efficient therapy to combat severe dengue and sepsis. Here, we discuss the differences and similarities between the pathogenesis of severe dengue and that of bacterial sepsis. We identify gaps in knowledge that need to be better understood in order to move towards the rational development and/or usage of therapeutic strategies to ameliorate severe dengue disease.

Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases

Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.

Early initiation of extracorporeal membrane oxygenation (ECMO) in emergency department to rescue severe diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a serious disease whose main clinical manifestations are hemoptysis and dyspnea. In some cases, invasive mechanical ventilation is ineffective and patients can die quickly. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy that can provide oxygenation support to patients when mechanical ventilation fails. This article reports successful early initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) in an emergency department to rescue an adult patient with diffuse alveolar hemorrhage caused by viral pneumonia.

Two Immunocompromised Patients With Diffuse Alveolar Hemorrhage as a Complication of Severe Coronavirus Disease 2019

Diffuse alveolar hemorrhage (DAH) is a severe and potentially life-threatening disease manifestation. In addition to autoimmune diseases such as antineutrophil cytoplasmic antibody-associated vasculitis and anti-glomerular basement membrane syndrome, pulmonary viral infections are known to be culprits of DAH. Health-care providers worldwide in the coronavirus disease 2019 pandemic have been confronted with an unprecedented number of viral lung infections, with great variance in symptoms and severity. Hemoptysis, the key symptom of DAH, is a rare complication. We present two cases of immunocompromised patients with rapidly developing hypoxemic respiratory failure and evidence of DAH in the context of severe acute respiratory syndrome coronavirus 2 infection.

Leptospirosis manifested with severe pulmonary haemorrhagic syndrome successfully treated with venovenous extracorporeal membrane oxygenation

Leptospirosis, one of the most important of neglected tropical diseases, is a common zoonosis in the tropics. Recent reports have demonstrated that pulmonary haemorrhage is one of the fatal complications of severe leptospirosis. In this report, we present a case of leptospirosis manifested with severe pulmonary haemorrhagic syndrome successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). A 39-year-old man who lives in Bangkok presented with fever, severe myalgia and haemoptysis. With rapid progression of acute respiratory failure in 6 hours, he was intubated and a litre of fresh blood was suctioned. Chest x-ray showed diffuse alveolar infiltrates compatible with ARDS, then mechanical ventilator with lung protective strategy was used. Diagnosis of leptospirosis with diffuse alveolar haemorrhage was made. Refractory hypoxaemia was not responsive to positive end-expiratory pressure (PEEP); thus, VV-ECMO was initiated on the first day. Other treatments included plasmapheresis, intravenous pulse methylprednisolone and intravenous antibiotics. The outcome of treatment was successful, and this patient was discharged to home on day 14 after admission.

Bleeding pneumonia: Diffuse alveolar hemorrhage due to human metapneumovirus

Diffuse alveolar hemorrhage is a condition with high morbidity and mortality. The majority of cases are caused by pulmonary capillaritis associated with systemic vasculitis. Infection disease has also been associated with this condition. A 62-year-old woman with a history of chronic alcohol abuse presented with shortness of breath, hemoptysis, constipation, and icterus. Chest x-rays on admission showed diffuse patchy opacities concerning for diffuse alveolar hemorrhage. The patient quickly developed acute respiratory failure requiring intubation. PCR identified human metapneumovirus and bronchoalveolar lavage confirmed alveolar hemorrhage. Despite all efforts, the patient ultimately developed multi-organ failure and died. Human metapneumovirus is usually associated with mild upper and lower respiratory tract infections in young children. Nevertheless, clinicians should recognize that this virus has recently emerged as a significant pathogen, particularly in adult patients with underlying conditions and the elderly population.

Infective endocarditis presenting as diffuse alveolar hemorrhage: A case report

An 80-year-old man was admitted to the hospital because of fever, bloody sputum and exertional dyspnea of 3 days. Laboratory tests showed anemia and increase of the C-reactive protein level. A chest computed tomography scan revealed diffuse bilateral ground-glass opacities. Bronchoalveolar lavage confirmed the clinical diagnosis of diffuse alveolar hemorrhage (DAH). After methylprednisolone pulse therapy, Enterococcus faecalis was detected in the blood cultures. A diagnosis of infective endocarditis was made according to the Modified Duke's criteria. The causes of DAH are certainly diverse; however, we should consider infective endocarditis as one of the etiologies of DAH.

Cytomegalovirus-associated acute respiratory failure in lupus patients: case reports in relation to cytomegalovirus biology

With the wide use of immunosuppressive agents, life-threatening cytomegalovirus-associated acute respiratory failure occurs frequently. However, this condition is yet to be fully recognized and the therapeutic approach to it can only be based on comprehensive protocols rather than the biological characteristics of cytomegalovirus. We describe three acute respiratory failure events that were related to the pathogenicity of cytomegalovirus, the primary cytopathic effect and secondary antiviral immunity-mediated damage. All cytomegalovirus infection occurred after immunosuppressive usage while the acute respiratory failure events took place in different clinical settings. The first acute respiratory failure event originated from the immunoinflammatory response after cytomegalovirus infection was circumscribed, while the second resulted from cytomegalovirus reactivation and the third was caused by the combined effect of acute cytomegalovirus infection and the subsequent immunoinflammatory response. According to the clinical setting, corresponding therapeutic approaches (sequential or combined strategy) were carried out. All the patients here presented were responsive to the above therapeutic strategies. Consequently, cytomegalovirus-associated acute respiratory failure in systemic lupus erythematosus patients should be carefully differentiated and a sequential or combined strategy should be carried out according to the clinical setting. Overall, we find that there are three patterns of cytomegalovirus-associated acute respiratory failure in systemic lupus erythematosus patients and propose a novel therapeutic strategy in relation to cytomegalovirus biology.

Leptospirosis With Acute Renal Failure and Vasculitis: A Case Report

Leptospirosis is a zoonotic disease that occurs worldwide. Various clinical manifestations of leptospirosis can be seen. In this article, we present a case with acute renal failure, severe vasculitis and hyperbilirubinemia occurring simultaneously with leptospirosis. A 45-year-old male patient presented with fever, myalgia, jaundice and reddish skin lesions and anuria. Physical examination findings were icteric sclera, large tender hepatomegaly, and lower extremities' cutaneous necrosis due to vasculitis. Hemodialysis was started. Kidney biopsy revealed degenerative changes of proximal tubules, some of them containing bile casts. Microscopic agglutination test was positive and consistent with leptospirosis. Intravenous ampicillin and oral tetracycline were started. Methylprednisolone 60 mg per day was given for skin vasculitis. Hemodialysis therapy was discontinued. All clinical findings gradually regressed.

Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome

PURPOSE OF REVIEW

Diffuse alveolar hemorrhage (DAH) is a rare but devastating manifestation of antiphospholipid syndrome (APS) patients with or without other systemic autoimmune diseases. Data regarding diagnosis and treatment are limited to case series. We review diagnostic and therapeutic strategies employed in APS patients with DAH and discuss our experience in managing these complex patients.

RECENT FINDINGS

Pulmonary capillaritis likely contributes to the pathogenesis, however is only observed in half of the biopsies. Corticosteroids induce remission in the majority of patients, however almost half recur and require a steroid-sparing immunosuppressive to maintain remission. Cyclophosphamide- or rituximab-based regimens achieve the highest remission rates (50%); other strategies include intravenous immunoglobulin, plasmapheresis, mycophenolate mofetil, and/or azathioprine. Given the rarity of DAH in APS, treatment is guided by interdisciplinary experience. Why certain patients achieve full remission with corticosteroids while others require immunosuppressive agents is unknown; future research should focus on the pathophysiology and optimal management.

Successful Management of Immune Thrombocytopenia Presenting with Lethal Alveolar Hemorrhage

Immune thrombocytopenic purpura (ITP) typically presents with bleeding due to immunologic thrombocytopenia. Severe hemorrhage due to ITP is sometimes lethal, and the urgent recovery of platelets is necessary. In addition to conventional therapeutic strategies, romiplostim shows promising efficacy for chronic ITP. However, there is little evidence for the utilization of this treatment for acute ITP or acute exacerbation of chronic ITP. We report the case details of three elderly ITP patients presenting with lethal diffuse alveolar hemorrhage. These patients had the following underlying pulmonary diseases: case 1, nontuberculous mycobacterial infection and sarcoidosis; case 2, cryptogenic organizing pneumonia; case 3, pulmonary emphysema. These patients recovered following treatment with romiplostim at a higher dose (10 μg/kg), in addition to conventional therapies including corticosteroids and high-dose intravenous immunoglobulin. In summary, the addition of romiplostim resulted in earlier recovery of thrombocytopenia than has been previously reported. Our three cases suggest that early romiplostim at a higher dose could be an efficacious therapeutic option for acute ITP patients with severe lethal bleeding.

Diffuse alveolar hemorrhage: how relevant is etiology?

Background

Diffuse Alveolar Hemorrhage (DAH) is a rare and potentially life-threatening clinical syndrome whose early recognition is essential.

Objectives

Characterization of patients with DAH and comparison of presentation and evolution of the disease according to etiology.

Methods

We retrospectively reviewed the clinical records of patients admitted to our hospital over a 7-year period with DAH. Criteria for DAH (1+2): 1 - hemoptysis and/or pulmonary infiltrates and/or anemia (DAH triad); 2 - hemorrhagic bronchoalveolar lavage (BAL) or siderophagic alveolitis. DAH was grouped in immune and nonimmune and the course of disease was compared.

Results

We included 24 patients admitted with DAH, of which 11 had an immune cause: p-ANCA vasculitis (n=7), Systemic Lupus Erythematosus (n=2), c-ANCA vasculitis (n=1), Rheumatoid Arthritis (n=1) and 13 had a nonimmune cause: heart disease (n=6), amiodarone toxicity (n=2), clotting disorder (n=2), cannabis toxicity (n=1), S. aureus infection (n=1) and idiopathic (n=1). Patients with nonimmune DAH were significantly older than those with immune DAH (67.9±18.1 vs 56.6±18.8 years, p=0.042). DAH triad was observed in 54% of all patients, hemoptysis in 67%, anemia in 79%, and pulmonary infiltrates in all cases. Patients with immune DAH had more frequently pulmonary-renal syndrome (p<0.001), kidney failure (p=0.048), shock (p=0.049) and needed more frequently admition in ICU (p=0.039) and blood transfusion (p=0.043). Hospital length of stay was superior in immune group (29.5±20.0 vs 19.5±14.3 days, p=0.047). In-hospital mortality was exclusive to immune DAH (12.5%).

Conclusions

Patients with DAH due to immune causes were significantly younger, had more severe presentations of the disease and worst outcomes.

Influenza A Pneumonia Associated with Diffuse Alveolar Hemorrhage. A Case Report and Literature Review

Patient: Female, 80

Final Diagnosis: Diffuse alveolar hemorrhage in influenza A viral pneumonia

Symptoms: Generalized fatigue • shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine

Recreational 'mud fever': Leptospira interrogans induced diffuse alveolar hemorrhage and severe acute respiratory distress syndrome in a U.S. Navy seaman following 'mud-run' in Hawaii

A 23-year-old man with a viral-like prodrome developed sudden severe dyspnea and was found to have renal failure, anemia, shock, and diffuse alveolar hemorrhage with acute respiratory distress syndrome, requiring emergent endotracheal intubation and extracorporeal membrane oxygenation (ECMO). Travel and exposure history from peripheral sources revealed that the patient had participated in a 'mud-run' in Hawaii two weeks prior to symptom onset. The patient was subsequently diagnosed with leptospirosis and treated with ceftriaxone and doxycycline. He was discharged on hospital day 13 with full recovery. Leptospirosis is associated with exposure to water, soil, or other matter contaminated with urine of carrier animals. It has been associated with a multitude of activities over time; most recently recreational water-based activities including 'mud-runs' in endemic areas have been added to the list of routes of exposure. This case underscores the importance of obtaining a thorough epidemiological exposure and travel history and being aware of areas of endemicity for life-threatening infections. Additionally, to our knowledge this is the second case of a patient in the United States treated with ECMO for leptospirosis induced pulmonary hemorrhage.

Pulmonary complications of influenza infection: a targeted narrative review

Severe influenza infection represents a leading cause of global morbidity and mortality. Several clinical syndromes that involve a number of organs may be associated with Influenza infection. However, lower respiratory complications remain the most common and serious sequel of influenza infection. These include influenza pneumonia, superinfection with bacteria and fungi, exacerbation of underlying lung disease and ARDS. This review analyzes the available literature on the epidemiology and clinical considerations of these conditions. It also provides an overview of the effects of type of influenza, antiviral therapy, vaccination and other therapies on the outcome of these complications.

Hemoptysis in the Immunocompromised Patient: Do Not Forget Strongyloidiasis

Strongyloidiasis, due to infection with the nematode Strongyloides stercoralis, affects millions of people in the tropics and subtropics. Strongyloides has a unique auto-infective lifecycle such that it can persist in the human host for decades. In immunosuppressed patients, especially those on corticosteroids, potentially fatal disseminated strongyloidiasis can occur, often with concurrent secondary infections. Herein, we present two immunocompromised patients with severe strongyloidiasis who presented with pneumonia, hemoptysis, and sepsis. Both patients were immigrants from developing countries and had received prolonged courses of corticosteroids prior to admission. Patient 1 also presented with a diffuse abdominal rash; a skin biopsy showed multiple intradermal Strongyloides larvae. Patient 1 had concurrent pneumonic nocardiosis and bacteremia with Klebsiella pneumoniae and Enterococcus faecalis. Patient 2 had concurrent Aspergillus and Candida pneumonia and developed an Aerococcus meningitis. Both patients had negative serologic tests for Strongyloides; patient 2 manifested intermittent eosinophilia. In both patients, the diagnosis was afforded by bronchoscopy with lavage. The patients were successfully treated with broad-spectrum antibiotics and ivermectin. Patient 1 also received albendazole. Strongyloidiasis should be considered in the differential diagnosis of hemoptysis in immunocompromised patients with possible prior exposure to S. stercoralis.

Platelets inhibit apoptotic lung epithelial cell death and protect mice against infection-induced lung injury

Thrombocytopenia is associated with worse outcomes in patients with acute respiratory distress syndrome, which is most commonly caused by infection and marked by alveolar-capillary barrier disruption. However, the mechanisms by which platelets protect the lung alveolar-capillary barrier during infectious injury remain unclear. We found that natively thrombocytopenic Mpl ^-/- mice deficient in the thrombopoietin receptor sustain severe lung injury marked by alveolar barrier disruption and hemorrhagic pneumonia with early mortality following acute intrapulmonary Pseudomonas aeruginosa (PA) infection; barrier disruption was attenuated by platelet reconstitution. Although PA infection was associated with a brisk neutrophil influx, depletion of airspace neutrophils failed to substantially mitigate PA-triggered alveolar barrier disruption in Mpl ^-/- mice. Rather, PA cell-free supernatant was sufficient to induce lung epithelial cell apoptosis in vitro and in vivo and alveolar barrier disruption in both platelet-depleted mice and Mpl ^-/- mice in vivo. Cell-free supernatant from PA with genetic deletion of the type 2 secretion system, but not the type 3 secretion system, mitigated lung epithelial cell death in vitro and lung injury in Mpl ^-/- mice. Moreover, platelet releasates reduced poly (ADP ribose) polymerase cleavage and lung injury in Mpl ^-/- mice, and boiling of platelet releasates, but not apyrase treatment, abrogated PA supernatant-induced lung epithelial cell cytotoxicity in vitro. These findings indicate that while neutrophil airspace influx does not potentiate infectious lung injury in the thrombocytopenic host, platelets and their factors protect against severe pulmonary complications from pathogen-secreted virulence factors that promote host cell death even in the absence of overt infection.

Niemann-Pick disease type B: HRCT assessment of pulmonary involvement

OBJECTIVE

To analyze HRCT findings in patients with Niemann-Pick disease (NPD) type B, in order to determine the frequency of HRCT patterns and their distribution in the lung parenchyma, as well as the most common clinical characteristics.

METHODS

We studied 13 patients (3 males and 10 females) aged 5 to 56 years. HRCT images were independently evaluated by two observers, and disagreements were resolved by consensus. The inclusion criteria were presence of abnormal HRCT findings and diagnosis of NPD type B confirmed by histopathological examination of a bone marrow, lung, or liver biopsy specimen.

RESULTS

The most common clinical findings were hepatosplenomegaly and mild to moderate dyspnea. The most common HRCT patterns were smooth interlobular septal thickening and ground-glass opacities, which were both present in all patients. Intralobular lines were present in 12 patients (92.3%). A crazy-paving pattern was observed in 5 patients (38.4%), and areas of air trapping were identified in only 1 case (7.6%). Pulmonary involvement was bilateral in all cases, with the most affected area being the lower lung zone.

CONCLUSIONS

Smooth interlobular septal thickening, with or without associated ground-glass opacities, in patients with hepatosplenomegaly is the most common finding in NPD type B.

Pulmonary Hemorrhaging as a Fatal Complication of IgA Vasculitis

A 64-year-old man was admitted to our hospital for purpuric rash, joint pain, and a fever. He had earlier undergone a follow-up examination for interstitial lung disease. At the current visit, the diagnosis was immunoglobulin A (IgA) vasculitis, based on skin and renal biopsy findings. He developed sudden breathlessness and hemoptysis. Chest computed tomography revealed ground glass opacity in the right lower lung fields, suggesting pulmonary hemorrhaging associated with IgA vasculitis. Despite steroid and cyclophosphamide therapy, and plasma exchange, he died 52 days after admission. Early aggressive therapies may be recommended for old patients with IgA vasculitis who have an additional comorbidities.

Is it just an infection?

A 75-year-old man (body mass index 24.49 kg·m⁻²) presents to the emergency department with fever, myalgia and dyspnoea, which he has had for the last 4 days. He quit smoking 15 years ago (40 pack-years). His only medical history is hypertension treated with valsartan and amlodipine. He travelled recently and stayed in a motel. On admission, his temperature is 38.7°C, blood pressure 132/67 mmHg, heart rate 102 beats per min and respiratory rate 24 breaths per min. Arterial blood gases (ABG) analysis shows severe hypoxaemia with arterial oxygen tension (P_aO2) 47.1 mmHg (6.3 kPa), arterial carbon dioxide tension (P_aCO2) 40.9 mmHg (5.5 kPa), pH 7.464, HCO₃⁻ 28.4 mmol·L⁻¹ and arterial oxygen saturation (S_aO2) 84.2% while breathing room air. Laboratory tests show anaemia (haemoglobin 10.7 g·dL⁻¹), elevated white blood cells (11 420 per μL; 92.0% neutrophils and 4.6% lymphocytes), elevated C-reactive protein (19.97 mg·dL⁻¹) and hyponatraemia with serum Na⁺ 127 mmol·L⁻¹. The rest of laboratory tests are normal. Chest radiograph showa infiltrates in both lungs. Antibiotic therapy with intravenous ampicillin/sulbactam 3 g per 6 h and antiviral therapy with oral oseltamivir 75 mg per 12 h are initiated.

Is it just an infection or something more?http://ow.ly/HEcH30lSO6a