1
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Ba-Shammakh SA, Al-Zughali EA, Kalaji ZH, Al-Bourah AM, Al-Shami NA. Clinical Dilemmas in Immune Thrombocytopenic Purpura With Diffuse Alveolar Hemorrhage: Diagnosis, Treatment, and Outcomes. Cureus 2023; 15:e47300. [PMID: 38021484 PMCID: PMC10656495 DOI: 10.7759/cureus.47300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
This report elucidates a unique case of a 39-year-old female with immune thrombocytopenic purpura (ITP) who developed a rare and severe complication: diffuse alveolar hemorrhage (DAH). Despite initial treatments for ITP, the patient experienced fluctuating platelet (PLT) counts and shortness of breath, which were later identified as symptoms of DAH. An urgent splenectomy improved the patient's platelet counts and overall condition. This case underscores the imperative to recognize DAH as a possible ITP complication, requiring clinicians' vigilance for prompt diagnosis and intervention. The intricate nature of ITP in adults necessitates individualized, patient-centered treatment approaches to enhance outcomes. This report provides invaluable insights into the clinical understanding and management of ITP and its complications through detailed analysis and documentation of the patient's treatment journey.
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Affiliation(s)
- Saleh A Ba-Shammakh
- Department of General Surgery, The Islamic Hospital, Amman, JOR
- Department of General Surgery, Princess Rahma Teaching Hospital, Irbid, JOR
| | | | - Zeina H Kalaji
- Faculty of Medicine, The University of Jordan, Amman, JOR
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2
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Orlando PBC, Ines SGC, Eduardo RVG, Fernanda ÁBM. An unusual case of heart failure due to ANCA-negative vasculitis: A case report and focused review of the literature. Clin Case Rep 2023; 11:e7749. [PMID: 37546160 PMCID: PMC10397480 DOI: 10.1002/ccr3.7749] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/09/2023] [Accepted: 07/22/2023] [Indexed: 08/08/2023] Open
Abstract
Key Clinical Message Heart failure due to ANCA-negative vasculitis, is a rare potentially life-threatening manifestation of ANCA vasculitis. Therefore, physicians must always pay attention to this manifestation for proper disease diagnosis and treatment. Abstract Less than 10% of primary vasculitides cause cardiac dysfunction, with Takayasu's arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis being the most common cases. However, any cardiac tissue can be affected by ANCA vasculitis. We present a case of heart failure with reduced ventricular ejection fraction due to ANCA negative-vasculitis.
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Affiliation(s)
| | - Saldarriaga Giraldo Clara Ines
- Department of Cardiology and Heart FailureUniversidad de Antioquía, Universidad Pontificia Bolivariana, Clínica Cardio VIDMedellínColombia
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3
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Boyle N, O'Callaghan M, Ataya A, Gupta N, Keane MP, Murphy DJ, McCarthy C. Pulmonary renal syndrome: a clinical review. Breathe (Sheff) 2022; 18:220208. [PMID: 36865943 PMCID: PMC9973488 DOI: 10.1183/20734735.0208-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023] Open
Abstract
The term "pulmonary renal syndrome" describes a clinical syndrome which is characterised by the presence of both diffuse alveolar haemorrhage and glomerulonephritis. It encompasses a group of diseases with distinctive clinical and radiological manifestations, as well as different pathophysiological processes. The most common diseases implicated are anti-neutrophil cytoplasm antibodies (ANCA)-positive small vessel vasculitis and anti-glomerular basement membrane (anti-GBM) disease. Prompt recognition is required as respiratory failure and end-stage renal failure can rapidly occur. Treatment includes a combination of glucocorticoids, immunosuppression, plasmapheresis and supportive measures. The use of targeted treatments has significantly reduced mortality. Thus, an understanding of pulmonary renal syndrome is essential for the respiratory physician.
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Affiliation(s)
- Niamh Boyle
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Marissa O'Callaghan
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Michael P. Keane
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - David J. Murphy
- School of Medicine, University College Dublin, Dublin, Ireland,Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Cormac McCarthy
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland,Corresponding author: Cormac McCarthy ()
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4
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Ogoshi T, Fukunaga M, Suzuki Y, Taura Y, Yatera K. Percutaneous Left Atrial Appendage Closure in a Patient with Diffuse Alveolar Hemorrhaging Associated with Anticoagulant Therapy and Atrial Fibrillation. Intern Med 2022; 61:2045-2050. [PMID: 34840230 PMCID: PMC9334249 DOI: 10.2169/internalmedicine.8551-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Diffuse alveolar hemorrhaging (DAH) due to oral anticoagulation (OAC) is a life-threatening condition that leads to severe respiratory failure. There is a clinical dilemma in that OAC-induced DAH often forces the discontinuation of OAC therapy and the administration of high-dose corticosteroids, which increases the risk of stroke and cardiovascular events. We herein report the first case of OAC-induced DAH and atrial fibrillation (AF) in a patient who completely discontinued OAC therapy and high-dose corticosteroids after experiencing percutaneous left atrial appendage (LAA) occlusion. This case suggests that percutaneous LAA closure may aid in the management of OAC-induced DAH and AF.
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Affiliation(s)
- Takaaki Ogoshi
- Department of Respiratory, Kokura Memorial Hospital, Japan
| | - Masato Fukunaga
- Department of Cardiovascular Medicine, Kokura Memorial Hospital, Japan
| | - Yu Suzuki
- Department of Respiratory, Kokura Memorial Hospital, Japan
| | - Yusuke Taura
- Department of Respiratory, Kokura Memorial Hospital, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan
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5
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Seth I, Bhagavata Srinivasan SP, Bulloch G, Yi DS, Frankel A, Hsu K, Passam F, Garsia R, Corte TJ. Diffuse alveolar haemorrhage as a rare complication of antiphospholipid syndrome. Respirol Case Rep 2022; 10:e0948. [PMID: 35414937 PMCID: PMC8980908 DOI: 10.1002/rcr2.948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/01/2022] [Accepted: 03/25/2022] [Indexed: 12/24/2022] Open
Abstract
Diffuse alveolar haemorrhage (DAH) is a rare complication of antiphospholipid syndrome. With a mortality rate of 46%, early diagnosis and management remain an ongoing challenge. Case reports are limited, and management guidelines are not yet definitive. In this case report, we present a 43-year-old male with DAH who required high-dose oral steroids, intravenous methylprednisolone cyclophosphamide and rituximab over 18 months to control life-threatening episodes of pulmonary bleeding.
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Affiliation(s)
- Ishith Seth
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | | | - Gabriella Bulloch
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Dong Seok Yi
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Anthony Frankel
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Kelvin Hsu
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Freda Passam
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Roger Garsia
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Tamera J. Corte
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
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6
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Veno-venous extracorporeal membrane oxygenation (VV-ECMO) for life-threatening isolated pulmonary anti-GBM disease. Respir Med Case Rep 2022; 38:101680. [PMID: 35677578 PMCID: PMC9168115 DOI: 10.1016/j.rmcr.2022.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-glomerular basement membrane disease (anti-GBM disease) associated with renal and lung lesions has a poor prognosis. Diffuse alveolar hemorrhage (DAH) is a complication that worsens anti-GBM disease prognosis. We report a rescue case using veno-venous extracorporeal membrane oxygenation (VV-ECMO) for diffuse alveolar hemorrhage due to isolated pulmonary anti-GBM disease; a rare anti-GBM syndrome. A 30-year-old Japanese female with no past medical history. Presented with acute hypoxemic respiratory failure requiring mechanical ventilation. Progressive deterioration and refractory hypoxemia prompted therapy with VV-ECMO. Serum anti-GBM antibody confirmed the diagnosis of anti-GBM disease. Multi-modal systemic therapy with pulse-dosed methylprednisolone, plasma exchange, and rituximab resulted in significant clinical improvement. VV-ECMO for 10 days was uncomplicated. Renal replacement therapy was not required. The patient was extubated on day 18 and discharged from the hospital after 45 days. VV-ECMO supportive therapy for DAH with refractory respiratory failure was demonstrated to be effective pending definitive diagnostic and therapeutic management in this case of isolated pulmonary anti-GBM disease. •We report a rescue case using VV-ECMO for diffuse alveolar hemorrhage with isolated pulmonary anti-GBM disease. •VV-ECMO can provide life-support bridge therapy until a response to disease control with fundamental specific therapy becomes effective. VV-ECMO with associated required anticoagulation was an effective and safe life-support therapy in the setting of DAH.
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7
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Tret’yakov AY, Radenska-Lopovok SG, Novikov PI, Tret’yakova VA, Zakharchenko SP. Pulmonary embolism and diffuse alveolar bleeding: combination options and therapy features. TERAPEVT ARKH 2021; 93:311-319. [DOI: 10.26442/00403660.2021.03.200657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
The analysis of the mechanisms of the formation of a rare clinical combination of pulmonary embolism (PE) and diffuse alveolar hemorrhage (DAH), which are complications of systemic vasculitis associated with antibodies to the cytoplasm of neutrophils (primarily granulomatosis with polyangiitis), systemic lupus erythematosus and secondary antiphlogistic syndrome primary antiphospholipid syndrome and Goodpastures syndrome. Taking into account the chronological sequence of the occurrence of PE and DAH, 3 variants of the onset of these potentially fatal additions to the underlying disease were considered: the anticipatory DAH development of PE, delayed from DAH PE and joint (within 24 hours) formation of PE and DAH. A review of single descriptions of such a combination of complications of granulomatosis with polyangiitis is carried out, criteria are indicated, a working classification of severity is given and, taking this into account, a modern program of therapy for DAH as an independent event and in combination with PE.
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8
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Reddy HG, Maynes EJ, Saxena A, Austin MA, O'Malley TJ, Gadda MN, Al-Rawas NN, Baram M, Awsare BK, Massey HT, Tchantchaleishvili V. Utilization of extracorporeal life support for diffuse alveolar damage and diffuse alveolar hemorrhage: A systematic review. Artif Organs 2021; 45:559-568. [PMID: 33190331 DOI: 10.1111/aor.13861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/08/2020] [Accepted: 11/08/2020] [Indexed: 11/30/2022]
Abstract
Modern extracorporeal life-support (ECLS) technology has been successfully utilized to treat patients with diffuse alveolar damage (DAD) and diffuse alveolar hemorrhage (DAH); however, reports in the literature remain scarce. We sought to pool existing evidence to better characterize ECLS use in these patients. An electronic search was conducted to identify all studies in the English literature reporting the use of ECLS for DAD/DAH. Thirty-two articles consisting of 38 patients were selected, and patient-level data were extracted and pooled for analysis. Median patient age was 36 [IQR: 27, 48] years, and the majority (63.2%) were female. Most common etiological factors included granulomatosis with polyangiitis (8/38, 21.1%), systemic lupus erythematosus (8/38, 21.1%), Goodpasture's syndrome (4/38, 10.5%), and microscopic polyangiitis (4/38, 10.5%). Immunologic markers included anti-neutrophil cytoplasmic antibody (ANCA) in 15/38 (39.5%), anti-nuclear antibody (ANA) in 6/38 (15.8%), and anti-glomerular basement membrane (anti-GBM) antibodies in 4/38 (10.5%). DAH was present in 32/38 (84.2%) of cases and DAD without evidence of DAH was present in 6/38 (15.8%) of cases. ECLS strategies included extracorporeal membrane oxygenation of veno-venous type (VV-ECMO) in 28/38 (73.7%), veno-arterial type (VA-ECMO) in 5/38 (13.2%), and one case of right ventricular assist device with oxygenator (RVAD-ECMO). Heparin was utilized in 18/38 (47.4%) of cases with no difference in use between DAH versus no DAH (P = .46) or VA- versus VV-ECLS (P = 1). Median duration of ECLS was 10 [5, 14] days. Pre- versus post-ECLS comparison of blood gases showed improvement in median PaO2 (49 [45, 59] mm Hg vs. 80 [70, 99] mm Hg, P < .001), PaO2:FiO2 ratio (48.2 [41.4, 54.8] vs. 182.0 [149.4, 212.2], P < .01), and pulse oximetry values (76% [72, 80] vs. 96% [94, 97], P = .086). Overall, 94.7% (36/38) of patients survived to decannulation while 30-day mortality was 10.5% (4/38) with no differences between VA- and VV-ECMO (P = 1 and P = .94, respectively). DAD/DAH occurs in a younger, predominantly female population, and tends to be associated with systemic autoimmune processes. ECLS, independent of its type, appears to result in favorable short-term survival.
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Affiliation(s)
- Haritha G Reddy
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Melissa A Austin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc N Gadda
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nawar N Al-Rawas
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Baram
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bharat K Awsare
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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9
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Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:E793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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10
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Xie J, Zhao YY, Liu J, Nong GM. Diffuse alveolar hemorrhage with histopathologic manifestations of pulmonary capillaritis: Three case reports. World J Clin Cases 2020; 8:2662-2666. [PMID: 32607347 PMCID: PMC7322415 DOI: 10.12998/wjcc.v8.i12.2662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a multicause pulmonary capillary hemorrhage or pulmonary vascular small vessel injury (mainly capillaries, including arteries and veins), causing pulmonary microcirculation blood to accumulate in the alveolar space. DAH is classified by the histological absence or presence of pulmonary capillaritis (PC) and is rarely reported in the literature.
CASE SUMMARY This is a report of three girls aged 6-11 years with DAH and PC. Two patients had decreased hemoglobin and one had increased erythrocyte sedimentation rate. High-resolution computed tomography showed bilateral diffuse pulmonary infiltrate, and diagnosis of PC was confirmed by lung biopsy. Immunofluorescence test in one case showed granular IgG and a small amount of granular IgA deposit on the alveolar walls, and was negative in the other two cases, describing isolated pauci-immune PC. Treatment was with glucocorticoid alone or combination with immunosuppressants, and the symptoms resolved in all patients.
CONCLUSION PC is classified as isolated and immune-mediated PC associated with systemic disease. It can be controlled in most children with glucocorticoid alone or combined with immunosuppressants.
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Affiliation(s)
- Jun Xie
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ying-Yue Zhao
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Jing Liu
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guang-Min Nong
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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11
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Jiang C, Martinez Pena GN, Xie M, Gafoor K. Rapidly progressive course of pauci-immune pulmonary capillaritis in a 70-year-old Asian male refractory to immunosuppression and plasma exchange. BMJ Case Rep 2020; 13:13/3/e233577. [PMID: 32169990 DOI: 10.1136/bcr-2019-233577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 70-year-old man presented with acute respiratory failure, alveolar infiltrates and haemoptysis requiring supplemental oxygen. Flexible bronchoscopy with bronchoalveolar lavage identifies diffuse alveolar haemorrhage. Clinical and serological evaluations do not identify a precise aetiology and histopathology establishes the diagnosis of isolated pauci-immune pulmonary capillaritis. The patient received induction therapy with high dose methylprednisolone at 1000 mg/day for 5 days and weekly rituximab at 375 mg/m2 scheduled over 4 weeks. Although the patient demonstrated clinical improvement after the first week, he experienced a rapid relapse requiring mechanical ventilation. His induction rituximab regimen was continued and plasma exchange was initiated. Despite these therapies, the patient's condition deteriorated and passed away. Our case adds insight to the management of this rare entity and describes the use of plasma exchange as salvage therapy.
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Affiliation(s)
- Chuan Jiang
- Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, New York, USA
| | | | - Meng Xie
- Medicine - Clinical Research, Jamaica Hospital Medical Center, Jamaica, New York, USA
| | - Khalid Gafoor
- Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, New York, USA
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12
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Tauseef A, Asghar MS, Amir M, Zafar M, Anum A, Alvi H, Dawood M, Rasheed U, Akram M, Ahmed N. Microscopic polyangiitis: an incidental finding in a patient with stroke. J Community Hosp Intern Med Perspect 2020; 10:50-54. [PMID: 32128059 PMCID: PMC7034484 DOI: 10.1080/20009666.2020.1718479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/30/2019] [Indexed: 10/31/2022] Open
Abstract
Microscopic polyangiitis (MPA) is a primary systemic vasculitis characterized by inflammation
of small-sized vessels associated with the presence of anti-neutrophilic cytoplasmic
antibodies. We report a case of a 39-year-old female diagnosed with microscopic polyangiitis as
an incidental finding who presented with signs and symptoms of a stroke at a young age.
Usually, it presents with fever, malaise, skin rash, weight loss, mononeuritis multiplex, and
arthralgia/myalgia. Very rarely, it can involve meninges to cause meningeal vasculitis which
can present as a febrile seizure. The most frequent neurological manifestation is peripheral
neuropathy. Cerebral infarction or hemorrhage as an isolated finding is very rarely observed in
the patient with MPA as was seen in our patient.
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Affiliation(s)
- Abubakar Tauseef
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | | | - Mariam Amir
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Maryam Zafar
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Ayesha Anum
- Internal Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Haris Alvi
- Medicine, Dow University Hospital, DUHS, Karachi, Pakistan
| | - Mustafa Dawood
- Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Mohammed Akram
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Nisar Ahmed
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, Pakistan
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13
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Bucchino L, Monzani A, Fracon S, Genoni G, Cena T, Bellone S. Cannabis-Related Diffuse Alveolar Hemorrhage in a 16-Year-Old Patient: A Case Report. Front Pediatr 2019; 7:468. [PMID: 31799223 PMCID: PMC6867963 DOI: 10.3389/fped.2019.00468] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/28/2019] [Indexed: 12/28/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a clinical condition characterized by the rapid onset of dyspnea, hemoptysis and acute respiratory failure (ARF). It is commonly caused by autoimmune systemic vasculitis, pulmonary infections, drugs and tumors. Here, we report a case of DAH caused by frequent cannabis smoking. A 16-year old boy presented with hemoptysis, dyspnea and ARF soon after laparoscopic surgery for varicocele in general anesthesia. The suspected diagnosis of DAH emerged from the initial chest radiography, and it was then confirmed by CT scan findings and the bronchoalveolar lavage. His general conditions completely recovered after only 24 h of oxygen supplementation and after intravenous corticosteroid and antibiotic therapy. This is the first pediatric case of DAH related to smoking marijuana, even though the inhalational anesthetic agent sevoflurane might have also been involved in this pathogenesis. Other possible causes of DAH have been considered. Negative-pressure pulmonary edema could be ruled out because no clinical evidence of upper airway obstruction was observed during general anesthesia and throughout the surgery. In addition, a possible causative role of cannabis additives/contaminants could not be excluded. Given the high prevalence of cannabis smoking in young people and that DAH can be a complication in cannabis smokers, a careful history and high index of suspicion are recommended as part of the pre-operative assessment before these patients are proceeded to receive general anesthesia.
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Affiliation(s)
- Laura Bucchino
- Pediatric Unit, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Alice Monzani
- Pediatric Unit, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Sara Fracon
- Anesthesiology and Intensive Care Unit, Accident and Emergency Department, University of Eastern Piedmont, Novara, Italy
| | - Giulia Genoni
- Neonatal and Pediatric Intensive Care Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Tiziana Cena
- Anesthesiology and Intensive Care Unit, Accident and Emergency Department, University of Eastern Piedmont, Novara, Italy
| | - Simonetta Bellone
- Pediatric Unit, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
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14
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Jarrot PA, Tellier E, Plantureux L, Crescence L, Robert S, Chareyre C, Daniel L, Secq V, Garcia S, Dignat-George F, Panicot-Dubois L, Dubois C, Kaplanski G. Neutrophil extracellular traps are associated with the pathogenesis of diffuse alveolar hemorrhage in murine lupus. J Autoimmun 2019; 100:120-130. [PMID: 30930069 DOI: 10.1016/j.jaut.2019.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/30/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE) and systemic vasculitis. Although initially described to have antibacterial properties, increasing evidence suggests that neutrophil extracellular traps (NETs) have a detrimental role in both autoimmune diseases and acute lung injury. We investigated whether NETs could be detected in a murine model of pristane-induced lupus DAH and contribute to lung injury. Such NETs might constitute a therapeutic target. NETs were characterized by immunofluorescence staining of DNA, neutrophil elastase and citrullinated histones. Evaluation of lung injury was performed by haematoxylin-eosin staining and a quantification program. Clinical status of the mice was assessed by measurement of arterial oxygen saturation and survival curves after recombinant human deoxyribonuclease-1 (Rh-DNase-1) inhalations or polymorphonuclear neutrophil (PMN) depletion. Pristane was found to promote NETs formation in vitro and in vivo. Treatment of mice with Rh-DNase-1 inhalations cleared NETs and reduced lung injury. Clinical status improved significantly, with increased arterial oxygenation and survival. Following PMN depletion, NETs were absent with a subsequent reduction of lung injury and improved arterial oxygenation. These results support a pathogenic role of PMNs and NETs in lung injury during pristane-induced DAH. Targeting NETs with Rh-DNase-1 inhalations could constitute an interesting adjuvant therapy in human DAH.
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Affiliation(s)
- Pierre-André Jarrot
- Aix-Marseille Univ, INSERM, INRA, C2VN, Marseille, France; Department of Internal Medicine and Clinical Immunology CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France.
| | - Edwige Tellier
- Aix-Marseille Univ, INSERM, INRA, C2VN, Marseille, France
| | - Lea Plantureux
- Aix-Marseille Univ, INSERM, INRA, C2VN, Marseille, France
| | | | | | | | - Laurent Daniel
- Laboratory of Pathology, CHU La Timone, AP-HM, Marseille, France
| | - Véronique Secq
- Laboratory of Pathology, CHU Nord, AP-HM, Marseille, France
| | | | - Françoise Dignat-George
- Aix-Marseille Univ, INSERM, INRA, C2VN, Marseille, France; Laboratory of Haematology, CHU La Conception, AP-HM, Marseille, France
| | | | | | - Gilles Kaplanski
- Aix-Marseille Univ, INSERM, INRA, C2VN, Marseille, France; Department of Internal Medicine and Clinical Immunology CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
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15
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Galvagno SM, Shah NG, Cornachione CR, Deatrick KB, Mazzeffi MA, Menaker J. Long term veno-venous extracorporeal life support without intravenous anticoagulation for diffuse alveolar hemorrhage. Perfusion 2019; 34:523-525. [PMID: 30744494 DOI: 10.1177/0267659119826828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Diffuse alveolar damage is the histologic hallmark for the acute phase of acute respiratory distress syndrome and can occasionally present as diffuse alveolar hemorrhage. CASE REPORT We report a patient with diffuse alveolar hemorrhage and acute respiratory distress syndrome requiring veno-venous extracorporeal life support for 210 days, who was successfully treated for a period of 130 consecutive days without intravenous anticoagulation. DISCUSSION Although there are a few brief reports detailing long extracorporeal life support runs, the literature is largely devoid of data regarding long-term extracorporeal life support without full systemic anticoagulation. Regular inspection of the extracorporeal membrane oxygenation circuit is critical because externally visible thrombi may predict internal thrombus generation with the potential for systemic embolization or abrupt oxygenator failure. In our case, multiple circuit and oxygenators changes were required. CONCLUSION We have demonstrated that a patient with a contraindication for systemic anticoagulation can safely have veno-venous extracorporeal life support for prolonged periods without catastrophic thrombotic complications.
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Affiliation(s)
- Samuel M Galvagno
- University of Maryland School of Medicine, Baltimore, MD, USA.,Program in Trauma and Department of Anesthesiology, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nirav G Shah
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jay Menaker
- University of Maryland School of Medicine, Baltimore, MD, USA.,Program in Trauma, Critical Care Resuscitation Unit and Lung Rescue Unit, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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16
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Han SW, Park MJ, Lee SH. Hyaluronic acid-induced diffuse alveolar hemorrhage: unknown complication induced by a well-known injectable agent. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:13. [PMID: 30788360 DOI: 10.21037/atm.2018.11.51] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hyaluronic acid (HA) is widely used in medicine, especially for contouring or volumizing soft tissue and intra-articular injection. However, it is not well known that HA injection can cause life-threatening pulmonary complications. We recently experienced a case of a woman who was diagnosed with diffuse alveolar hemorrhage (DAH) after receiving an illegal vaginal HA filler injection. A 54-year-old female visited our clinic complaining of hemoptysis and dyspnea. Chest computed tomographic (CT) scan showed diffuse ground glass opacities and consolidation in both lower lobes. Bronchoalveolar lavage (BAL) disclosed hemorrhagic feature in sequential samples compatible with DAH. There were no relevant drugs or past medical histories, and no positive result in autoantibodies tests. During detailed history taking, she recalled that she got an illegal HA filler injection in her vaginal wall performed by nonmedical personnel the very day before the onset of symptoms. Although the procedure itself or an additive of HA preparation could be a cause, HA that might have been introduced into circulation was thought to be the most possible cause for the development of DAH. The clinical symptoms and lung lesions were dramatically improved after the treatment with systemic steroid. Pulmonary complications after HA injections were scarcely reported. Only one case of HA-related DAH has been previously described so far. Our present case emphasizes that physician and other health care providers must be aware of possible pulmonary complications of this most widely-using injectable agent.
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Affiliation(s)
- Seoung Woo Han
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Myung Jae Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Seung Hyeun Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
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17
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Alba MA, Jennette JC, Falk RJ. Pathogenesis of ANCA-Associated Pulmonary Vasculitis. Semin Respir Crit Care Med 2018; 39:413-424. [PMID: 30404109 DOI: 10.1055/s-0038-1673386] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antineutrophil cytoplasmic antibodies (ANCAs) are autoantibodies specific for antigens located in the cytoplasmic granules of neutrophils and lysosomes of monocytes. ANCAs are associated with a spectrum of necrotizing vasculitis that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Pulmonary vasculitis and related extravascular inflammation and fibrosis are frequent components of ANCA vasculitis. In this review, we detail the factors that have been associated with the origin of the ANCA autoimmune response and summarize the most relevant clinical observations, in vitro evidence, and animal studies strongly indicating the pathogenic potential of ANCA. In addition, we describe the putative sequence of pathogenic mechanisms driven by ANCA-induced activation of neutrophils that result in small vessel necrotizing vasculitis and extravascular granulomatous necrotizing inflammation.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- University of North Carolina Kidney Center, Chapel Hill, North Carolina.,UNC Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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18
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Systemic Lupus Erythematosus–associated Diffuse Alveolar Hemorrhage: A Case Report and Review of the Literature. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/cpm.0000000000000271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Batra K, Chamarthy M, Chate RC, Jordan K, Kay FU. Pulmonary vasculitis: diagnosis and endovascular therapy. Cardiovasc Diagn Ther 2018; 8:297-315. [PMID: 30057877 DOI: 10.21037/cdt.2017.12.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.
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Affiliation(s)
- Kiran Batra
- UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Rodrigo Caruso Chate
- Hospital Israelita Albert Einstein and Instituto to Coração HCFMUSP, Sao Paulo, Brazil
| | - Kirk Jordan
- UT Southwestern Medical Center, Dallas, TX, USA
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20
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Lee EKS, Gillrie MR, Li L, Arnason JW, Kim JH, Babes L, Lou Y, Sanati-Nezhad A, Kyei SK, Kelly MM, Mody CH, Ho M, Yipp BG. Leukotriene B4-Mediated Neutrophil Recruitment Causes Pulmonary Capillaritis during Lethal Fungal Sepsis. Cell Host Microbe 2017; 23:121-133.e4. [PMID: 29290576 DOI: 10.1016/j.chom.2017.11.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/12/2017] [Accepted: 11/27/2017] [Indexed: 11/24/2022]
Abstract
Candida albicans bloodstream infection causes fungal septicaemia and death in over half of afflicted patients. Polymorphonuclear leukocytes (PMN) mediate defense against invasive candidiasis, but their role in protection versus tissue injury and sepsis is unclear. We observe PMN intravascular swarming and subsequent clustering in response to C. albicans yeast in a lethal septic mouse and human pulmonary circulation model. Live C. albicans sequester to the endothelium and are immediately captured by complement-dependent PMN chemotaxis, which is required for host survival. However, complement activation also leads to Leukotriene B4 (LTB4)-mediated intravascular PMN clustering and occlusion, resulting in capillaritis with pulmonary hemorrhage and hypoxemia. This clustering is unique to fungi and triggered by fungal cell wall components. PMN clustering is absent in mice lacking LTB4-receptor, and capillaritis is attenuated upon pharmacological LTB4 blockade without affecting phagocytosis. Therefore, therapeutically disrupting infection-induced capillaritis may limit organ injury without impairing host defense during fungal sepsis.
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Affiliation(s)
- Esther K S Lee
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark R Gillrie
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Medicine, Division of Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lu Li
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason W Arnason
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jung Hwan Kim
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Liane Babes
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yuefei Lou
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amir Sanati-Nezhad
- Department of Mechanical and Manufacturing Engineering, BioMEMS and Bioinspired Microfluidic Laboratory, Center for BioEngineering Research and Education, University of Calgary, Calgary, AB, Canada
| | - Stephen K Kyei
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Margaret M Kelly
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher H Mody
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - May Ho
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryan G Yipp
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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21
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Zhuang H, Han S, Lee PY, Khaybullin R, Shumyak S, Lu L, Chatha A, Afaneh A, Zhang Y, Xie C, Nacionales D, Moldawer L, Qi X, Yang LJ, Reeves WH. Pathogenesis of Diffuse Alveolar Hemorrhage in Murine Lupus. Arthritis Rheumatol 2017; 69:1280-1293. [PMID: 28217966 DOI: 10.1002/art.40077] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 02/14/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) in lupus patients confers >50% mortality, and the cause is unknown. We undertook this study to examine the pathogenesis of DAH in C57BL/6 mice with pristane-induced lupus, a model of human lupus-associated DAH. METHODS Clinical/pathologic and immunologic manifestations of DAH in pristane-induced lupus were compared with those of DAH in humans. Tissue distribution of pristane was examined by mass spectrometry. Cell types responsible for disease were determined by in vivo depletion using clodronate liposomes and antineutrophil monoclonal antibodies (anti-Ly-6G). The effect of complement depletion with cobra venom factor (CVF) was examined. RESULTS After intraperitoneal injection, pristane migrated to the lung, causing cell death, small vessel vasculitis, and alveolar hemorrhage similar to that seen in DAH in humans. B cell-deficient mice were resistant to induction of DAH, but susceptibility was restored by infusing IgM. C3-/- and CD18-/- mice were also resistant, and DAH was prevented in wild-type mice by CVF. Induction of DAH was independent of Toll-like receptors, inflammasomes, and inducible nitric oxide. Mortality was increased in interleukin-10 (IL-10)-deficient mice, and pristane treatment decreased IL-10 receptor expression in monocytes and STAT-3 phosphorylation in lung macrophages. In vivo neutrophil depletion was not protective, while treatment with clodronate liposomes prevented DAH, which suggests that macrophage activation is central to DAH pathogenesis. CONCLUSION The pathogenesis of DAH involves opsonization of dead cells by natural IgM and complement followed by complement receptor-mediated lung inflammation. The disease is macrophage dependent, and IL-10 is protective. Complement inhibition and/or macrophage-targeted therapies may reduce mortality in lupus-associated DAH.
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Affiliation(s)
| | | | - Pui Y Lee
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Li Lu
- University of Florida, Gainesville
| | | | | | | | - Chao Xie
- University of Florida, Gainesville
| | | | | | - Xin Qi
- University of Florida, Gainesville
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22
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Onuk T, İpek G, Karataş MB, Hacı R, Çam N. Diffuse Alveolar Hemorrhage after Clopidogrel Use. Balkan Med J 2016; 33:719-720. [PMID: 27994935 DOI: 10.5152/balkanmedj.2016.151545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 04/22/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tolga Onuk
- Department of Cardiology, Dr. Siyami Ersek Cardiothoracic and Vascular Surgery Center, İstanbul, Turkey
| | - Göktürk İpek
- Department of Cardiology, Dr. Siyami Ersek Cardiothoracic and Vascular Surgery Center, İstanbul, Turkey
| | - Mehmet Baran Karataş
- Department of Cardiology, Dr. Siyami Ersek Cardiothoracic and Vascular Surgery Center, İstanbul, Turkey
| | - Recep Hacı
- Department of Cardiology, Dr. Siyami Ersek Cardiothoracic and Vascular Surgery Center, İstanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, Dr. Siyami Ersek Cardiothoracic and Vascular Surgery Center, İstanbul, Turkey
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23
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Hughes KT, Beasley MB. Pulmonary Manifestations of Acute Lung Injury: More Than Just Diffuse Alveolar Damage. Arch Pathol Lab Med 2016; 141:916-922. [PMID: 27652982 DOI: 10.5858/arpa.2016-0342-ra] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Acute pulmonary injury may occur as a result of myriad direct or indirect pulmonary insults, often resulting in hypoxemic respiratory failure and clinical acute respiratory distress syndrome. Histologically, most patients will exhibit diffuse alveolar damage on biopsy, but other histologic patterns may be encountered, such as acute eosinophilic pneumonia, acute fibrinous and organizing pneumonia, and diffuse alveolar hemorrhage with capillaritis. OBJECTIVE - To review the diagnostic features of various histologic patterns associated with a clinical picture of acute lung injury, and to discuss key features in the differential diagnosis. DATA SOURCES - The review is drawn from pertinent peer-reviewed literature and the personal experience of the authors. CONCLUSIONS - Acute pulmonary injury is a significant cause of morbidity and mortality. In addition to diffuse alveolar damage, pathologists should be aware of alternate histologic patterns of lung disease that may present with a similar clinical presentation because this may impact treatment decisions and disease outcome.
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Affiliation(s)
| | - Mary Beth Beasley
- From the Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
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24
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Mahmoud S, Ghosh S, Farver C, Lempel J, Azok J, Renapurkar RD. Pulmonary Vasculitis: Spectrum of Imaging Appearances. Radiol Clin North Am 2016; 54:1097-1118. [PMID: 27719978 DOI: 10.1016/j.rcl.2016.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pulmonary vasculitis is a relatively uncommon disorder, usually manifesting as part of systemic vasculitis. Imaging, specifically computed tomography, is often performed in the initial diagnostic workup. Although the findings in vasculitis can be nonspecific, they can provide important clues in the diagnosis, and guide the clinical team toward the right diagnosis. Radiologists must have knowledge of common and uncommon imaging findings in various vasculitides. Also, radiologists should be able to integrate the clinical presentation and laboratory test findings together with imaging features, so as to provide a meaningful differential diagnosis.
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Affiliation(s)
- Shamseldeen Mahmoud
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Subha Ghosh
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Carol Farver
- Department of Pathology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jason Lempel
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Joseph Azok
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rahul D Renapurkar
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Section of Cardiovascular Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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25
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Taniguchi H, Kondoh Y. Acute and subacute idiopathic interstitial pneumonias. Respirology 2016; 21:810-20. [PMID: 27123874 DOI: 10.1111/resp.12786] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
Idiopathic interstitial pneumonias (IIPs) may have an acute or subacute presentation, or acute exacerbation may occur in a previously subclinical or unrecognized chronic IIP. Acute or subacute IIPs include acute interstitial pneumonia (AIP), cryptogenic organizing pneumonia (COP), nonspecific interstitial pneumonia (NSIP), acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) and AE-NSIP. Interstitial lung diseases (ILDs) including connective tissue disease (CTD) associated ILD, hypersensitivity pneumonitis, acute eosinophilic pneumonia, drug-induced lung disease and diffuse alveolar haemorrhage need to be differentiated from acute and subacute IIPs. Despite the severe lack of randomized controlled trials for the treatment of acute and subacute IIPs, the mainstream treatment remains corticosteroid therapy. Other potential therapies reported in the literature include corticosteroids and immunosuppression, antibiotics, anticoagulants, neutrophil elastase inhibitor, autoantibody-targeted treatment, antifibrotics and hemoperfusion therapy. With regard to mechanical ventilation, patients in recent studies with acute and subacute IIPs have shown better survival than those in previous studies. Therefore, a careful value-laden decision about the indications for endotracheal intubation should be made for each patient. Noninvasive ventilation may be beneficial to reduce ventilator associated pneumonia.
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Affiliation(s)
- Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
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26
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Thompson G, Klecka M, Roden AC, Specks U, Cartin-Ceba R. Biopsy-proven pulmonary capillaritis: A retrospective study of aetiologies including an in-depth look at isolated pulmonary capillaritis. Respirology 2016; 21:734-8. [DOI: 10.1111/resp.12738] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Gwen Thompson
- Department of Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Mary Klecka
- Department of Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Anja C. Roden
- Division of Anatomic Pathology; Mayo Clinic; Rochester Minnesota USA
| | - Ulrich Specks
- Department of Medicine; Mayo Clinic; Rochester Minnesota USA
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Rodrigo Cartin-Ceba
- Department of Medicine; Mayo Clinic; Rochester Minnesota USA
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic; Rochester Minnesota USA
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27
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Hashmi HRT, Venkatram S, Diaz-Fuentes G. A Case Report of an Elderly Woman With Thrombocytopenia and Bilateral Lung Infiltrates: A Rare Association Between Diffuse Alveolar Hemorrhage and Idiopathic Thrombocytopenic Purpura. Medicine (Baltimore) 2015; 94:e2235. [PMID: 26683938 PMCID: PMC5058910 DOI: 10.1097/md.0000000000002235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Etiologies for diffuse alveolar hemorrhage are wide and range from infectious to vasculitis and malignant processes. Idiopathic thrombocytopenic purpura is an autoimmune disorder characterized by persistent thrombocytopenia, with a relatively indolent course in young patients, but a more complicated progression and high associated mortality in the older patients. Diffuse alveolar hemorrhage, complicating idiopathic thrombocytopenic purpura, is a very uncommon association, with only 2 reported cases in the literature. We present a 69-year-old healthy woman presenting with petechial rash, progressive dyspnea, and bilateral alveolar infiltrates. She was found to have idiopathic thrombocytopenic purpura associated with diffuse alveolar hemorrhage. The patient had an excellent response to high doses of pulse steroids and immunoglobulins. A high index of suspicion for noninfectious pulmonary diseases should be considered in patients with autoimmune diseases presenting with pulmonary infiltrates and hypoxia. Flexible bronchoscopy with sequential lavage is a relatively safe procedure in patients with coagulopathy and should be attempted to detect and confirm the diagnosis; absence of hemoptysis should not preclude the diagnosis.
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28
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Microscopic polyangiitis: Advances in diagnostic and therapeutic approaches. Autoimmun Rev 2015; 14:837-44. [PMID: 25992801 DOI: 10.1016/j.autrev.2015.05.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/12/2015] [Indexed: 11/24/2022]
Abstract
Microscopic polyangiitis (MPA) is an idiopathic autoimmune disease characterized by systemic vasculitis. The disease predominantly affects small-calibre blood vessels and is associated with the presence of antineutrophil cytoplasmic autoantibodies (ANCA). Microscopic polyangiitis was considered to be a disease entity by Savage et al. in 1985. Microscopic polyangiitis has a reported low incidence and a slight male predominance. The aetiology of MPA remains unknown. There is, however, increased evidence that MPA is an autoimmune disease in which ANCAs, particularly those reacting with MPO, are pathogenic. MPA belongs to the systemic vasculitides, indicating that multiple organs can be affected. The major organs involved in MPA are the kidneys and the lungs. As expected for an illness that affects multiple organ systems, patients with MPA can present with a myriad of different symptoms. Ear, nose and throat (ENT) manifestations are not considered to be clinical symptoms of MPA, but in the majority of populations described, ENT involvement was found in surprisingly high percentages. MPA is part of the ANCA-associated vasculitides, which are characterized by necrotizing vasculitis of small vessels. Diagnosis is mainly established by clinical manifestations, computed tomography (TC), ANCA antibody detection and renal and pulmonary biopsy. The introduction of aggressive immunosuppressive treatment has substantially improved the prognosis. The standardized therapeutic regimen is based on cyclophosphamide and corticosteroids. Using this regimen, remission can be achieved in most of the patients. Rituximab may represent an important alternative to cyclophosphamide for patients who may not respond adequately to antimetabolite therapies.
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Neubert Z, Hoffmann P, Owshalimpur D. Acute kidney injury with hypoxic respiratory failure. BMJ Case Rep 2014; 2014:bcr-2014-206582. [PMID: 25246473 DOI: 10.1136/bcr-2014-206582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 27-year-old Caucasian man was transferred from a remote clinic with acute kidney injury for the prior 7-10 days preceded by gastroenteritis. His kidney biopsy showed non-specific mesangiopathic glomerular changes, minimal tubulointerstitial disease without sclerosis, crescents, nor evidence of vasculitis. On his third hospital day, he developed acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Pulmonary renal syndromes ranked highest on his differential diagnosis. He was extubated after 2 days of mechanical ventilation and after pulse dose steroids. His lung biopsy showed pulmonary capillaritis. Our case describes a patient with clinically appearing renopulmonary syndrome, but found to have pulmonary capillaritis, a rare form of lung disease that may also cause acute kidney injury.
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Affiliation(s)
- Zachary Neubert
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Paul Hoffmann
- Department of Anesthesia, Walter Reed Army Medical Center, Washington, District of Columbia, USA
| | - David Owshalimpur
- Department of Medicine/Nephrology, Madigan Army Medical Center, Tacoma, Washington, USA
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Disfunción respiratoria crónica por hemorragia alveolar difusa en pacientes con lupus eritematoso sistémico y vasculitis primaria. ACTA ACUST UNITED AC 2013; 9:263-8. [DOI: 10.1016/j.reuma.2013.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 01/16/2013] [Accepted: 01/29/2013] [Indexed: 01/15/2023]
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Flanagan F, Glackin L, Slattery DM. Successful treatment of idiopathic pulmonary capillaritis with intravenous cyclophosphamide. Pediatr Pulmonol 2013; 48:303-5. [PMID: 22573417 DOI: 10.1002/ppul.22583] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 04/04/2012] [Indexed: 01/09/2023]
Abstract
Idiopathic pulmonary hemosiderosis (IPH), a subtype of diffuse alveolar hemorrhage is a rare condition, first described by Virchow in 1864. Historically, it manifests in children in the first decade of life with the combination of hemoptysis, iron deficiency anemia, and alveolar infiltrates on chest radiograph. More recently, diffuse alveolar hemorrhage has been classified by the absence or presence of pulmonary capillaritis (PC), the latter carrying a potential for a poorer outcome. While systemic corticosteroids remain the first line treatment option, other immune modulators have been trailed including hydroxychloroquine, azathioprine, 6-mercaptopurine, and cyclophosphamide with varying results. Our case demonstrates for the first time, the successful use of intravenous cyclophosphamide in the management of chronic idiopathic PC.
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Affiliation(s)
- Frances Flanagan
- Department of Respiratory Medicine, Children's University Hospital, Dublin, Ireland.
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Patel JJ, Lipchik RJ. Systemic lupus-induced diffuse alveolar hemorrhage treated with extracorporeal membrane oxygenation: a case report and review of the literature. J Intensive Care Med 2012; 29:104-9. [PMID: 23753220 DOI: 10.1177/0885066612464335] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We report the case of a 28-year-old patient with systemic lupus erythematosus (SLE) with rapid onset of dyspnea and hemoptysis found to have diffuse alveolar hemorrhage (DAH) with refractory hypoxemia successfully treated with venovenous extracorporeal membrane oxygenation (ECMO). The discussion includes clinical presentation, diagnosis, management, outcome, and a review of the available adult literature on the use of ECMO in patients with DAH. DESIGN Case report. SETTING Froedtert Hospital and the Medical College of Wisconsin. DATA SOURCES Data were collected from the patient's electronic medical record and the hospital radiology database. CONCLUSIONS Diffuse alveolar hemorrhage secondary to SLE is quite rare. The adult literature on the utilization of ECMO for DAH is limited mostly to antineutrophil cytoplasmic antibody (ANCA)-associated alveolar hemorrhage and a few reports of nonvasculitis DAH. Bleeding has been a contraindication to ECMO due to the need for systemic anticoagulation. Our case, along with a review of the literature, indicates that ECMO with anticoagulation can be safely utilized in patients with DAH. To our knowledge, this is the first reported adult case of DAH due to SLE successfully treated with ECMO.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Martín-Suñé N, Ríos-Blanco JJ. Pulmonary affectation of vasculitis. Arch Bronconeumol 2012; 48:410-8. [PMID: 22682604 DOI: 10.1016/j.arbres.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.
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Martinez F, Chung JH, Digumarthy SR, Kanne JP, Abbott GF, Shepard JAO, Mark EJ, Sharma A. Common and Uncommon Manifestations of Wegener Granulomatosis at Chest CT: Radiologic-Pathologic Correlation. Radiographics 2012; 32:51-69. [DOI: 10.1148/rg.321115060] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Buendía-Roldán I, Navarro C, Rojas-Serrano J. [Diffuse alveolar hemorrhage: Causes and outcomes in a referral center]. REUMATOLOGIA CLINICA 2011; 6:196-8. [PMID: 21794712 DOI: 10.1016/j.reuma.2009.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 07/09/2009] [Accepted: 07/09/2009] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Ivette Buendía-Roldán
- Instituto Nacional de Enfermedades Respiratorias Dr. Ismael Cosio Villegas, Facultad de Medicina, Universidad Nacional Autónoma de México, México
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Kim SH, Kim KH, Kim TS, Han SS, Moon KW. A Case of a Patient with Dermatomyositis Who Developed a Diffuse Alveolar Hemorrhage. JOURNAL OF RHEUMATIC DISEASES 2011. [DOI: 10.4078/jrd.2011.18.2.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Se-Hyun Kim
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Kyung-Hyun Kim
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Tae-Suk Kim
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Seon-Sook Han
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Ki-Won Moon
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
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Abstract
In 1923, Friedrich Wohlwill described two patients with a "microscopic form of periarteritis nodosa," which was distinct from the classical form. This disease, now known as microscopic polyangiitis (MPA), is a primary systemic vasculitis characterized by inflammation of the small-caliber blood vessels and the presence of circulating antineutrophil cytoplasmic antibodies. Typically, microscopic polyangiitis presents with glomerulonephritis and pulmonary capillaritis, although involvement of the skin, nerves, and gastrointestinal tract is not uncommon. Treatment of MPA generally requires use of a cytotoxic agent (such as cyclophosphamide) in addition to high-dose glucocorticoids. Recent research has focused on identifying alternate treatment strategies that minimize or eliminate exposure to cytotoxic agents. This article reviews the history, pathogenesis, clinical manifestations, and treatment of MPA.
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Beasley MB. The pathologist's approach to acute lung injury. Arch Pathol Lab Med 2010; 134:719-27. [PMID: 20441502 DOI: 10.5858/134.5.719] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Acute lung injury and acute respiratory distress syndrome are significant causes of pulmonary morbidity and are frequently fatal. These 2 entities have precise definitions from a clinical standpoint. Histologically, cases from patients with clinical acute lung injury typically exhibit diffuse alveolar damage, but other histologic patterns may occasionally be encountered such as acute fibrinous and organizing pneumonia, acute eosinophilic pneumonia, and diffuse hemorrhage with capillaritis. OBJECTIVE To review the diagnostic criteria for various histologic patterns associated with a clinical presentation of acute lung injury and to provide diagnostic aids and discuss the differential diagnosis. DATA SOURCES The review is drawn from pertinent peer-reviewed literature and the author's personal experience. CONCLUSIONS Acute lung injury remains a significant cause of morbidity and mortality. The pathologist should be aware of histologic patterns of lung disease other than diffuse alveolar damage, which are associated with a clinical presentation of acute lung injury. Identification of these alternative histologic findings, as well as identification of potential etiologic agents, especially infection, may impact patient treatment and disease outcome.
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Affiliation(s)
- Mary Beth Beasley
- Department of Pathology, The Mount Sinai Medical Center, New York, New York 10029, USA.
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Abstract
The presence of pulmonary vasculitis can be suggested by a clinical presentation that includes diffuse pulmonary hemorrhage, acute glomerulonephritis, chronic refractory sinusitis or rhinorrhea, imaging findings of nodules or cavities, mononeuritis multiplex, multisystemic disease, and palpable purpura. Serologic tests, including the use of cytoplasmic antineutrophil cytoplasmic antibody (ANCA) and perinuclear ANCA, are performed for the differential diagnosis of the diseases. A positive cytoplasmic ANCA test result is specific enough to make a diagnosis of ANCA-associated granulomatous vasculitis if the clinical features are typical. Perinuclear ANCA positivity raises the possibility of Churg-Strauss syndrome or microscopic polyangiitis. Imaging findings of pulmonary vasculitis are diverse and often poorly specific. The use of a pattern-based approach to the imaging findings may help narrow the differential diagnosis of various pulmonary vasculitides. Integration of clinical, laboratory, and imaging findings is mandatory for making a reasonably specific diagnosis.
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Affiliation(s)
- Man Pyo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea
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41
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Castañer E, Alguersuari A, Gallardo X, Andreu M, Pallardó Y, Mata JM, Ramírez J. When to Suspect Pulmonary Vasculitis: Radiologic and Clinical Clues. Radiographics 2010; 30:33-53. [DOI: 10.1148/rg.301095103] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
OBJECTIVE Wegener's granulomatosis is an uncommon necrotizing vasculitis having variable presentations in the chest that are best depicted on high-resolution CT. Imaging findings may include nodules, which may cavitate; ground-glass opacity secondary to pulmonary hemorrhage; and airway stenoses and ulcerations. Active Wegener's granulomatosis can mimic pneumonia, septic emboli, and metastases. CONCLUSION This article will illustrate the high-resolution CT findings of Wegener's granulomatosis in the chest.
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Benson A, Schwarz M. A 26-year-old woman with recurrent hemoptysis and a sleep disturbance. Chest 2009; 134:1325-1331. [PMID: 19059964 DOI: 10.1378/chest.08-1410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Marvin Schwarz
- University of Colorado Health Sciences Center, Denver, CO
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Jin SM, Yim JJ, Yoo CG, Kim YW, Han SK, Shim YS, Lee SM. Aetiologies and outcomes of diffuse alveolar haemorrhage presenting as acute respiratory failure of uncertain cause. Respirology 2008; 14:290-4. [PMID: 19210654 DOI: 10.1111/j.1440-1843.2008.01444.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Sang-Man Jin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Most frequent reasons for intensive care unit (ICU) admission in vasculitis patients are severe respiratory insufficiency due to diffuse alveolar haemorrhage, sepsis and/or pneumonia and an acute abdomen due to bowel infarction. Other reasons are massive gastrointestinal bleeding, thromboembolism and/or scissures. In a patient, not previously diagnosed as having vasculitis, diagnosis can be difficult and must be made as soon as possible, since immunosuppressive therapy should be instituted immediately. Immunosuppressive therapy in severe cases consists of high-dose corticosteroids and cyclophosphamide. In addition, in many cases plasma exchange has to be instituted as well. Prognosis is related to disease activity scores of vasculitis and of severity of illness as measured by the APACHE III scoring system and/or the SOFA score. Septic shock is still the leading cause of death in patients with vasculitis. Nowadays, death due to active untreated vasculitis is rare in experienced clinics.
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Affiliation(s)
- J W Cohen Tervaert
- Department of Clinical and Experimental Immunology, Univerity Hospital Maastricht, The Netherlands.
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Abstract
PURPOSE OF REVIEW In this review we discuss the changing concepts of diffuse alveolar hemorrhage in children in terms of an expanded differential diagnosis and new approaches to diagnosis and treatment. RECENT FINDINGS More commonly found in adults, pulmonary capillaritis, an immune-mediated form of diffuse alveolar hemorrhage often associated with systemic disease, has been recently reported in children. In a series of eight children with pulmonary capillaritis, serology for immune-mediated disorders was positive in only half. Acute idiopathic pulmonary hemorrhage is a unique condition of infants who present with acute pulmonary hemorrhage and respiratory failure. The hypothesis that acute idiopathic pulmonary hemorrhage is caused by toxigenic mold has not been proven, and its cause remains uncertain. SUMMARY Classification of diffuse alveolar hemorrhage in children has been revised to include those conditions with and without pulmonary capillaritis. As idiopathic pulmonary hemosiderosis, the classic form of diffuse alveolar hemorrhage in children, is a diagnosis of exclusion and children with pulmonary capillaritis may have negative serology, lung biopsy should be strongly considered in any child with diffuse alveolar hemorrhage without a cardiovascular cause. Generally, patients with immune-mediated lung disease require more aggressive pharmacologic intervention.
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Affiliation(s)
- Sarat C Susarla
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Street, Houston, TX 77030, USA.
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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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48
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Picard C, Parrot A, Mayaud C, Cadranel J. Hémorragies intra-alvéolaires de l’adulte d’origine immunitaire. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)73417-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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
International travel, changing immigration patterns, and political upheavals have transformed the epidemiological picture of many tropical granulomatous disorders [53]. These diseases are seen with an increasing frequency in the United States, Europe, and other developed countries. Physicians must now become familiar with illnesses that were previously regarded as being "exotic" because of this increasing prevalence. Accurate diagnosis is important because therapy is significantly different for infectious granulomatous disorders than for non-infectious diseases.
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Affiliation(s)
- Om P Sharma
- Keck School of Medicine, University of Southern California at Los Angeles, LAC+USC Medical Center, 1200 North State Street, GNH-11900, Los Angeles, CA 90033, USA.
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