Diffuse alveolar hemorrhage with predominantly right-sided infiltration resulting from cardiac comorbidities

Early diagnosis of negative-pressure pulmonary edema presenting as diffuse alveolar hemorrhage using lung ultrasonography -A case report

BACKGROUND

Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening condition that can occur due to a variety of disorders. Hence, rapid diagnosis and prompt initiation of appropriate treatment are imperative.

CASES

A 55-year-old woman with a deep neck infection underwent emergent tonsillectomy. General anesthesia and surgery proceeded uneventfully. Upon transfer to the post-anesthesia care unit, ongoing respiratory distress and occasional expectoration of blood-tinged sputum were noted. Lung ultrasonography (LUS) revealed multiple B-profiles and irregular pleural lines with subpleural consolidations. Emergent bronchoscopy with bronchoalveolar lavage was diagnostic of DAH. She underwent a comprehensive evaluation for rheumatologic and infectious etiologies of DAH, all of which yielded negative results. The patient was managed with steroids and conservative treatment.

CONCLUSIONS

The integration of LUS with clinical information allows for more rapid differentiation of acute respiratory failure causes. Therefore, anesthesiologists' awareness and utilization of LUS findings of DAH can significantly contribute to appropriate management.

Differentiation of idiopathic pulmonary hemosiderosis from rheumatologic and autoimmune diseases causing diffuse alveolar hemorrhage: establishing a diagnostic approach

This narrative review provides an overview of diffuse alveolar hemorrhage (DAH) associated with rheumatologic and autoimmune diseases and their differentiation from idiopathic pulmonary hemosiderosis (IPH). Relevant immunologic diseases associated with DAH are discussed, and a diagnostic flowchart is proposed to establish a "definitive" diagnosis of IPH within the spectrum of DAH. IPH is a rare cause of recurrent DAH both in children and adults. In adults, a definitive diagnosis of IPH requires a lung biopsy and histopathologic examination demonstrating intraalveolar hemorrhage, hemosiderin-laden macrophages, and a variable degree of fibrosis in the absence of both capillaritis and cellular inflammation. The presence of small vessel vasculitis points towards immunologic, well-differentiated, or sometimes undifferentiated rheumatologic diseases. However, it is essential to recognize that many rheumatologic diseases may in the initial phase present with DAH without any evidence of capillaritis, thus mimicking IPH. Although not definitely established, it is likely that immunologic processes are involved in IPH, and we, therefore, suggest the consideration of a more suitable term for the disease, e.g., "Immune-mediated Pulmonary Hemosiderosis" to acknowledge the aberrancy in the immune parameters and a positive response to immunosuppressive therapy.

Diffuse Alveolar Hemorrhage Associated with Dilated Cardiomyopathy and Sleep Apnea Syndrome

We herein report a case of diffuse alveolar hemorrhage (DAH) associated with dilated cardiomyopathy (DCM) and sleep apnea syndrome (SAS) in a 47-year-old man. The patient exhibited recurring dyspnea and bloody sputum. Chest radiography showed bilateral diffuse infiltrative opacities without pleural effusion. A bronchoscopic analysis of bronchoalveolar lavage fluid revealed hemosiderin-laden macrophages. Based on these findings, he was diagnosed with DAH. Laboratory and pathological findings ruled out the possibility of collagen diseases and vasculitis. Overnight polysomnography revealed concomitant severe obstructive SAS. Treatment with continuous positive-pressure ventilation and pharmacological therapy for DCM prevented recurrence of DAH.

Unilateral Diffuse Alveolar Hemorrhage Due to Selective Directionality of Mitral Regurgitant Jet in a Patient With Severe Aortic Stenosis

Diffuse alveolar hemorrhage (DAH) in cardiac diseases results from pulmonary capillary stress failure due to pulmonary venous hypertension. The most common cardiac causes of DAH are heart failure and mitral valvular disease. Patients typically manifest with hemoptysis, radiologic chest abnormalities, and anemia. The chest infiltrates are generally bilateral, similar to pulmonary edema. Rarely, the chest infiltrates can be unilateral, mimicking an infectious etiology. We present the case of an 88-year-old female with critical aortic stenosis, who presented with shortness of breath, unilateral right lung infiltrates, and mild leukocytosis. The patient was misdiagnosed with pneumonia as pulmonary edema or DAH was expected to be a bilateral finding on chest imaging. The patient deteriorated and DAH was eventually diagnosed by bronchoscopy.

Negative-pressure-related diffuse alveolar hemorrhage after monitored anesthesia care for vertebroplasty: a case report

Background

Diffuse alveolar hemorrhage (DAH) is a rare, life-threatening condition that can present as a spectrum of nonspecific symptoms, ranging from cough, dyspnea, and hemoptysis to severe hypoxemic respiratory failure. Perioperative DAH is frequently caused by negative pressure pulmonary edema resulting from acute airway obstruction, such as laryngospasm, although hemorrhage itself is rare.

Case presentation

This case report describes an unexpected hemoptysis following monitored anesthesia care for vertebroplasty. A 68-year-old Asian woman, with a compression fracture of the third lumbar vertebra was admitted for vertebroplasty. There were no noticeable events during the procedure. After the procedure, the patient was transferred to the postanesthesia care unit (PACU), at which sudden hemoptysis occurred. The suspected airway obstruction may have developed during transfer or immediate arrive in PACU. In postoperative chest x-ray, newly formed perihilar consolidation observed in both lung fields. The patients was transferred to a tertiary medical institution for further evaluation. She diagnosed with DAH for hemoptysis, new pulmonary infiltrates on chest x-ray and anemia. The patient received supportive care and discharged without further events.

Conclusions

Short duration of airway obstruction may cause DAH, it should be considered in the differential diagnosis of postoperative hemoptysis of unknown etiology.

Diffuse Alveolar Hemorrhage in Cardiac Diseases

Diffuse alveolar hemorrhage (DAH) is a rare condition with reported mortality ranging between 20 and 100%. There are many etiologies of DAH. Cardiac diseases are likely underreported causes of DAH. Heart failure and mitral valve diseases are the most common cardiac causes of DAH. The DAH results from pulmonary venous hypertension leading to stress failure of the pulmonary capillaries. There is also a contribution of the bronchial circulation. The Alveolar-capillary membrane or blood-gas barrier is an extremely thin structure that allows rapid and passive diffusion of oxygen from the inhaled air to the pulmonary capillaries while preventing pulmonary edema and DAH with chronic elevation of the transmural hydrostatic pressure. The purpose of this manuscript is to inform the clinician about this rare cause of DAH, which may be overlooked unless specifically sought after. We also discuss the pathophysiologic aspects of DAH and the safety mechanisms in place to prevent such occurrences.

Acute mitral valve regurgitation causing severe alveolar hemorrhage

Background

Acute mitral regurgitation could occur without common symptoms like hemodynamic instability, but with dyspnea, hemoptysis, and right‐sided infiltration on radiography. We report a case of severe alveolar hemorrhage caused by acute mitral regurgitation, which occurred in the absence of shock.

Case Presentation

A 40‐year‐old man presented with dyspnea with bloody phlegm and hypoxia, despite being hemodynamically stable. Chest radiography revealed right‐sided infiltration, and bronchoscopy showed fresh bloody phlegm in his tracheae. No specific findings were detected with any tests. After treatment with several medications and support with extracorporeal membrane oxygenation, his condition improved, although the etiology of the disease remained unknown. Transthoracic and transesophageal echocardiogram revealed severe mitral valve regurgitation with ruptured mitral chordae tendineae. These suggested that the sudden onset of mitral valve regurgitation had caused severe alveolar hemorrhage.

Conclusion

Severe alveolar hemorrhage, especially with right‐sided infiltration on chest radiography, should be considered a symptom of acute mitral regurgitation.

Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Serial Lung Ultrasonography to Monitor Patient With Diffuse Alveolar Hemorhage

Diffuse alveolar haemorrhage (DAH) leads to acute respiratory failure. This is why it requires rapid diagnosis and implementation of appropriate treatment. The standard diagnosis of a patient with DAH includes laboratory tests, diagnostic imagining (X-ray of the chest, high-resolution computed tomography), and bronchoscopy with bronchoalveolar lavage. We present a description of 2 patients diagnosed with systemic connective tissue disease and DAH, monitored with the help of lung ultrasound. To our knowledge, this is the first description of the use of lung ultrasound in DAH in adult patients.

Diffuse alveolar haemorrhage with predominant upper lung lobe involvement associated with congestive heart failure: a case series

BACKGROUND

Diffuse alveolar haemorrhage (DAH) may accompany or complicate various diseases with different pathophysiology. The diagnosis of DAH, especially when presenting as diffuse non-resolving and predominantly upper lobe lung consolidations, is particularly difficult in patients with cardiac disease.

METHODS

We retrospectively reviewed seven cases of DAH with predominant upper lobe involvement in the setting of acute or acute-on-chronic congestive heart failure (CHF).

RESULTS

In general, time from onset till diagnostic confirmation of DAH was long. Chest CT scan mostly confirmed diffuse lung infiltrates without preferential side location but with typical cortical sparing in all patients. Echocardiography showed presence of some degree of mitral valve insufficiency in all subjects.

CONCLUSIONS

Diagnosis of DAH presenting as non-resolving upper lobe densities, accompanying CHF remains cumbersome but may be suggested indirectly by the presence of cortical sparing and mitral valve insufficiency. The latter may play a crucial role in the development of DAH.

Kidney-lung connections in acute and chronic diseases: current perspectives

Lung and kidney functions are intimately related in both health and disease. The regulation of acid-base equilibrium, modification of partial pressure of carbon dioxide and bicarbonate concentration, and the control of blood pressure and fluid homeostasis all closely depend on renal and pulmonary activities. These interactions begin in fetal age and are often responsible for the genesis and progression of diseases. In gestational age, urine is a fundamental component of the amniotic fluid, acting on pulmonary maturation and growth. Moreover, in the first trimester of pregnancy, kidney is the main source of proline, contributing to collagen synthesis and lung parenchyma maturation. Pathologically speaking, the kidneys could become damaged by mediators of inflammation or immuno-mediated factors related to a primary lung pathology or, on the contrary, it could be the renal disease that determines a consecutive pulmonary damage. Furthermore, non immunological mechanisms are frequently involved in renal and pulmonary diseases, as observed in chronic pathologies such as sleep apnea syndrome, pulmonary hypertension, progressive renal disease and hemodialysis. Kidney damage has also been related to mechanical ventilation. The aim of this review is to describe pulmonary-renal interactions and their related pathologies, underscoring the need for a close collaboration between intensivists, pneumologists and nephrologists.