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Samuel S, Brown B, Mason N, Abdo T. Diffuse alveolar hemorrhage, a rare presentation of polymyositis. Respir Med Case Rep 2020; 31:101261. [PMID: 33145158 PMCID: PMC7593619 DOI: 10.1016/j.rmcr.2020.101261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/15/2020] [Accepted: 10/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Diffuse alveolar hemorrhage is a medical emergency caused by persistent and recurrent pulmonary hemorrhage [1]. It is an uncommon presentation of polymyositis. Symptoms of polymyositis include fatigue, muscle pains, proximal muscle weakness, and joint pains [2]. Case presentation A 44-year-old male presented with new onset shortness of breath and productive cough with white sputum and occasional hemoptysis. The patient was diagnosed with diffuse alveolar hemorrhage (DAH) via bronchoscopy and discharged initially on prednisone. The patient's laboratory work indicated positive titers of ANA & anti-Jo-1 antibody with low complement levels. These results pointed towards the diagnosis of polymyositis [3]. DAH can also be caused by systemic lupus erythematosus, Goodpasture's syndrome, Sjogren syndrome, anticoagulant therapy, and antiphospholipid antibody syndrome [4]. However, the possibility of these potential causes was excluded. Conclusion This case of diffuse alveolar hemorrhage was most likely due to polymyositis.
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Affiliation(s)
- Sharoon Samuel
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, USA
| | - Brent Brown
- Department of Pulmonary & Critical Care, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Nita Mason
- Department of Radiological Sciences, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Tony Abdo
- Department of Pulmonary & Critical Care, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
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Shen CR, Jia XY, Cui Z, Yu XJ, Zhao MH. Clinical-Pathological Features and Outcome of Atypical Anti-glomerular Basement Membrane Disease in a Large Single Cohort. Front Immunol 2020; 11:2035. [PMID: 33013861 PMCID: PMC7494752 DOI: 10.3389/fimmu.2020.02035] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Atypical cases of anti-glomerular basement membrane (GBM) disease had absent circulating antibodies but linear IgG deposits along GBM in the kidneys. Herein, we reported the clinical-pathological features and outcome of these rare cases. Methods: Linear IgG deposit along GBM were examined by immunofluorescence on renal specimens, with exclusion of diabetic kidney disease. Circulating anti-GBM antibodies were tested by commercial ELISA assay. Clinical, pathological and follow-up data were retrospectively analyzed. Results: From 2013 to 2018, a total of 60 patients were diagnosed as atypical anti-GBM disease. They had a male predominance, with an average age of 51.7 ± 15.6 years. Three (5.0%) patients had alveolar hemorrhage. Forty five percent of them presented with acute kidney disease. All patients had linear IgG deposit along GBM, some in addition on tubular basement membrane and/or Bowmans' capsules. C3 deposition was found in 65.0% of the patients. 41.7% (25/60) of the patients showed crescent formation and the percentage of crescent was (34.7 ± 23.5)% in those patients. They had higher prevalence of hematuria and C3 deposit, higher levels of serum creatinine, worse renal and patient survival than those without crescent (P < 0.05). During the follow-up of 35.7 ± 21.4 months, 14 (23.3%) patients progressed to ESRD. The serum creatinine on diagnosis [per 200 μmol/L increase, HR (95% CI): 2.663 (1.372, 5.172), P = 0.004], serum C3 [per 0.1 g/L increase, HR (95% CI): 0.689(0.483, 0.984), P = 0.040] and the intensity of kidney C3 staining [per 1+ increase, HR (95% CI): 2.770 (1.115, 6.877), P = 0.028] were independent predictive factors for kidney outcome. Nine (15.0%) patients died of all causes. Conclusions: Atypical anti-GBM disease manifested milder kidney injury and scarce pulmonary hemorrhage compared to the classical cases. Though heterogeneous, a substantial number of the patients had complement activation and crescent formation. Patients having crescents presented with more severe clinical course and worse outcomes. The poor kidney and patient prognosis emphasize prompt interventions from physicians. The immunosuppressive intervention was not associated with kidney or patient outcome. Further studies are needed to address the optimal therapeutic regimen.
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Affiliation(s)
- Cong-Rong Shen
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Hao D, Basnet S, Melnick S, Kim J. Negative pressure pulmonary edema-related diffuse alveolar hemorrhage associated with Sevoflurane and cigarette smoking. J Community Hosp Intern Med Perspect 2019; 9:247-251. [PMID: 31258867 PMCID: PMC6586085 DOI: 10.1080/20009666.2019.1608140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Negative-pressure pulmonary edema (NPPE)-related diffuse alveolar hemorrhage (DAH) is an underdiagnosed clinical entity seen with alveolar capillary damage. The pathophysiology of type I NPPE is generation of a negative pleural pressure against an upper airway obstruction. We suspect this process was facilitated by preexisting alveolar damage with smoking and administration of the irritating and coagulopathic inhaled anesthetic sevoflurane. We present a case of a healthy 31-year-old man who developed postoperative hemoptysis, diffuse ground-glass opacity and infiltrates on computed tomography (CT) of the chest, anemia, and hypoxic respiratory failure. A diagnosis of DAH was made and a serologic workup for systemic disorders including vasculitis and connective tissue diseases was negative. The patient rapidly improved with supportive care and had complete resolution of his bilateral infiltrates on repeat chest x-ray two weeks later. Our literature review identified three cases of DAH in the setting of sevoflurane administration. Our case illustrates the importance of including NPPE-related DAH on the differential of post-operative hemoptysis, especially in association with sevoflurane administration and a history of cigarette smoking.
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Affiliation(s)
- David Hao
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - Sijan Basnet
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - Stephen Melnick
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - James Kim
- Pulmonary and Critical Care Medicine, Respiratory Specialists, Reading, PA, USA
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