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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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Andrade C, Mendonça T, Farinha F, Correia J, Marinho A, Almeida I, Vasconcelos C. Alveolar hemorrhage in systemic lupus erythematosus: a cohort review. Lupus 2015; 25:75-80. [DOI: 10.1177/0961203315605365] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 08/18/2015] [Indexed: 11/17/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but potentially catastrophic manifestation with a high mortality. Among rheumatologic diseases, it occurs most frequently in patients with systemic lupus erythematosus (SLE) and systemic vasculitis. Despite new diagnostic tools and therapies, it remains a diagnostic and therapeutic challenge. The aim of this work was to characterize the SLE patients with an episode of alveolar hemorrhage followed in our Clinical Immunology Unit (CIU). A retrospective chart review was carried out for all patients with SLE followed in CIU between 1984 and the end of 2013. We reviewed the following data: demographic characteristics, clinical and laboratory data, radiologic investigations, histologic studies, treatment, and outcome. We identified 10 episodes of DAH, corresponding to seven patients, all female. These represent 1.6% of SLE patients followed in our Unit. The age at DAH attack was 42.75 ± 18.9 years. The average time between diagnosis of SLE and the onset of DAH was 7.1 years. Three patients had the diagnosis of SLE and the DAH attack at the same time. Disease activity according to SLEDAI was high, ranging from 15 to 41. All patients were treated with methylprednisolone, 37.5% cyclophosphamide and 28.6% plasmapheresis. The overall mortality rate was 28.6%.
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Affiliation(s)
- C Andrade
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - T Mendonça
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - F Farinha
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - J Correia
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - A Marinho
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - I Almeida
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - C Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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Esper RC, Estrada IEDLM, de la Torre León T, Gutiérrez AOR, López JAN. Treatment of diffuse alveolar hemorrhage secondary to lupus erythematosus with recombinant activated factor VII administered with a jet nebulizer. J Intensive Care 2014; 2:47. [PMID: 25705408 PMCID: PMC4336265 DOI: 10.1186/s40560-014-0047-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 07/21/2014] [Indexed: 11/10/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a serious pulmonary complication in patients with autoimmune diseases who are undergoing chemotherapy or have had hematopoietic stem cell transplantation. The use of recombinant factor VIIa (rFVIIa) to treat the acute phase of DAH by endobronchial bronchoscopy has been shown to have a significant clinical impact on the survival and evolution of these patients. We report a clinical case of a patient with DAH secondary to systemic lupus erythematosus (SLE) who was treated with rFVIIa administered using a jet nebulizer, obtaining an adequate hemostatic effect with immediate control of DAH and a significant improvement in gas exchange.
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Affiliation(s)
- Raúl Carrillo Esper
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | | | - Teresa de la Torre León
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Agustín Omar Rosales Gutiérrez
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Jorge Arturo Nava López
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
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Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus. Semin Immunopathol 2014; 36:495-517. [PMID: 25102991 DOI: 10.1007/s00281-014-0440-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 06/30/2014] [Indexed: 12/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.
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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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Diffuse alveolar hemorrhage: a rare life-threatening condition in systemic lupus erythematosus. Case Rep Pulmonol 2012; 2012:836017. [PMID: 22934226 PMCID: PMC3420594 DOI: 10.1155/2012/836017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/06/2012] [Indexed: 11/17/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication in systemic lupus erythematosus (SLE) associated with high mortality rates. DAH is more common in women, and mean age of onset is around 30 years. It mostly occurs in patients with established diagnosis of SLE but can be the initial presentation of lupus in approximately 20%. DAH should be suspected in lupus patient presenting with new pulmonary infiltrates, decline in hemoglobin, hemoptysis, dyspnea, hypoxemia, and increase in carbon monoxide diffusion capacity. Radiographic evidence of bilateral pulmonary alveolar infiltrates that are usually perihilar or basilar with sparing of apices is seen. DAH can often mimic clinically and radiologically severe pneumonia or ARDS. Treatment includes high-dose corticosteroids, cyclophosphamide, and plasmapheresis. We report a case of diffuse alveolar hemorrhage complicating SLE flare-up in a male patient.
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Abstract
Goodpasture's disease, or anti-glomerular basement membrane (anti-GBM) disease, is a systemic autoimmune disorder defined by anti-GBM antibody-mediated damage (mainly immunoglobulin G-1) resulting in progressive crescentic glomerulonephritis and, frequently, diffuse pulmonary alveolar hemorrhage. It may be regarded as a "conformeropathy" where the quaternary structure of the α345NC1 hexamer that constitutes GBM undergoes a conformational change, exposing pathogenic epitopes on the α3 and α5 chains, eliciting a pathogenic autoantibody anti-GBM response. Goodpasture's disease accounts for 20% of all patients presenting with a pulmonary-renal syndrome and may be associated with detectable perinuclear antineutrophil cytoplasmic autoantibody positivity in up to a third of patients. Associated triggers may include tobacco smoking, hydrocarbon solvent exposure, and cocaine abuse. Cough, hemoptysis, and dyspnea with fatigue are the commonest presenting features. It is critical to rapidly distinguish Goodpasture's disease from other causes of pulmonary-renal syndromes such as Wegener's granulomatosis. Early and intensive treatment with plasmapheresis and immunosuppression with systemic corticosteroids pending results of diagnostic testing, and later cyclophosphamide, is often beneficial, with 90% of patients surviving the acute presentation of Goodpasture's disease. The need for hemodialysis on initial presentation, a serum creatinine >5 mg/dL, and 50% to 100% crescents on renal biopsy, portend the necessity of long-term hemodialysis. Further elucidation of the molecular pathobiology of Goodpasture's disease, particularly the regulation of involved antigen-specific T cells, may improve early diagnosis, treatment, and outcomes in this rare but potentially lethal autoimmune disorder.
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Martínez-Martínez MU, Abud-Mendoza C. Predictors of mortality in diffuse alveolar haemorrhage associated with systemic lupus erythematosus. Lupus 2011; 20:568-574. [DOI: 10.1177/0961203310392430] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The objective of this study was the evaluation of clinical, demographic and treatment-associated mortality factors in patients with diffuse alveolar haemorrhage (DAH) associated with systemic lupus erythematosus (SLE). Clinical, laboratory test, SLEDAI-2K, predictors of mortality (APACHE II) and different treatments including cyclophosphamide, methylprednisolone and rituximab were evaluated in SLE patients who were diagnosed with DAH, to determine potential association with mortality. Twenty-nine episodes of DAH in 22 SLE patients were included (one patient with four episodes, four patients with two episodes (seven recurrences)), 15 died. Mean age was 25.1 years and 1.5 years of SLE evolution with haemoglobin drop 3.4 g/dl. In 4 of 22 patients, the DAH diagnosis was confirmed by autopsy. Six episodes were in patients under 18 years of age (2 patients with recurrence). DAH was the initial manifestation of SLE in 10 patients. Of the 22 patients, 17 were women and 22/29 had DAH episodes. Dyspnoea and nephritis occurred in all patients, less common were arthritis (75.9%) and fever (65.5%); haemoptysis was present only in 44.8%. Through evaluation of all included factors, only thrombocytopenia, renal failure, requirement for mechanical ventilation and high APACHE II were associated with higher mortality. Cyclophosphamide use was associated with less mortality (not statistically significant).
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Affiliation(s)
- MU Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - C Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
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10
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Alveolar hemorrhage in systemic lupus erythematosus: An overview. EGYPTIAN RHEUMATOLOGIST 2011. [DOI: 10.1016/j.ejr.2010.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lee RW, D'Cruz DP. Pulmonary renal vasculitis syndromes. Autoimmun Rev 2010; 9:657-60. [PMID: 20472100 DOI: 10.1016/j.autrev.2010.05.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 05/10/2010] [Indexed: 01/15/2023]
Abstract
The term pulmonary renal vasculitis syndrome describes a clinical syndrome of diffuse alveolar haemorrhage (DAH) complicating acute glomerulonephritis that often heralds severe, life-threatening systemic vasculitis requiring urgent, aggressive therapy. "Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis" and glomerular basement membrane ("Goodpasture's") disease are the commonest causes but other pathologies including systemic lupus erythematosus and the anti-phospholipid syndrome are also implicated. Such patients hence present most commonly to rheumatologists and nephrologists but usually require input from a number of specialties, respiratory and critical care medicine in particular. Such care is typically provided in specialist centres able to offer plasma exchange and experience in the use of immunosuppressants. We review clinical features, advances in therapy and understanding of pathophysiology.
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Usui K, Ochiai T, Muto R, Abe I, Aikawa M, Kikushima K, Nagao K. Diffuse pulmonary hemorrhage as a fatal complication of Schönlein-Henoch purpura. J Dermatol 2007; 34:705-8. [PMID: 17908143 DOI: 10.1111/j.1346-8138.2007.00364.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a case of a 69-year-old man with Schönlein-Henoch purpura who developed diffuse pulmonary hemorrhage. He complained of dyspnea and hemoptysis while he was treated with steroids for gastroenteropathy associated with Schönlein-Henoch purpura. The drop in his hemoglobin levels and diffuse ground-glass opacity at all levels of the lung fields on chest computed tomography were a significant clue to diagnosis. Despite pulse therapy, no clinical improvement of the lung was achieved, and he died on the 36th day after the admission. Although the combination of the corticosteroid and immunosuppressive agents is normally recommended, diffuse pulmonary hemorrhage could become a fatal complication in elderly Schönlein-Henoch patients.
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Affiliation(s)
- Keiko Usui
- Department of Dermatology, Surugadai Nihon University Hospital, Chiyoda-ku, Tokyo, Japan.
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Shintaku M, Hwang MH, Amitani R. Primary Choriocarcinoma of the Lung Manifesting as Diffuse Alveolar Hemorrhage. Arch Pathol Lab Med 2006; 130:540-3. [PMID: 16594748 DOI: 10.5858/2006-130-540-pcotlm] [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: 11/06/2022]
Abstract
Abstract
An autopsy case of primary pulmonary choriocarcinoma that manifested as diffuse alveolar hemorrhage is reported. A 44-year-old nurse presented with fever, dry cough, hemoptysis, and progressive dyspnea, and died after a downhill course of 2 weeks. Chest radiographs showed diffuse parenchymal shadows throughout the entire lung and a nodular lesion in the right lower lobe. Findings suggestive of acute renal failure were not seen. The autopsy revealed primary pure choriocarcinoma of the right lower lobe and diffuse alveolar hemorrhage throughout the entire lung. Findings of small vessel vasculitis (“pulmonary alveolar capillaritis”) were not observed, and extensive neoplastic involvement of the pulmonary vasculature was considered the cause of the diffuse alveolar hemorrhage. Small metastatic foci were found in the liver, adrenal glands, pancreas, and ovaries. This case shows that primary pulmonary neoplasms, on rare occasions, can produce the clinical and pathologic features of diffuse alveolar hemorrhage, probably through elevated pulmonary venous pressure caused by extensive destruction of the vasculature.
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Fullmer JJ, Langston C, Dishop MK, Fan LL. Pulmonary capillaritis in children: a review of eight cases with comparison to other alveolar hemorrhage syndromes. J Pediatr 2005; 146:376-81. [PMID: 15756223 DOI: 10.1016/j.jpeds.2004.10.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To review clinical, laboratory, and outcome characteristics of children diagnosed with pulmonary capillaritis (PC), a small-vessel vasculitis, presenting as diffuse alveolar hemorrhage (DAH), and to compare these findings with those for children with other alveolar hemorrhage syndromes. STUDY DESIGN A retrospective chart review of patients who underwent a lung biopsy because of a clinical suggestion of pulmonary hemorrhage. RESULTS PC was identified in 8 of 23 patients. In these patients, cough, crackles, and hypoxia were common. Alveolar infiltrates on radiography and anemia were present in 7 of 8 cases. Serologic evidence of a systemic vasculitis was present in 50% of patients. High-dose corticosteroids proved effective in controlling alveolar hemorrhage in all cases. There were no presenting signs or symptoms that could differentiate patients with PC from those with non-immune-mediated alveolar hemorrhage. In general, patients with PC had a lower hematocrit and higher erythrocyte sedimentation rate (ESR). CONCLUSION Children presenting with lower respiratory tract symptoms, chest x-ray abnormalities, and anemia should undergo evaluation for PC, as early initiation of immunosuppression can be lifesaving and organ sparing. No clinical signs to differentiate immune and non-immune-mediated alveolar hemorrhage were evident in this study.
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Affiliation(s)
- Jason J Fullmer
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston 77030, USA.
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Abstract
A large and diverse group of pathologic conditions manifests clinically and radiologically as diffuse parenchymal lung disease. Diffuse interstitial lung diseases (ILDs) encompass mainly inflammatory processes that involve the structural elements of this organ. Some ILDs are caused by infections, but most are the result of immunologic, environmental, or toxic mechanisms. Currently, less morbid sampling techniques have increased dramatically the probability that pulmonologists will be faced with establishing a specific and clinically relevant diagnosis using surgical lung biopsy material. Most of the concepts presented in this article have been established using this type of specimen. In the early years of surgical lung biopsy, a small number of diffuse inflammatory conditions came to light that exclusively involved the lungs and did not seem to be caused by infection, toxin, sarcoidosis, pneumoconiosis, or neoplasm. In this article, these idiopathic disorders are discussed in the context of their dominant pathologic findings rather than presented as a separate group of entities.
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Affiliation(s)
- Kevin O Leslie
- Department of Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Luks AM, Lakshminarayanan S, Hirschmann JV. Leptospirosis presenting as diffuse alveolar hemorrhage: case report and literature review. Chest 2003; 123:639-43. [PMID: 12576395 DOI: 10.1378/chest.123.2.639] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The literature on diffuse alveolar hemorrhage heavily emphasizes the causal role of vasculitides. We present a patient with diffuse alveolar hemorrhage caused by leptospirosis. Although the pathology in leptospirosis occurs secondary to a vasculitic process, this disease is not listed as a cause of diffuse alveolar hemorrhage in the review literature. In the right clinical scenario, the disease should be considered in a patient presenting with diffuse alveolar hemorrhage.
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Affiliation(s)
- Andrew M Luks
- Department of Medicine (Dr. Luks), University of Washington, Seattle 98108, USA
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Epstein CE, Elidemir O, Colasurdo GN, Fan LL. Time course of hemosiderin production by alveolar macrophages in a murine model. Chest 2001; 120:2013-20. [PMID: 11742936 DOI: 10.1378/chest.120.6.2013] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The diagnosis of alveolar hemorrhage is assisted by the presence of hemosiderin-laden macrophages (HLMs) in the BAL fluid or lung tissue. Despite the importance of this diagnostic method in clinical settings, limited information is available on the formation and clearance of HLMs as a function of time. The objectives of this study are to determine the time course of HLMs within the BAL and lung tissue, and to evaluate the effect of a single blood aspiration on the recruitment of inflammatory cells within the BAL. DESIGN Under light anesthesia, Balb/c mice received a single intranasal instillation of species-specific blood (50 microL). Control animals received heparinized sterile saline solution in a similar manner. At several time points after blood aspiration, BAL was recovered for cell differentials and determination of HLMs. The time course for HLMs was also established in the lung tissue. RESULTS Hemosiderin staining within alveolar macrophages was first detected in the BAL and lung tissue at day 3, peaked at day 7, and persisted through 2 months. The analysis of the BAL revealed an increased number of total cells, with an acute inflammatory reaction that resolved within 2 weeks. CONCLUSIONS Our findings demonstrate the validity of this model for the study of HLM production after blood aspiration. Additional work using animal models of lung hemorrhage is needed to further characterize the cellular events leading to clearance of erythrocytes within the lung.
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Affiliation(s)
- C E Epstein
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine, Houston, TX 77030-2399, USA
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 32-2001. A 77-year-old man with rheumatoid arthritis and acute dyspnea and renal failure. N Engl J Med 2001; 345:1193-200. [PMID: 11642236 DOI: 10.1056/nejmcpc322001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Herndon TM, Kim TT, Goeckeritz BE, Moores LK, Oglesby RJ, Dennis GJ. Alveolar Hemorrhage and Pulmonary Hypertension in Systemic Sclerosis: A Continuum of Scleroderma Renal Crisis? J Clin Rheumatol 2001; 7:115-9. [PMID: 17039108 DOI: 10.1097/00124743-200104000-00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Alveolar hemorrhage occurs as a complication of systemic inflammatory diseases. In addition to alveolar hemorrhage, patients with systemic sclerosis (SSc) may suffer from digital infarction, pulmonary hypertension, and renal crisis. Although a common pathogenesis of this disease that explains the variety of problems during a patient's illness has yet to be identified, the unique characteristics of SSc may alter our approach to alveolar hemorrhage in this patient population. We describe a patient with SSc, who presented with pulmonary hypertension and alveolar hemorrhage complicated by features suggesting re-occurrence of scleroderma renal crisis. Our successful management of this patient, with complications that are usually of high morbidity, may be attributed to our judicious use of glucocorticosteroid therapy and maximization of angiotensin-converting enzyme inhibition. In view of the potential for glucocorticoids to precipitate scleroderma renal crisis, we suggest caution in the use of these medications for manifestations that may be similar in their pathogenesis.
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Affiliation(s)
- T M Herndon
- Department of Cellular Injury, Walter Reed Army Medical Center, Washington, D.C. 20307, USA
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Santos-Ocampo AS, Mandell BF, Fessler BJ. Alveolar hemorrhage in systemic lupus erythematosus: presentation and management. Chest 2000; 118:1083-90. [PMID: 11035681 DOI: 10.1378/chest.118.4.1083] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AIM To describe our experience with alveolar hemorrhage (AH) in systemic lupus erythematosus (SLE). METHODS Review of medical records and pertinent medical literature using MEDLINE and reference lists from retrieved publications. PATIENTS Seven patients with SLE admitted with episodes of AH (n = 11). RESULTS Six patients were female, and one was male. Mean age at the time of AH was 31.1 years. Mean duration of SLE was 4.5 years. AH occurred within 3 weeks of SLE onset in two patients. Recurrent AH was observed in four patients. Six patients were already receiving treatment for SLE at the time of AH. All patients presented with dyspnea and new pulmonary infiltrates. Hemoptysis occurred in only 54%. All patients had BAL within 48 h of presentation. Temperature > or =39 degrees C (102.2 degrees F) accompanied 82% of episodes. Glomerulonephritis was the most common nonpulmonary SLE manifestation (74%). Treatment with empiric IV antibiotics was initiated in 10 episodes. Initial treatment included high-dose corticosteroids (prednisone, 1 to 3 mg/kg/d [n = 2]; or IV methylprednisolone, 1 g/d [n = 9], with or without oral cyclophosphamide, 2 to 3 mg/kg/d [n = 7]). Plasmapheresis (three to four sessions) was added in five episodes for persistent AH. All patients survived. CONCLUSIONS AH may mimic pneumonia. Hemoptysis may not be evident. Infection must be aggressively excluded, especially since many patients with AH are already receiving immunosuppressive therapy. AH frequently recurs despite ongoing immunosuppression. Although high mortality rates have been reported with AH in SLE, we observed 100% survival.
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Affiliation(s)
- A S Santos-Ocampo
- Department of Medicine, Makati Medical Center, Makati City, Philippines
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Le Clainche L, Le Bourgeois M, Fauroux B, Forenza N, Dommergues JP, Desbois JC, Bellon G, Derelle J, Dutau G, Marguet C, Pin I, Tillie-Leblond I, Scheinmann P, De Blic J. Long-term outcome of idiopathic pulmonary hemosiderosis in children. Medicine (Baltimore) 2000; 79:318-26. [PMID: 11039080 DOI: 10.1097/00005792-200009000-00005] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We retrospectively analyzed the long-term outcome of idiopathic pulmonary hemosiderosis (IPH) in 15 children. IPH started at a mean age of 5 years, and the mean duration of follow-up was 17.2 years (range, 10-36 yr). Four patients developed immune disorders, 3 cases of rheumatoid polyarthritis or rheumatoid polyarthritis-like diseases and 1 case of celiac disease. Respiratory outcome showed that 3 patients had severe symptoms: 2 patients developed severe pulmonary fibrosis resulting in major chronic respiratory insufficiency, and 1 patient had severe asthma. Twelve patients (80%) had mild or no respiratory problems and were able to lead a normal life. According to chest X-ray and pulmonary function test data, 4 patients had normal chest X-ray and no evidence of restrictive syndrome, 6 patients had an interstitial pattern on chest X-ray and evidence of restrictive pattern, 1 patient had an interstitial pattern but normal lung function, and 1 patient had a normal chest X-ray but evidence of mixed obstructive and restrictive pattern. Our results show that long-term survival is possible in patients with IPH. Factors of poor prognosis seem to be the presence of antineutrophil cytoplasm antibodies (ANCA) or other autoantibodies. No other clinical or biological predictive factors for prolonged survival were found.
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22
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Affiliation(s)
- M I Schwarz
- Interstitial Lung Disease Center, National Jewish Medical and Research Center and University of Colorado Health Sciences Center, Denver 80262, USA.
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23
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Tandon M, Reynolds HN, Borg U, Habashi NM, Cottingham C. Life-threatening acute systemic lupus erythematosus: survival after multiple extracorporeal modalities: a place for the multipotential extracorporeal service. ASAIO J 2000; 46:146-9. [PMID: 10667734 DOI: 10.1097/00002480-200001000-00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Diffuse alveolar hemorrhage secondary to systemic lupus erythematosus (SLE) may cause life-threatening respiratory failure and may be associated with multiple organ failure. Extensive support may be necessary to sustain life while systemic therapy becomes effective. We report here a patient with profound respiratory failure secondary to SLE associated with multiorgan failure, who was supported with veno-arterial extracorporeal lung assist (ECLA), veno-venous ECLA, and multiple continuous renal replacement therapies during plasmapheresis. The full spectrum of extracorporeal life support and treatment modalities was performed seamlessly by a single service within the critical care department.
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Affiliation(s)
- M Tandon
- Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medicine, Baltimore 21201, USA
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24
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Ramírez T, Prados C, Gómez de Terreros Caro J, Villamor J, Alvarez-Sala R. [Idiopathic pulmonary hemosiderosis in a patient of advanced age]. Arch Bronconeumol 1999; 35:507-9. [PMID: 10618752 DOI: 10.1016/s0300-2896(15)30026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology characterized by hemoptysis, diffuse pulmonary infiltrates and iron-deficiency anemia. It is typically found in children and young adults. Finding that the concentration of siderophages exceeds 20% in bronchoalveolar lavage indicates a diagnosis of IPH. We report the case of a 72-year-old man with repeated diagnoses of respiratory infection, bronchiectasis and melena. Because such a clinical picture is rare for IPH, the final diagnosis was obtained by open lung biopsy.
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Affiliation(s)
- T Ramírez
- Servicio de Neumología, Hospital La Paz, Universidad Autónoma de Madrid
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25
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Affiliation(s)
- M A Jantz
- Division of Pulmonary Medicine, University of South Carolina, Charleston, South Carolina, USA
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26
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Abstract
The well-recognized pathology of the collagen vascular diseases is reviewed along with pathologic findings in systemic vasculitides that commonly involve the lung. The pathology of alveolar hemorrhage syndromes is also reviewed.
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Affiliation(s)
- T V Colby
- Mayo Clinic Scottsdale, Arizona, USA
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27
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Abstract
Pulmonary vascular inflammation may be seen in a variety of primary lung diseases and in the setting of numerous systemic illnesses. This article reviews those entities in which pulmonary vasculitis represents a central feature of the pathologic process (Wegener's granulomatosis, Churg-Strauss syndrome, and pulmonary capillaritis). In addition, features of pulmonary involvement in other systemic vasculitides (Giant Cell Arteritis, Takayasu's Arteritis, and Behçet's disease) are described. Finally, general principles for the treatment of vasculitis are reviewed.
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Affiliation(s)
- E J Sullivan
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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28
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Mulligan MS, Lentsch AB, Shanley TP, Miyasaka M, Johnson KJ, Ward PA. Cytokine and adhesion molecule requirements for lung injury induced by anti-glomerular basement membrane antibody. Inflammation 1998; 22:403-17. [PMID: 9675611 DOI: 10.1023/a:1022372900175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute hemorrhagic lung injury occurs in humans with anti-GBM antibody (Goodpasture's syndrome), however, the mechanism of this injury is still largely unknown. To date, treatment has been confined to steroids and plasmaphoresis. Infusion of anti-GBM antibody into rats caused lung injury with intra-alveolar hemorrhage and intrapulmonary accumulation of neutrophils. Lung injury was dependent on the presence of neutrophils and complement and required both TNF alpha and IL-1. Experiments employing blocking antibodies to adhesion molecules demonstrated requirements for the beta 1 integrin VLA-4, beta 2 integrins LFA-1 and Mac-1, and L-selection. The endothelial cell adhesion molecules, E-selectin and ICAM-1, were also required for the full development of lung injury. Inhibition of TNF alpha or IL-1 or adhesion molecules reduced both lung injury and tissue neutrophil accumulation. Thus, this study underscores cytokine and adhesion molecule requirements for neutrophil mediated injury in lung and kidney caused by anti-GBM, suggesting potential targets for the treatment of Goodpasture's syndrome in humans.
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Affiliation(s)
- M S Mulligan
- Department of Pathology, University of Michigan Medical School, Ann Arbor 48109, USA
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29
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Affiliation(s)
- L J States
- Department of Radiology, Childrens' Hospital of Philadelphia, PA 19104, USA
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30
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Abstract
Pulmonary hemorrhage may occur in patients with immune-mediated glomerulonephritis. This association can be seen in a variety of disorders including systemic lupus erythematosus, vasculitis, Wegener's granulomatosis, anaphylactoid purpura and Goodpasture's syndrome. Immune mechanisms, such as immune complexes and/or autoantibodies, play a role in the pathogenesis of pulmonary and glomerular injury. Acute pulmonary hemorrhage can lead to respiratory failure and has a high mortality. Therapy with immunosuppressive agents such as pulse methylprednisolone and cyclophosphamide will control the hemorrhage and improve pulmonary function in most cases.
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Affiliation(s)
- V M Reznik
- Department of Pediatrics, University of California School of Medicine, San Diego, California, USA
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31
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Supervía A, Curull V, Corominas JM, Campodarve I, Sanjuás C. Pulmonary metastases from renal cell carcinoma simulating alveolar haemorrhage. Respir Med 1995; 89:67-8. [PMID: 7708986 DOI: 10.1016/0954-6111(95)90076-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- A Supervía
- Department of Internal Medicine, Hospital del Mar, Barcelona, Spain
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32
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Erickson RW, Franklin WA, Emlen W. Treatment of hemorrhagic lupus pneumonitis with plasmapheresis. Semin Arthritis Rheum 1994; 24:114-23. [PMID: 7839153 DOI: 10.1016/s0049-0172(05)80005-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pulmonary hemorrhage is a rare and often fatal complication of systemic lupus erythematosus (SLE). Treatment with high-dose steroids and cyclophosphamide has been of only modest value, with a reported mortality of up to 92%. We have recently seen three patients with active SLE who developed acute life-threatening pulmonary hemorrhage. Diagnostic evaluation of these patients showed negative sputum and blood cultures, negative glomerular basement membrane antibodies, and negative antineutrophilic cytoplasmic antibodies. In two patients, an open-lung biopsy was performed, and histological examination showed granular alveolar immunofluorescence staining for immunoglobulin and complement components. Treatment with plasmapheresis was initiated with prompt resolution of symptoms and clearing of chest radiograph. Two patients had recurrent bleeds despite treatment with cyclophosphamide and high-dose steroids and required repeated intubation. Plasmapheresis resulted in rapid radiographic and clinical improvement on each occasion. Two patients survived long-term and are presently without pulmonary problems; one patient died of sepsis after initial response to plasmapheresis. The dramatic improvement of the pulmonary disease in these patients leads us to conclude that rapid initiation of plasmapheresis should be strongly considered in SLE patients with severe, life-threatening pulmonary hemorrhage.
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Affiliation(s)
- R W Erickson
- Division of Rheumatology, University of Colorado Health Sciences Center, Denver 80262
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33
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Wright WK, Krous HF, Griswold WR, Billman GF, Eichenfield LF, Lemire JM, Reznik VM. Pulmonary vasculitis with hemorrhage in anaphylactoid purpura. Pediatr Pulmonol 1994; 17:269-71. [PMID: 8208599 DOI: 10.1002/ppul.1950170411] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We report a 14-year-old female with anaphylactoid purpura (AP) who developed pulmonary hemorrhage with acute vasculitis on lung biopsy. She improved with pulse methylprednisolone, daily prednisone and ventilatory assistance. Pulmonary vasculitis is a rare but serious manifestation of AP.
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Affiliation(s)
- W K Wright
- Department of Pediatrics, University of California School of Medicine, La Jolla 92093
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34
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Louie S, Russell LA, Richeson RB, Cross CE. Circulating immune complexes with pulmonary hemorrhage during pregnancy in idiopathic pulmonary hemosiderosis. Chest 1993; 104:1907-9. [PMID: 8252984 DOI: 10.1378/chest.104.6.1907] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Circulating immune complexes occurred during pulmonary hemorrhage in a pregnant patient with idiopathic pulmonary hemosiderosis, an association not previously reported. The patient required mechanical ventilation, but recovered; after a prolonged hospitalization, she was delivered of a healthy infant without further complications.
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Affiliation(s)
- S Louie
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento 95817
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35
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Schwab EP, Schumacher HR, Freundlich B, Callegari PE. Pulmonary alveolar hemorrhage in systemic lupus erythematosus. Semin Arthritis Rheum 1993; 23:8-15. [PMID: 8235667 DOI: 10.1016/s0049-0172(05)80022-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pulmonary alveolar hemorrhage (PAH) is a rare and often fatal presenting feature of systemic lupus erythematosus (SLE). Reported mortality rates are extremely high, 70% to 90%. Death frequently occurs within the first several days of the hemorrhage. The hospital records of all inpatients with PAH and SLE between April 1986 and May 1991 at the Hospital of the University of Pennsylvania were reviewed. The complete resolution of PAH and the 75% survival rate found in this study is in marked contrast to previous reports. This experience suggests that patients with PAH and SLE may have a better prognosis than previously reported.
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Affiliation(s)
- E P Schwab
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
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36
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Buschman DL, Ballard R. Progressive massive fibrosis associated with idiopathic pulmonary hemosiderosis. Chest 1993; 104:293-5. [PMID: 8325091 DOI: 10.1378/chest.104.1.293] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Progressive massive fibrosis is a recognized complication of pneumoconiosis secondary to pulmonary fibrosis, with retraction forming conglomerate masses symmetrically in the upper lobes. Idiopathic pulmonary hemosiderosis is known to cause pulmonary fibrosis secondary to recurrent alveolar hemorrhage with deposition of hemosiderin in the interstitium. We present a case in which progressive massive fibrosis developed in a patient with long-standing idiopathic pulmonary hemosiderosis.
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Affiliation(s)
- D L Buschman
- Department of Medicine, National Jewish Center for Immunology and Respiratory Medicine, Denver
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37
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Alvarez Vega JL, Salazar Vallinas JM, Ortega Alberdi R, Muñoz Sanz A, Turegano JM, Fernandez Alonso J. Pulmonary haemorrhage and focal necrotizing glomerulonephritis in a case of systemic sclerosis. Clin Rheumatol 1992; 11:116-9. [PMID: 1582110 DOI: 10.1007/bf02207098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report a case of a 53-year-old woman diagnosed of systemic sclerosis. She underwent an episode of pulmonary haemorrhage, characterized by haemoptysis, sudden anaemization, and bilateral alveolar infiltration during her hospitalization, which was resolved with steroid treatment. Subsequently, she developed a focal necrotizing glomerulonephritis. After searching in the literature, we have found only three cases of systemic sclerosis associated with pulmonary haemorrhage. We discuss the etiopathogenesis of this association and stress the importance of early steroid therapy.
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Affiliation(s)
- J L Alvarez Vega
- Unit of Rheumatology, University of Extremadura, Infanta Cristina Hospital, Badajoz, Spain
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38
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Müller NL, Miller RR. Diffuse Pulmonary Hemorrhage. Radiol Clin North Am 1991. [DOI: 10.1016/s0033-8389(22)02097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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39
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40
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Misset B, Glotz D, Escudier B, Nochy D, Bosq J, Gilles E, Leclercq B, Nitenberg G. Wegener's granulomatosis presenting as diffuse pulmonary hemorrhage. Intensive Care Med 1991; 17:118-20. [PMID: 1865033 DOI: 10.1007/bf01691435] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A 35-year-old woman experienced diffuse intraalveolar haemorrhage with respiratory distress and acute renal failure. Renal histology and evolution confirmed Wegener's granulomatosis. Early use of immunosuppressive drugs allowed weaning from mechanical ventilation and temporary improvement of the renal failure. A review of the literature emphasizes the rarity of alveolar hemorrhage as an initial symptom of Wegener's granulomatosis and the necessity of aggressive management.
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Affiliation(s)
- B Misset
- Service de Réanimation Médicochirurgicale, Hôpital Broussais, Paris, France
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41
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Bell DD, Moffatt SL, Singer M, Munt PW. Antibasement membrane antibody disease without clinical evidence of renal disease. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1990; 142:234-7. [PMID: 2195932 DOI: 10.1164/ajrccm/142.1.234] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A 20-yr-old man is described with the rare presentation of antibasement membrane antibody (ABMA) disease confirmed on renal biopsy, but with normal renal function and urinary sediment. This distinct subgroup of ABMA appears to have an excellent prognosis. The relevant literature is reviewed and summarized.
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Affiliation(s)
- D D Bell
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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42
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Imoto EM, Lombard CM, Sachs DP. Pulmonary capillaritis and hemorrhage. A clue to the diagnosis of systemic necrotizing vasculitis. Chest 1989; 96:927-8. [PMID: 2571462 DOI: 10.1378/chest.96.4.927] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients with systemic necrotizing vasculitis frequently present as diagnostic dilemmas. In previous series of patients with polyarteritis nodosa, less than one third were diagnosed antemortem. Although current clinical awareness of systemic necrotizing vasculitis is greater than in the past and procedures for the diagnosis of these diseases have improved, patients commonly present with atypical features. The diagnosis of a systemic necrotizing vasculitis frequently remains unsuspected or unproven until an involved tissue is biopsied. We report an unusual case of systemic necrotizing vasculitis in which the diagnosis was confirmed by a transbronchial biopsy of the lung which demonstrated pulmonary capillaritis with hemorrhage.
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Affiliation(s)
- E M Imoto
- Division of Respiratory Medicine, Stanford University Medical Center, CA
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43
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Lombard CM, Colby TV, Elliott CG. Surgical pathology of the lung in anti-basement membrane antibody-associated Goodpasture's syndrome. Hum Pathol 1989; 20:445-51. [PMID: 2707796 DOI: 10.1016/0046-8177(89)90009-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We report the findings of lung biopsies from five patients with anti-basement membrane antibody-associated Goodpasture's syndrome (ABMA-GS). In four patients, pulmonary capillaritis with hemorrhage was found on lung biopsy, confirming that pulmonary capillaritis can be found in ABMA-GS. Although alveolar hemorrhage was the dominant pathologic finding in four of our five patients, all five patients had evidence of injury at the level of the alveolar wall, manifested by hyaline membranes and widening of alveolar walls by edematous connective tissue. In one of our patients, alveolar hemorrhage was only focal, and diffuse alveolar damage was the dominant pathologic finding. This pattern of lung disease has not been previously described in ABMA-GS.
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Affiliation(s)
- C M Lombard
- Stanford University Medical Center, Department of Pathology, CA 94305
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44
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 30-1988. A 9-year-old girl with chronic interstitial lung disease and recurrent bouts of pneumonia. N Engl J Med 1988; 319:227-37. [PMID: 3393173 DOI: 10.1056/nejm198807283190407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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45
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Segal SL, Lenchner GS, Cichelli AV, Promisloff RA, Hofman WI, Baiocchi GA. Angiosarcoma presenting as diffuse alveolar hemorrhage. Chest 1988; 94:214-6. [PMID: 3383641 DOI: 10.1378/chest.94.1.214] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Angiosarcoma has been reported as occurring in both postirradiation and postradical mastectomy patients. Described is a patient, postmastectomy and irradiation, with alveolar hemorrhage secondary to angiosarcoma. Angiosarcoma, primary or metastatic to lung, should be included in the differential diagnosis of diffuse alveolar hemorrhage in this patient population.
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Affiliation(s)
- S L Segal
- Division of Pulmonary Diseases, Hahnemann University Hospital, Philadelphia, PA
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