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Saleem T, Al-Jaghbeer MJ, Arrossi Valeria AV, Mehta AC. Panacinar emphysema complicating idiopathic pulmonary hemosiderosis: a case report. Oxf Med Case Reports 2023; 2023:omad091. [PMID: 38145263 PMCID: PMC10735625 DOI: 10.1093/omcr/omad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 12/26/2023] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare entity with no known underlying etiology. It can be complicated by lung fibrosis. Emphysema is rarely reported as a consequence of IPH. We present a case of a 30-year-old female who presented with recurrent hemoptysis and shortness of breath. Radiographs revealed advanced emphysematous changes of the lower lobes. The diagnosis of IPH was established with an open lung biopsy. She was treated with systemic steroids, underwent bullectomy and was subsequently maintained on inhaled steroids.
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Affiliation(s)
- Talha Saleem
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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2
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Chan J. Idiopathic Pulmonary Hemosiderosis: The Great Hemolytic Anemia Mimicker. Cureus 2023; 15:e40362. [PMID: 37456468 PMCID: PMC10339854 DOI: 10.7759/cureus.40362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare, potentially fatal disease characterized by recurrent diffuse alveolar hemorrhage. Presentation varies, and delay in diagnosis and treatment can result in respiratory complications and increased mortality. It is imperative to consider IPH in the differential of a patient presenting with transfusion-dependent microcytic anemia and concomitant pulmonary symptoms. This case series describes two pediatric patients with persistent severe microcytic anemia despite multiple blood transfusions. Both patients underwent extensive workup for their anemia, and ultimately, their respiratory symptoms led to their diagnosis of IPH. Both were then managed with long-term corticosteroids and had significant clinical improvement.
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Affiliation(s)
- Jaclyn Chan
- Internal Medicine/Pediatrics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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3
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Knoflach K, Rapp CK, Schwerk N, Carlens J, Wetzke M, Emiralioğlu N, Kiper N, Ring AM, Buchvald F, Manali E, Papiris S, Reu-Hofer S, Kappler M, Schieber A, Seidl E, Gothe F, Robinson PN, Griese M. Diffuse alveolar hemorrhage in children with interstitial lung disease: Determine etiologies! Pediatr Pulmonol 2023; 58:1106-1121. [PMID: 36588100 DOI: 10.1002/ppul.26301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/11/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) in children is a rare condition resulting from different underlying diseases. This study aimed at describing characteristics and diagnostic measures in children with ILD (children's interstitial lung disease, chILD) and DAH to improve the diagnostic approach by increasing clinician's awareness of diagnostic shortcomings. PATIENTS AND METHODS A retrospective data analysis of patients with ILD and DAH treated in our own or collaborating centers between 01/07/1997 and 31/12/2020 was performed. Data on clinical courses and diagnostic measures were systematically retrieved as case-vignettes and investigated. To assess suitability of diagnostic software-algorithms, the Human Phenotype Ontology (HPO) was revised and expanded to optimize conditions of its associated tool the "Phenomizer." RESULTS For 97 (74%) of 131 patients, etiology of pulmonary hemorrhage was clarified. For 34 patients (26%), no underlying condition was found (termed as idiopathic pulmonary hemorrhage, IPH). Based on laboratory findings or clinical phenotype/comorbidities, 20 of these patients were assigned to descriptive clusters: IPH associated with autoimmune features (9), eosinophilia (5), renal disease (3) or multiorgan involvement (3). For 14 patients, no further differentiation was possible. CONCLUSION Complete and sometimes repeated diagnostics are essential for establishing the correct diagnosis in children with DAH. We suggest assignment of patients with IPH to descriptive clusters, which may also guide further research. Digital tools such as the Phenomizer/HPO are promising, but need to be extended to increase diagnostic accuracy.
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Affiliation(s)
- Katrin Knoflach
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Christina Katharina Rapp
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Nicolaus Schwerk
- Department of Pediatrics, Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DLZ), Partner Site Hannover (BREATH), Hanover, Germany
| | - Julia Carlens
- Department of Pediatrics, Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Martin Wetzke
- Department of Pediatrics, Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Nagehan Emiralioğlu
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Astrid Madsen Ring
- Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Buchvald
- Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Effrosyni Manali
- Department of Respiratory Medicine, 'Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros Papiris
- Department of Respiratory Medicine, 'Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Simone Reu-Hofer
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Matthias Kappler
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Alexandra Schieber
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Elias Seidl
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Florian Gothe
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Peter N Robinson
- The Jackson Laboratory for Genomic Medicine, Farmington, Connecticut, USA
| | - Matthias Griese
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany.,German center for Lung Research (DLZ), Partner Site Munich, Munich, Germany
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4
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Nayir Buyuksahin H, Kiper N. Childhood Interstitial Lung Disease. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2023; 36:5-15. [PMID: 36695653 DOI: 10.1089/ped.2022.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Childhood interstitial lung disease (chILD) is a heterogeneous group of diseases with various clinical and imaging findings. The incidence and prevalence have increased in recent years, probably due to better comprehension of these rare diseases and increased awareness among physicians. chILDs present with nonspecific pulmonary symptoms, such as tachypnea, hypoxemia, cough, rales, and failure to thrive. Unnecessary invasive procedures can be avoided if specific mutations are detected through genetic examinations or if typical imaging patterns are recognized on computed tomography. Disease knowledge and targeted therapies are improving through international collaboration. Pulmonary involvement in systemic diseases is not uncommon. Pulmonary involvement may be the first finding in connective tissue diseases. This review aims to present a systematic patient-targeted approach to the diagnosis of chILD.
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Affiliation(s)
- Halime Nayir Buyuksahin
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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Saha BK, Aiman A, Chong WH, Saha S, Song J, Bonnier A. Updates in idiopathic pulmonary hemosiderosis in 2022: A state of the art review. Pediatr Pulmonol 2023; 58:382-391. [PMID: 36324124 DOI: 10.1002/ppul.26230] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
This manuscript reports the recent advances in idiopathic pulmonary hemosiderosis (IPH), a rare cause of diffuse alveolar hemorrhage in children and adults. This narrative review of the literature summarizes different aspects of IPH, including proposed pathogenesis, patient demographics, clinical and radiological characteristics, treatment, and prognosis. Additionally, the association between Celiac Disease (CD) and IPH is carefully evaluated. IPH is a frequently misdiagnosed disease. The delay in the diagnosis of IPH is often significant but fortunately, appears to have decreased in recent years. IPH in adults and children have distinct demographic preferences. The autoantibodies are common in IPH but with a definite difference between the adult and pediatric populations. The definitive diagnosis of IPH requires lung biopsy and careful exclusion of all competing diagnoses, even with lung biopsy showing bland pulmonary hemorrhage. The presence of nonspecific inflammatory cells or lymphoid aggregates may suggest a secondary immunologic phenomenon and needs careful evaluation and follow-up. A substantial number of patients suffer from coexisting CD, also known as Lane-Hamilton syndrome (LHS), and all patients with IPH need to be evaluated for LHS by serology. Although strict gluten free diet can manage the majority of patients with LHS, other patients generally require immunosuppressive therapy. The corticosteroids are the backbone of IPH therapy. Recently utilized experimental treatment options include mesenchymal stem cell transplant, liposteroid and bronchial artery embolization. The immunosuppression should be adjusted to achieve optimal disease control. Patients may progress to end-stage lung disease despite all measures, and lung transplantation may be the only viable option.
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Affiliation(s)
- Biplab K Saha
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Alexis Aiman
- New York Institute of Technology College of Osteopathic Medicine at Arkansas State University, Arkansas, USA
| | - Woon Hean Chong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore City, Singapore
| | - Santu Saha
- Department of Internal Medicine, Saha Clinic, Narail, Bangladesh
| | - Jini Song
- New York Institute of Technology College of Osteopathic Medicine at Arkansas State University, Arkansas, USA
| | - Alyssa Bonnier
- Department of Critical Care Nursing, Goldfarb School of Nursing, Barnes Jewish College, St. Louis, Missouri, USA
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Aiman A, Saha S, Chong WH, Saha BK. A 49-year-old man with ischemic cardiomyopathy and persistent hemoptysis for eighteen months. Am J Med Sci 2022; 364:111-117. [PMID: 35276072 DOI: 10.1016/j.amjms.2021.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of recurrent episodes of diffuse alveolar hemorrhage (DAH). IPH commonly manifests with hemoptysis, radiologic chest infiltrates and anemia. The etiology of IPH is unknown, but an immunologic mechanism is widely speculated. The definitive diagnosis of IPH requires a thorough exclusion of other causes of DAH, such as infections, inflammation, malignancy, cardiac diseases, drug and toxin exposure, and medications. Due to the rarity of the disease, a diagnosis is often delayed by years. We present the case of a 49-year-old man with ischemic cardiomyopathy who presented with hemoptysis for eighteen months. Serologic workup was negative for vasculitides and autoimmune diseases. Bronchoscopy revealed DAH. A surgical lung biopsy showed 'bland pulmonary hemorrhage.' A right heart catheterization ruled out cardiac causes of DAH. The patient was diagnosed with IPH and started on systemic corticosteroids with rapid improvement of hemoptysis.
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Affiliation(s)
- Alexis Aiman
- New York Institute of Technology College of Osteopathic Medicine at Arkansas State University, Jonesboro, AR, USA
| | - Santu Saha
- Division of Internal Medicine, Bangladesh Medical College, Dhaka, Bangladesh
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical College and Center, Albany, NY, USA
| | - Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, MO, USA.
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Chickmagalur S, Davitt M, Lahoutiharahdashti A, Mitchell W, Arens R, Wallace MW, Sutyla RF, Plemmons G, Schmitz A, Town R, Siembida J, Wood KE. Respiratory Distress: Three Patient Cases. Pediatr Rev 2022; 43:322-337. [PMID: 35641452 DOI: 10.1542/pir.2020-003780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
As mentioned in the January 2022 Pediatrics in Review Commentary, we now present three patients who have a common chief complaint followed by 5 questions for CME credit. All three cases have discussions on presentation, the differential diagnosis, and management that collectively serve as a Review article. The common theme here is that all three patients have difficulty breathing. We hope you will enjoy this review format.
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Saha BK, Saha S, Bonnier A, Saha BN. Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years. Pediatr Pulmonol 2022; 57:1127-1144. [PMID: 35088581 DOI: 10.1002/ppul.25847] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS). METHOD This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS. RESULTS A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients. CONCLUSION All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.
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Affiliation(s)
- Biplab K Saha
- Department of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri, USA
| | - Santu Saha
- Department of Internal Medicine, Bangladesh Medical College, Dhaka, Bangladesh
| | - Alyssa Bonnier
- Department of Critical Care Nursing, Goldfarb School of Nursing, Barnes Jewish College, St. Louis, Missouri, USA
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Saha BK, Bonnier A, Saha S, Saha BN, Milman NT. The Spectrum of Autoantibodies in Adult Patients With Idiopathic Pulmonary Hemosiderosis: A Brief Review of the Literature. Cureus 2022; 14:e24169. [PMID: 35586354 PMCID: PMC9108010 DOI: 10.7759/cureus.24169] [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] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
While autoimmune antibodies or autoantibodies have been reported sporadically in adult patients with idiopathic pulmonary hemosiderosis (IPH), their true prevalence is unknown. The question as to whether any difference exists between antibody-positive and negative patients has not been explored. The primary objective of this paper was to assess the spectrum of autoantibody testing and its positivity rate. The other objectives included a comparative analysis of demographics, symptom onset, clinical manifestations, and differences in clinical outcomes between antibody-positive (cohort A) and negative (cohort B) patients. To that end, we conducted a retrospective review of the relevant published literature. Multiple databases were searched to retrieve studies published between 1990 and 2022. A total of 35 studies, involving 38 patients, were identified. Five of these patients had a positive autoantibody. Patients in cohort A were older and more likely to be male. The frequencies of testing for these antibodies were as follows: antineutrophil cytoplasmic antibody (ANCA): 37/38 (97.4%), antinuclear antibody (ANA): 31/38 (81.6%), and anti-glomerular basement membrane antibody (anti-GBM): 30/38 (78.9%); 5/38 (13.2%) patients tested positive for an autoantibody, and two of these patients were positive for ANA, two for antithyroid antibody, and one patient tested positive for ANCA, rheumatoid factor (RF), and granulocyte monocyte-colony stimulating factor (GM-CSF) antibody. There was no difference between the cohorts regarding their clinical presentations, recurrence risks, and survival. The occurrence of autoantibodies is uncommon in adult IPH patients. This is in contrast with the pediatric IPH patient population, where the prevalence is much higher (26.4% vs. 13.2%), and the antibodies are more diverse. Unlike pediatric patients, adult patients with autoantibodies do not necessarily have worse outcomes.
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Saha BK, Chong WH, Saha S, Aiman A, Bonnier A. Proposed Pathogenesis of Diffuse Alveolar Hemorrhage in Idiopathic Pulmonary Hemosiderosis. Lung 2022; 200:205-215. [PMID: 35267072 DOI: 10.1007/s00408-022-00523-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/27/2022] [Indexed: 01/01/2023]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease that causes diffuse alveolar hemorrhage (DAH). The latest data suggests an immunologic origin of IPH, and a new name, immune mediated pulmonary hemosiderosis (ImPH), has been proposed. However, the exact immunologic mechanism has remained elusive for nearly eight decades despite extensive research, including detailed histopathologic analysis. Although several hypotheses have been proposed to describe the pathobiology of IPH, none of them explain the clinical and histopathologic findings conclusively. In this manuscript, we have presented a new hypothesis for the pathogenesis of DAH in IPH. We hypothesize that DAH in IPH is not immunocomplex mediated but due to histamine, eosinophilic cationic protein (ECP), and possibly vascular endothelial growth factor (VEGF). These bioactive proteins induce endothelial and alveolar epithelial damage, leading to the peri-capillary and intraalveolar escape of RBCs. The deformability of the RBC likely also plays a role. The supranormal secretion of histamine, ECP and VEGF occurs in genetically predisposed individuals with an aberrant immunologic response. The histamine is released from the basophils and possibly the mast cells in response to cytokines secreted by activated lymphocytes. The lymphocyte activation occurs after exposure to a known (gluten) or unknown antigen. The same lymphocyte-derived cytokines also induce eosinophilic degranulation of ECP and VEGF in the pulmonary circulation. We believe that our hypothesis unifies the observed clinical variabilities and histopathologic findings in IPH, and we hope that would promote future research in the field of IPH.
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Affiliation(s)
- Biplab K Saha
- Department of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 Kentucky Avenue, West Plains, Missouri, MO, 65775, USA.
| | - Woon H Chong
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Santu Saha
- Department of Internal Medicine, Bangladesh Medical College, Dhaka, Bangladesh
| | - Alexis Aiman
- New York Institute of Technology College of Osteopathic Medicine, Arkansas State University, Arkansas, USA
| | - Alyssa Bonnier
- Department of Critical Care Nursing, Goldfarb School of Nursing, Barnes Jewish College, St. Louis, MO, USA
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Saha BK, Bonnier A, Chenna P, Milman NT. Prevalence of autoantibodies in pediatric patients with idiopathic pulmonary hemosiderosis: a scoping review of the literature in the period 1980-2021. Clin Rheumatol 2022; 41:977-990. [PMID: 35067768 DOI: 10.1007/s10067-021-06029-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/04/2021] [Accepted: 12/18/2021] [Indexed: 11/03/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology. Due to the frequent findings of autoimmune antibodies - autoantibodies, immunologic causation of the diffuse alveolar hemorrhage in IPH has been proposed, to assess the prevalence/frequency and type of autoantibodies in pediatric patients with IPH. In addition, the patient demographics, diagnostic modalities used to diagnose IPH, treatment, and outcomes were also evaluated. Scoping review: The PubMed, Medline, and Embase databases were searched with appropriate MeSH terms to identify relevant papers consistent with the defined inclusion criteria. Thirteen observational studies comprising a total of 352 pediatric patients were included in this review. The majority of subjects were girls 217 out of 352 (61.6%). The mean and median ages of patients ranged from 3.1-6.5 years to 2.3-7 years, respectively. In the 10 studies that specified the number of patients in their cohorts with either at least one positive autoantibody or no antibody, the overall prevalence of autoantibodies was 76 out of 288 patients (26.4%). The prevalence of specific antibodies was as follows: ANA, 20.3%; ANCA, 17%; anti-dsDNA, 9.1%; RF, 12%; anti-SMA, 23.2%; and celiac antibodies, 25.9%. Cow's milk protein allergy was present in 16.2% of the children. The significance of an association between IPH and the presence of autoantibodies has not been clarified. The autoantibodies could be suggestive of an overall immune dysregulation rather than causation. However, limited evidence based on a single study suggests that the presence of ANA may be associated with a higher risk of recurrence and worse outcomes. Further research, including prospective studies, will be crucial to explore a possible genetic linkage between vasculitides, systemic rheumatologic diseases, and IPH.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 Kentucky Avenue, West Plains, MO, 65775, USA.
| | - Alyssa Bonnier
- Goldfarb School of Nursing at Barnes-Jewish College, Saint Louis, MO, USA
| | - Praveen Chenna
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, 4700, Næstved, Denmark
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Yang J, Gou RY, Ding X, Shao L, Xia G, Ni Q. Rare causes of anemia in children: Two cases of idiopathic pulmonary hemosiderosis. Respir Med Case Rep 2022; 36:101610. [PMID: 35256995 PMCID: PMC8897708 DOI: 10.1016/j.rmcr.2022.101610] [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: 09/27/2021] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage (DAH) with unknown etiology. Hemoptysis, dyspnea, anemia, diffuse infiltration in chest radiography and presence of hemosiderin-loaded macrophages (HLMs) in the sputum, gastric content or bronchoalveolar lavage fluid (BALF) are the major characteristics for diagnosis of IPH. Here we present two pediatric patients with IPH. Patient 1 was repeatly misdiagnosed with bronchopneumonia because of diffuse infiltration in her chest X ray, but her anemia was repeatedly ignored. Patient 2 was misdiagnosed with nutritional anaemia because she did not have dyspnea or hemoptysis, and her chest computed tomography (CT) only revealed mild alveolar infiltrates. IPH must be included in the differential diagnosis in patients with long-term anemia who respond poorly to the hematopoietic supplements. CT is superior to X-ray in detecting alveolar hemorrhage.
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Saha BK, Chong WH. Lung transplant to manage end-stage lung disease due to idiopathic pulmonary hemosiderosis: A review of the literature. Respir Investig 2022; 60:82-89. [PMID: 34312096 DOI: 10.1016/j.resinv.2021.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/05/2021] [Accepted: 06/19/2021] [Indexed: 06/13/2023]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare immunological disease with a genetic predisposition. It is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH). Timely use of immunosuppressive medications has significantly improved overall outcomes, including mortality. Still, uncontrolled and frequent episodes of DAH can eventually cause pulmonary fibrosis, leading to end-stage lung disease (ESLD). The objective of the present project was to scrutinize the literature and summarize the demographic, clinical, radiological, and histopathological features, as well as the overall outcomes, in this patient population following lung transplant. The Medline database was searched using the PubMed platform. Articles published in English between 1960 and 2020 were included in the search. Different search terms were used to identify all patients who underwent lung transplantation to manage ESLD due to IPH. Only four cases of lung transplantation have been reported in the literature in patients with IPH. All but one of these underwent deceased donor lung transplant; recurrence was reported in two of these patients and suspected in the third. One patient received living donor lung transplant and had no recurrence during a five-year follow-up. Patients with IPH should not be excluded from lung transplantation because the disease may not recur in all patients, and even when it does recur it can be promptly treated by increasing immunosuppression.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 N Kentucky Avenue, West Plains, MO, 65775, USA.
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, 43 New Scotland Avenue, Albany, NY, 12208, USA
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14
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Saha BK, Milman NT. Liposteroid Therapy for Idiopathic Pulmonary Hemosiderosis: A Scoping Review of the Literature. Prague Med Rep 2022; 123:65-81. [PMID: 35507939 DOI: 10.14712/23362936.2022.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage (DAH). Glucocorticosteroids (CS) represent the first line therapy for IPH. Although most patients respond to CS, steroid refractoriness is seen in an appreciable minority of patients. This paper reviews and evaluates the efficacy and safety profile of liposomal dexamethasone 21-palmitate (liposteroid) for the treatment of IPH. Medline, Embase and Web of Science biomedical databases were searched between 1980 and 2020 to identify papers describing patients with IPH, who were treated with liposteroid. A total of five articles were identified. Four in the form of case reports and one as a case series. A total of 12 pediatric patients (5 boys, 7 girls) were identified, with a median age of 2.3 years (range 0.5-8.6). Liposteroid therapy in intravenous doses ranging 0.06-0.1 mg/kg body weight appeared to be effective for both remission induction therapy, and maintenance therapy. There was no mortality among patients treated with liposteroid, either in the acute phase or during follow-up. The majority of patients for whom long-term follow-up data were available, were cured or in disease remission. No acute adverse events were reported, and long-term side effects were minimal and tolerable. Liposteroid represents a potential alternative or supplement to conventional CS therapy, as it appears to be more efficacious and associated with fewer side effects. Larger prospective, controlled trials are necessary to be able to define more precisely the therapeutic role of liposteroid in IPH.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, USA.
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, Næstved, Denmark
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Saha BK, Milman NT. Idiopathic pulmonary hemosiderosis: a review of the treatments used during the past 30 years and future directions. Clin Rheumatol 2021; 40:2547-2557. [PMID: 33184706 DOI: 10.1007/s10067-020-05507-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/31/2020] [Accepted: 11/10/2020] [Indexed: 12/26/2022]
Abstract
This paper reviews the literature on the treatment modalities for idiopathic pulmonary hemosiderosis (IPH) used over the past 30 years, attempting to define treatment options that appear to be efficacious and safe, and in addition presents a treatment algorithm. IPH is an uncommon etiology of diffuse alveolar hemorrhage. IPH is a rare disease in adults and often associated with a significant temporal delay in diagnosis. Patients present with hemoptysis, radiographic chest abnormalities, and iron deficiency anemia. Although several pathogenetic hypotheses have been proposed, IPH appears to be an immunologic disease, possibly with a genetic component. Corticosteroid therapy represents the first line of treatment, including liposome-incorporated dexamethasone palmitate (liposteroid). Additional immunomodulatory/immunosuppressive medications have been used with varying success, especially in the setting of steroid-refractory disease. Cyclophosphamide, azathioprine, hydroxychloroquine, mycophenolate mofetil, and mesenchymal cell transplantation have been attempted to improve outcome and reduce side effects. Controlled studies are needed to assess the optimal combination of medications, which are effective to control the disease.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, 1100 Kentucky Avenue, West Plains, MO, 65775, USA.
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, DK-4700, Næstved, Denmark
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Qin L, Zhang FZ, Yang TY, Tao XF, Tang LF. Pulmonary Nocardia infection in a child with idiopathic pulmonary hemosiderosis. BMC Pulm Med 2021; 21:182. [PMID: 34051779 PMCID: PMC8164755 DOI: 10.1186/s12890-021-01544-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/16/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary hemosiderosis (IPH) encompasses a rare and agnogenic group of diffuse alveolar capillary hemorrhagic diseases. Corticosteroid treatment is the globally preferred therapeutic strategy for IPH; however, it can cause immunodeficiency. Nocardia infection often occurs in immunocompromised patients and primarily involves the pleura and lungs. Herein, we describe a case of pediatric pulmonary Nocardia infection after the corticosteroid treatment of IPH. CASE PRESENTATION A 7-year-old girl presented with chief complaints of pale complexion persisting for 1 year and a cough for 20 days. Abundant hemosiderin-laden macrophages were detected in the gastric juice, which supported the diagnosis of IPH. Uninterrupted doses of corticosteroids were administered during the last hospitalization. After nearly 2 months of corticosteroids therapy, the patient began to cough and produce a purulent sputum. Next-generation sequencing of the bronchoalveolar lavage fluid revealed Nocardia abscessus (N. abscessus) DNA. Linezolid was administered with good response, and the patient was discharged after 18 days of hospitalization. Her symptoms and pulmonary lesions had recovered, and the IPH appeared to be well-controlled with low dose of corticosteroids in follow-up. CONCLUSIONS Nocardia infection should be considered in the differential diagnoses for IPH patients receiving corticosteroid therapy, especially in patients with poor response to conventional empirical antibiotic therapy. Next-generation sequencing of bronchoalveolar lavage fluid may be used to quickly identify the Nocardia. Sulfonamides or linezolid are effective for pediatric pulmonary Nocardia infection.
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Affiliation(s)
- Lu Qin
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, 3333 Binsheng Road, Hangzhou, 310051, China
| | - Fei-Zhou Zhang
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, 3333 Binsheng Road, Hangzhou, 310051, China
| | - Tong-Yu Yang
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, 3333 Binsheng Road, Hangzhou, 310051, China
| | - Xiao-Fen Tao
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, 3333 Binsheng Road, Hangzhou, 310051, China
| | - Lan-Fang Tang
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, 3333 Binsheng Road, Hangzhou, 310051, China.
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Hizal M, Eryilmaz Polat S, Ramasli Gursoy T, Ozsezen B, Ademhan Tural D, Karakaya J, Emiralioglu N, Pekcan S, Tana Aslan A, Yalcin E, Dogru D, Ozcelik U, Kiper N. Risk factors for recurrent pulmonary exacerbation in idiopathic pulmonary hemosiderosis. Pediatr Pulmonol 2021; 56:1060-1068. [PMID: 33247613 DOI: 10.1002/ppul.25189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/03/2020] [Accepted: 11/19/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate the risk factors of recurrent pulmonary exacerbation and poor prognosis in children with idiopathic pulmonary hemosiderosis (IPH). METHODS In this multicenter study, 54 patients with a diagnosis of IPH were included. Medical records were retrospectively reviewed from three tertiary care hospitals between 1979 and 2019. Also, current information and the long-term progress of patients was determined by contacting the families by telephone. RESULTS A total of 54 children were included. The median age of onset of symptoms was 4.5 years (3 months to 15.8 years). The median time from onset to diagnosis was 0.9 years (0.25 months to 12 years). The mean number of recurrent episodes per child in the recurrence-positive group was 3.55 (1-15). Univariate analysis demonstrated that patients presenting with hypoxia or requiring transfusion at the time of presentation had significantly more recurrence episodes (p = .002). Multivariate analysis showed that the presence of hypoxia at the time of initial presentation was a significant independent predictor of recurrent episodes (p = .027). The median follow-up was 3.3 years (0.75 months to 27 years). There was a significant relationship between the presence of hypoxia, transfusion history, antinuclear antibody positivity, and elevated transaminases at the time of initial evaluation and treatment response. CONCLUSIONS The present study provides substantial information regarding factors that may affect recurrent exacerbations and prognosis in children with IPH. Demonstrating hypoxia as an independent risk factor in recurrence episodes could guide physicians in the planning of treatment strategies.
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Affiliation(s)
- Mina Hizal
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | | | - Beste Ozsezen
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Jale Karakaya
- Department of Biostatistic, Hacettepe University, Ankara, Turkey
| | - Nagehan Emiralioglu
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sevgi Pekcan
- Pediatric Pulmonology, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Ayse Tana Aslan
- Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Dogru
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Ozcelik
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Abstract
OBJECTIVE. The purpose of this article is to review the clinical and imaging features of diffuse pulmonary hemorrhage. CONCLUSION. Diffuse pulmonary hemorrhage is a life-threatening syndrome associated with a wide variety of underlying pathologic categories. Nonspecific clinical and imaging features pose challenges to promptly diagnosing this condition. Chest radiography commonly shows alveolar opacification, and CT reveals the extent of disease. Integration of clinical, radiologic, laboratory, and pathologic findings facilitates timely diagnosis and etiologic identification.
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Yang CT, Chiang BL, Wang LC. Aggressive corticosteroid treatment in childhood idiopathic pulmonary hemosiderosis with better outcome. J Formos Med Assoc 2021; 120:838-846. [PMID: 32505591 DOI: 10.1016/j.jfma.2020.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/17/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND/PURPOSE Idiopathic pulmonary hemosiderosis (IPH) is a rare but fatal disease characterized by a triad of anemia, hemoptysis, and increased pulmonary infiltration. This study is aimed to review the clinical manifestations, diagnostic tools, medication and outcome of childhood IPH in Taiwan. METHODS We retrospectively enrolled the patients less than 18 years old in National Taiwan University Hospital in the past 30 years. The clinical data were collected and analyzed. RESULTS All of the twelve children diagnosed with IPH had anemia and increased pulmonary infiltration, eight had hemoptysis, and ten were confirmed with detection of hemosiderin-laden macrophages. The mean age at diagnosis were 4.9 (interquartile range 2.5-6.3) years old. Patients with high dose corticosteroid (CS, ≥ 1 mg/kg/day prednisolone equivalent) treatment had lower odds ratio for ICU admission and significant higher Hb recovery rate than those with mild disease activity not receiving high dose CS treatment (p = 0.011). The only factor that is significantly associated with persistent anemia is the usage of high dose CS (p < 0.001) after adjusting for hemoptysis, fulfilling triad, serum ferritin level, and ICU admission by multiple regression. The only factor that is significantly associated with ICU admission is the presence of microorganism yielded in sputum (p < 0.001) after adjusting for fever, serum ferritin level, usage of invasive MV, and high dose CS treatment days. CONCLUSION The aggressive high dose CS therapy might prevent ICU admission and improve anemia. Aggressive high dose CS treatment is suggested in IPH patients regardless of the disease activity.
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Affiliation(s)
- Cheng-Tsung Yang
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Pediatrics, Camillian Saint Mary's Hospital Luodong, Yilan, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan; Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chieh Wang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.
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20
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Saha BK. Idiopathic pulmonary hemosiderosis: A state of the art review. Respir Med 2021; 176:106234. [PMID: 33246295 DOI: 10.1016/j.rmed.2020.106234] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is an uncommon cause of diffuse alveolar hemorrhage (DAH). Patients with IPH usually present with hemoptysis, and the diagnosis is often delayed by years. Patients often present with intermittent episodes of hemoptysis interspersed between periods of relative normalcy. However, massive hemorrhage resulting in acute respiratory failure and non-remitting hemoptysis have also been described. The classic triad includes hemoptysis, radiologic lung infiltrate, and iron deficiency anemia. Several hypotheses regarding the pathogenesis of IPH have been proposed. These risk factors include an autoimmune, allergic or genetic predisposition, and possible environmental exposure. Since IPH appears to be responsive to corticosteroids, the autoimmune hypothesis is considered to play a crucial role. A diagnosis of IPH requires exclusion of other etiologies of DAH, including infection, medications, toxic inhalation, vasculitis, and anti-glomerular basement membrane disease, among others. Histologically, IPH is characterized by the presence of hemosiderin-laden macrophages in the alveolar space without any evidence of vasculitis or immunocomplex deposition. Corticosteroid therapy represents the primary modality of treatment. Other immunosuppressive medications have also been used with varying success, especially in the setting of steroid-refractory disease. The prognosis of IPH in adults is somewhat better compared to the pediatric population. The severity of the initial presentation does not predict future outcomes. Which risk factors and patient characteristics are associated with a poor outcome are also unknown. More research is necessary to elucidate the pathophysiology and appropriate treatment.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, MO, USA.
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21
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Tobai H, Yano J, Sato N, Amanuma F, Takahashi M, Endo M, Ishimura M, Ohga S, Maruyama H. Successful Liposteroid Therapy for a Recurrent Idiopathic Pulmonary Hemosiderosis with Down Syndrome. Case Rep Pediatr 2020; 2020:5292947. [PMID: 32373381 PMCID: PMC7197000 DOI: 10.1155/2020/5292947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/03/2020] [Indexed: 12/11/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare and life-threatening disorder. Early diagnosis and appropriate management are essential for their better prognosis and patients' quality of life (QOL). It is considered that Down syndrome patients with IPH have a worse prognosis compared to other IPH cases. A 2-year-old girl with Down syndrome received the diagnosis of IPH after two episodes of massive pulmonary hemorrhage requiring assist ventilation, who suffered from recurrent IPH during tapering period of oral corticosteroid, started liposteroid therapy. We report here a case of successful control of recurrent IPH and improved QOL enormously with tapering dose of corticosteroid after starting liposteroid therapy.
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Affiliation(s)
- Hiromi Tobai
- 1Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
- 2Department of Pediatrics, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Jun Yano
- 1Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
| | - Norio Sato
- 1Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
| | - Fumitaka Amanuma
- 1Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
| | - Mikio Takahashi
- 3Department of Clinical Laboratory, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
| | - Mikiya Endo
- 4Department of Pediatrics, Iwate Medical University, School of Medicine, Morioka, Japan
| | - Masataka Ishimura
- 2Department of Pediatrics, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Shouichi Ohga
- 2Department of Pediatrics, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Hidekazu Maruyama
- 1Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
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Temel MT, Temel L, Coskun ME, Konduk BT, Akbayram S, Demiryürek AT. Respiratory Distress and Severe Anemia in a Child With Idiopathic Pulmonary Hemosiderosis. J Pediatr Hematol Oncol 2019; 41:e254-e256. [PMID: 29683951 DOI: 10.1097/mph.0000000000001175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Idiopathic pulmonary hemosiderosis is an infrequent cause of pulmonary hemorrhage in children. It is classically defined by the triad of recurrent hemoptysis, iron-deficiency anemia, and diffuse parenchymal infiltration without an obvious cause. The pathogenesis remains unexplained, diagnosis may be difficult, and the clinical course exceedingly variable. A 4-year-old girl was admitted to the hospital with complaints of dyspnea, and skin and mucous membrane pallor. The suspicion of idiopathic pulmonary hemosiderosis led to the use of corticosteroid therapy with rapid improvement in clinical condition and discharge from hospital.
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Affiliation(s)
| | - Levent Temel
- Pediatrics Clinic, Private Gaziantep Defa Life Hospital, Gaziantep, Turkey
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Zhang Y, Luo F, Wang N, Song Y, Tao Y. Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients. J Int Med Res 2019; 47:293-302. [PMID: 30278795 PMCID: PMC6384493 DOI: 10.1177/0300060518800652] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 08/23/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE This study aimed to analyze the clinical characteristics and prognosis of pediatric idiopathic pulmonary hemosiderosis (IPH). METHODS Pediatric IPH cases that were diagnosed at West China Second University Hospital, Sichuan University between 1996 and 2017 were reviewed. Follow-up data from 34 patients were collected. RESULTS A total of 107 patients were included (42 boys and 65 girls). The median age was 6 years at diagnosis. The main manifestations of the patients were as follows: anemia (n = 100, 93.45%), cough (n = 68, 63.55%), hemoptysis (n = 61, 57%), fever (n = 23, 21.5%), and dyspnea (n = 23, 21.5%). There were relatively few pulmonary signs. The positive rates of hemosiderin-laden macrophages in sputum, gastric lavage fluid, and bronchoalveolar lavage fluid were 91.66%, 98.21%, and 100%, respectively. Seventy-nine patients were misdiagnosed. A total of 105 patients were initially treated with glucocorticoids, among whom 102 survived and three died. Among the followed up patients, two died and 32 survived, among whom 10 presented with recurrent episodes. CONCLUSIONS The classic triad of pediatric IPH is not always present. The rates of misdiagnosis and recurrence of IPH are high. Early recognition and adequate immunosuppressive therapy are imperative for improving prognosis of IPH.
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Affiliation(s)
- Yajun Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, China
| | - Fenglan Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan Province, China
| | - Nini Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan Province, China
| | - Yue Song
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan Province, China
| | - Yuhong Tao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan Province, China
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Biswas S, Shamim S, Mandal S. Idiopathic pulmonary hemosiderosis: A differential diagnosis of pulmonary tuberculosis in a young child. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2019. [DOI: 10.4103/injms.injms_44_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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25
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Welsh SK, Casey AM, Fishman MP. Pulmonary hemorrhage in infancy: A 10-year single-center experience. Pediatr Pulmonol 2018; 53:1559-1564. [PMID: 30125478 DOI: 10.1002/ppul.24142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/28/2018] [Indexed: 11/09/2022]
Abstract
AIM Pulmonary hemorrhage in infancy is rare, with challenges in determining its incidence, causes, and outcomes across diverse groups. Our aim was to better understand the incidence and identified causes. We further analyzed the subgroup of patients meeting criteria for acute idiopathic pulmonary hemorrhage of infancy (AIPHI) to determine recurrence, mortality, and treatment. METHODS We performed a 10-year retrospective cohort study of infants with pulmonary hemorrhage in a large tertiary care center. One-hundred fifty-seven patients overall were identified. RESULTS The most common diagnoses in infants with pulmonary hemorrhage were congenital heart disease (36.6%), prematurity/premature lung disease (34.6%), congenital or acquired lung disorders (15.0%), and congenital or acquired coagulopathies (13.7%). Nonaccidental trauma (NAT; n = 3) was also an important cause of pulmonary hemorrhage. All patients diagnosed with NAT had normal retinal examinations and skeletal surveys. Only four patients were identified with AIPHI. There was no mortality in this group of infants. One of four patients with AIPHI had a recurrence. Steroids were the consistent treatment for AIPHI, with a large range of treatment duration. CONCLUSION Diagnostic studies should focus on identifying non-pulmonary sources of bleeding, infection, underlying lung disease, congenital heart defects, coagulopathies, infection, and NAT, as these were the most frequently identified causes of bleeding. NAT is not adequately identified with ophthalmology exam and skeletal survey. Overall, we found AIPHI to be a rare diagnosis. All of the patients with idiopathic hemorrhage received systemic steroids with varying doses and lengths of treatment.
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Affiliation(s)
- Sebastian K Welsh
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Alicia M Casey
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Martha P Fishman
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
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26
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de Klerk KD, Bau S, Günther G. Diffuse pulmonary small nodular and patchy infiltrates on chest X-ray with hemoptysis: TB or not TB?-a call for scale up of respiratory medicine services in African TB high burden countries: a case of idiopathic pulmonary hemosiderosis. Pan Afr Med J 2018; 30:121. [PMID: 30364423 PMCID: PMC6195231 DOI: 10.11604/pamj.2018.30.121.12691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/11/2018] [Indexed: 11/11/2022] Open
Abstract
Tuberculosis is still one of the most common respiratory diseases in Africa and worldwide and miliary tuberculosis is a regular manifestation of it. Idiopathic pulmonary hemosiderosis is a rare disease entity, presenting in children as well as adults. It is characterized by the triad of recurrent episodes of alveolar hemorrhage, presenting as hemoptysis, iron deficiency anemia and bilateral pulmonary infiltrates seen on chest X-ray. These symptoms and signs can easily be confused for other diseases i.e. miliary tuberculosis, delaying appropriate management. The etiology of idiopathic pulmonary hemosiderosis remains unclear. Diagnosis is established by lung biopsy, revealing hemosiderin laden macrophages in the alveoli. Treatment during an acute episode includes corticosteroids and/or immunosuppressive therapy, as well as supportive measures. Long-term follow-up is essential.
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Affiliation(s)
| | - Steffen Bau
- Lady Pohamba Private Hospital, Windhoek, Namibia
| | - Gunar Günther
- Katutura State Hospital, UNAM School of Medicine, Windhoek, Namibia
- Research Center Borstel, Borstel, Germany
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27
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Toyomura D, Kodama Y, Tezuka J, Sagawa K, Ishikawa S. Prednisolone for pulmonary hemorrhage after Fontan procedure. Pediatr Int 2018; 60:294-295. [PMID: 29480648 DOI: 10.1111/ped.13503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/11/2017] [Accepted: 10/20/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Daisuke Toyomura
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Junichiro Tezuka
- Department of Allergy and Pulmonology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Kohichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Shiro Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
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Silva P, Ferreira PG. Idiopathic pulmonary hemosiderosis: Hemorrhagic flare after 6 years of remission. REVISTA PORTUGUESA DE PNEUMOLOGIA 2017; 23:368-369. [PMID: 28844597 DOI: 10.1016/j.rppnen.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/20/2017] [Accepted: 07/23/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- P Silva
- Respiratory Department, Centro Hospitalar do Baixo Vouga (CHBV), Aveiro, Portugal.
| | - P G Ferreira
- Respiratory Department, Centro Hospitalar do Baixo Vouga (CHBV), Aveiro, Portugal
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29
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Li YT, Guo YX, Cai LM, Pan L, Duan MQ, Yang LF, Sun YY, Tan WP, Chen ZG. Methylprednisolone pulse therapy rescued life-threatening pulmonary hemorrhage due to idiopathic pulmonary hemosiderosis. Am J Emerg Med 2017; 35:1786.e3-1786.e7. [PMID: 28784257 DOI: 10.1016/j.ajem.2017.07.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/30/2017] [Indexed: 12/16/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is an extremely rare cause of massive pulmonary hemorrhage in children. During the acute phase, death due to massive alveolar hemorrhage and subsequent severe respiratory failure. We report two cases of IPH children who developed hypoxemic respiratory failure and massive pulmonary hemorrhage. One case of a 10-year-old boy was treated with methylprednisolone pulse therapy (10mg/kg/d) for the first three days and followed by systemic steroid therapy, he successfully decannulated 10days later and discharged with a favorable quality of life. Another case of a 4year-old female child with Down's syndrome diagnosed as IPH for over one year and treated with oral corticosteroids for maintenance therapy. She sudden suffered severe hypoxemia with rapid falls in the hemoglobin level. We applied methylprednisolone pulse therapy (10mg/kg/d) for three days and other supportive therapies, the girl survived through complicated with oxygen dependence. We suggest that methylprednisolone pulse therapy provides a chance of recovery and survival for patients with IPH at the acute phase, even if accompanied by severe pulmonary hemorrhage.
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Affiliation(s)
- Ya-Ting Li
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
| | - Yu-Xiong Guo
- Pediatric Intensive Care Unit, Department of Pediatrics, Guangdong General Hospital, Guangdong Academic of Medical Sciences, Guangzhou 510080, PR China.
| | - Liang-Ming Cai
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
| | - Li Pan
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
| | - Meng-Qi Duan
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
| | - Li-Fen Yang
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
| | - Yue-Yu Sun
- Pediatric Intensive Care Unit, Department of Pediatrics, Guangdong General Hospital, Guangdong Academic of Medical Sciences, Guangzhou 510080, PR China.
| | - Wei-Ping Tan
- Department of Pediatrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510120, PR China.
| | - Zhuang-Gui Chen
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, PR China.
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Xu LH, Ou RQ, Wu BJ, Wang HY, Fang JP, Tan WP. Corticosteroid in Combination with Leflunomide and Mesenchymal Stem Cells for Treatment of Pediatric Idiopathic Pulmonary Hemosiderosis. J Trop Pediatr 2017; 63:389-394. [PMID: 28158572 DOI: 10.1093/tropej/fmx002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background This study evaluated the efficiency of corticosteroid, leflunomide and mesenchymal stem cells (MSCs) in the treatment of pediatric idiopathic pulmonary hemosiderosis (IPH). Methods Ten patients were included in the study. The diagnosis of IPH was based on clinical symptoms, laboratory examinations and pulmonary hemosiderosis. Induction therapy consisted of methylprednisolone pulse therapy, followed by prednisone plus leflunomide. Maintenance therapy consisted of low-dose prednisone, leflunomide and administration of MSCs. Results All the patients achieved complete response after treatment with corticosteroid, leflunomide and MSCs. The median follow-up was 23 months (range: 4-34 months). Moreover, administration of MSCs induced an increase in the percentage of CD4+ CD25+ regulatory T cells but a decrease in the percentage of Th17 cells. Conclusion Treatment with corticosteroid, leflunomide and MSCs for pediatric IPH was safe and effective.
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Affiliation(s)
- Lu-Hong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Rong-Qiong Ou
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Bao-Jing Wu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Hai-Yan Wang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Jian-Pei Fang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Wei-Ping Tan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
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Koker SA, Gözmen S, Oymak Y, Karapinar TH, Can D, Genç S, Vergin RC. Idiopathic Pulmonary Hemosiderosis Mimicking Iron Deficiency Anemia: A Delayed Diagnosis? Hematol Rep 2017; 9:7048. [PMID: 28670434 PMCID: PMC5477471 DOI: 10.4081/hr.2017.7048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/21/2017] [Indexed: 11/22/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is an uncommon chronic disorder in children. It is characterized by recurrent pulmonary hemorrhage and may result in hemoptysis and pulmonary insufficiency. The most common hematologic manifestation of IPH is iron deficiency anemia. The etiology of IPH is not known and its diagnosis may be difficult due to the variable clinical courses. The most helpful signs for identifying IPH are iron deficiency anemia and recurrent or chronic cough, hemoptysis, dyspnea, wheezing. We report here 5 pediatric cases of IPH presenting with iron deficiency anemia and without pulmonary symptoms. Mean corpuscular volume was low in all patients; iron was low in 4 out of 5 cases; total iron binding capacity was high in all of them; ferritin was low in 3 patients. At follow up, none of them had responded successfully to the iron therapy. Although they didn’t present with pulmonary symptoms, chest radiographs incidentally revealed diffuse reticulonoduler shadows in all of them. Computed tomography revealed diffuse ground-glass opacities, consolidation, increased density. The diagnosis was confirmed by the detection of hemosiderin-laden macrophages in bronchoalveolar lavage fluid and gastric aspirate. If patients with iron deficiency anemia don’t respond to iron therapy, they should be examined for IPH. Chest radiographs should be taken even in absence of pulmonary symptoms. Early diagnosis is important for a timely management of IPH.
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Affiliation(s)
- Sultan Aydin Koker
- Division of Pediatric Hematology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Salih Gözmen
- Division of Pediatric Hematology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Yeşim Oymak
- Division of Pediatric Hematology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | | | - Demet Can
- Division of Pediatric Allergy, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Sinan Genç
- Division of Pediatric Radiology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Raziye Canan Vergin
- Division of Pediatric Hematology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
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Idiopathic Pulmonary Hemosiderosis in a Child with Recurrent Macrophage Activation Syndrome Secondary to Systemic Juvenile Idiopathic Arthritis. Case Rep Pediatr 2017; 2017:5693501. [PMID: 28251009 PMCID: PMC5303873 DOI: 10.1155/2017/5693501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/28/2016] [Accepted: 01/05/2017] [Indexed: 11/26/2022] Open
Abstract
Macrophage activation syndrome, a severe complication of systemic juvenile idiopathic arthritis and other inflammatory diseases, represents one of the most important rheumatological emergencies. Delayed diagnosis could lead to life-threatening complications. Pulmonary hemosiderosis has been classically characterized by a triad of anemia, hemoptysis, and lung infiltrates on chest radiogram. Although the majority of patients of pulmonary hemosiderosis are considered idiopathic, secondary hemosiderosis associated with known diseases could be seen. In this case report, we aimed to present gradually increased pulmonary manifestations due to pulmonary hemosiderosis with recurrent macrophage activation syndrome attacks in a child with systemic juvenile idiopathic arthritis.
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Patra C, Sarkar S, Dasgupta MK. A child with recurrent pallor and hemoptysis: Diagnostic challenges. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/1687-8426.198993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Park K, Yoo Y, Pai K, Park JE. Three Cases of Pulmonary Hemosiderosis with Long-term Treatment of Deflazacort in Children. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.2.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kyujung Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Yeongmyong Yoo
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Kisoo Pai
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jun Eun Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
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Castellazzi L, Patria MF, Frati G, Esposito AA, Esposito S. Idiopathic pulmonary haemosiderosis in paediatric patients: how to make an early diagnosis. Ital J Pediatr 2016; 42:86. [PMID: 27644948 PMCID: PMC5029079 DOI: 10.1186/s13052-016-0296-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/15/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary haemosiderosis (IPH) is a rare but potentially lethal condition in paediatric patients. This condition is considered an immune-mediated disorder, but its pathogenesis is still unknown. Idiopathic pulmonary haemosiderosis is characterized by the classical triad of haemoptysis, iron-deficiency anaemia, and diffuse parenchymal consolidation on chest radiology. Unfortunately, this triad of signs is not frequent in children at the onset of this disease, resulting in a delay in diagnosis and a negative outcome. CASE PRESENTATION This case report describes a 4-year-old girl who was admitted for an acute episode of lower respiratory tract infection associated with severe dyspnoea, polypnoea, and severe anaemia (haemoglobin levels, 5.9 g/dL). She had a history of previous similar episodes, with anaemia treated unsuccessfully with iron supplementation and managed through repeated blood transfusions in the acute phase. She did not experience haemoptysis. A computed tomography (CT) scan of the thorax showed ground-glass opacity suggestive of pulmonary haemorrhage. After other causes of intra-alveolar haemorrhage were excluded, IPH was confirmed by the presence of siderophages in bronchoalveolar lavage. Immunosuppressive corticosteroid treatment was immediately started with a good clinical response. CONCLUSION This case highlights the fact that IPH should be suspected in children with recurrent lower respiratory tract infections who have a history of iron-deficiency anaemia who shows no signs of improvement with iron supplementation and may require repeated blood transfusions. The absence of haemoptysis does not exclude the diagnosis of IPH in children. An early and prompt diagnosis is recommended in order to start adequate immunosuppressive treatment.
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Affiliation(s)
- Luca Castellazzi
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
| | - Maria Francesca Patria
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
| | - Gemma Frati
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
| | | | - Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
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Huang SH, Lee PY, Niu CK. Treatment of Pediatric Idiopathic Pulmonary Hemosiderosis with Low-Dose Cyclophosphamide. Ann Pharmacother 2016; 37:1618-21. [PMID: 14565801 DOI: 10.1345/aph.1d042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To report the safety and efficacy of long-term, low-dose cyclophosphamide therapy in a child with idiopathic pulmonary hemosiderosis (IPH). CASE SUMMARY: A 7-year-old boy diagnosed with IPH 4 years previously was initially prescribed prednisolone. Because he only had a transient response to prednisolone, oral cyclophosphamide 2 mg/kg/d was later added. A dramatic improvement was noted during the subsequent follow-up. One year after cyclophosphamide therapy, the patient suddenly developed thrombocytopenia (platelet count 75 times 103/mm3), with the platelet count decreasing to 10 times 103/mm3 over the following 10 months. Cyclophosphamide was tapered to an alternating daily dosage of 1 mg/kg. The tapering resulted in a subsequent increase in the platelet count, which was maintained between 20 and 50 times 103/mm3 without occurrence of petechiae or spontaneous bleeding. Under this reduced dosing regimen, the disease has remained in remission for >1 year. DISCUSSION: Due to the low prevalence of IPH, only limited data document the safety and efficacy of immunosuppressive therapy in treating this disease. Although our patient showed a good response to low-dose cyclophosphamide, he developed thrombocytopenia with its use. The mechanism is unclear, but it may be similar to that of high-dose cyclophosphamide-induced myelosuppression. Due to the development of thrombocytopenia, the use of cyclophosphamide was maintained under a reduced dosing regimen. The benefit of long-term immunosuppressive therapy is controversial, and more clinical evidence is required to support its continued usage. CONCLUSIONS: Long-term, low-dose cyclophosphamide is effective in treating childhood IPH, but caution should be exercised due to the possible development of thrombocytopenia. Periodic monitoring of the platelet count in long-term treatment is recommended.
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Affiliation(s)
- Shiou-Huei Huang
- Department of Pharmacy, Chang-Gung Memorial Hospital, Kaohsiung, Taiwan
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Chen CC, McManemy JK, Vece TJ, Cruz AT. Idiopathic Pulmonary Hemosiderosis Presenting as Anemia, Failure to Thrive, and Jaundice in a Toddler. Pediatr Emerg Care 2016; 32:237-9. [PMID: 26414632 DOI: 10.1097/pec.0000000000000501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disease characterized by the triad of hemoptysis, pulmonary infiltrates on chest radiograph, and anemia. Its diagnosis should be considered in any child presenting with moderate to severe anemia and failure to thrive of unclear etiology. Consideration of the differential diagnosis in such a child should include the review of both extravascular and intravascular causes of hemolysis. Systemic treatment of IPH with glucocorticoids has been shown to decrease morbidity, mortality, and disease progression to pulmonary fibrosis. Thus, diagnostic delays can impact prognosis. Here, we present a case of a 15-month-old boy with IPH who presented with anemia, jaundice, and failure to thrive, as well as a history of hemoptysis that was not initially elicited.
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Affiliation(s)
- Carol C Chen
- From the Sections of *Emergency Medicine, and †Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
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38
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Peng S, Xiao Y, Luo J, Chen R, Huang P, Liu P, Deng X. Cor triatriatum sinister: a rare underlying cause of pulmonary hemosiderosis. SPRINGERPLUS 2016; 5:150. [PMID: 27026847 PMCID: PMC4766185 DOI: 10.1186/s40064-016-1752-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/12/2016] [Indexed: 11/24/2022]
Abstract
Pulmonary hemosiderosis is a disorder with unknown cause and characterized by hemosiderin appreciation in alveolar interstitium from decomposed hemoglobin following alveolar capillary bleeding, which finally leads to pulmonary fibrosis. It can be divided into primary and secondary types in terms of its etiology. While primary types are related to autoimmunity, secondary types can be associated with cardiovascular and pulmonary causes such as mitral stenosis leading to pulmonary congestion. We report a case of cor triatriatum sinister in a child who presented with hemoptysis as a main clinical manifestation and had been previously diagnosed with idiopathic pulmonary hemosiderosis. Based on clinical signs and imaging examinations, we considered the hemoptysis was most likely due to cor triatriatum. The child underwent corrective surgery with uneventful recovery. The hemoptysis has not recurred any more after operation. Cardiovascular disease including cor triatriatum should be considered with regards to the etiology of pulmonary hemosiderosis.
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Affiliation(s)
- Shuhan Peng
- Medical School, University of South China, Hengyang, China
| | - Yunbin Xiao
- Department of Cardiology, Hunan Children's Hospital, Changsha, 410007 Hunan China
| | - Jinwen Luo
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007 Hunan China
| | - Renwei Chen
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007 Hunan China
| | - Peng Huang
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007 Hunan China
| | - Pingbo Liu
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007 Hunan China
| | - Xicheng Deng
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007 Hunan China
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WAKIGUCHI H, OHGA S. Clinical utility of the liposteroid therapy: Potential effects on the macrophage activation. ACTA ACUST UNITED AC 2016; 39:190-6. [DOI: 10.2177/jsci.39.190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hiroyuki WAKIGUCHI
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine
| | - Shouichi OHGA
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine
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40
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Eldem İ, İleri T, İnce E, Asarcikli F, Pekpak E, Çakmakli HF, Ceyhan K, Uysal Z. Idiopathic Pulmonary Hemosiderosis With Allergic Asthma Diagnosis in a Pediatric Patient. J Pediatr Hematol Oncol 2015; 37:e435-7. [PMID: 26241728 DOI: 10.1097/mph.0000000000000412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder with unknown pathogenesis that usually presents in the first decade of life. As a result of diffuse alveolar hemorrhage, respiratory symptoms such as cough attacks, hemoptysis, dyspnea, and recurrent and refractory iron-deficiency anemia (IDA) are observed. We present an 8-year-old girl who was followed up with recurrent IDA and allergic asthma and later diagnosed with IPH. IPH was confirmed by the presence of hemosiderin-laden macrophages in bronchoalveolar lavage obtained by bronchoscopy and exclusion of the secondary causes of pulmonary hemosiderosis. Glucocorticoids and iron supplementation were started. Clinical and laboratory improvement was observed with therapy. Our case illustrates that refractory/recurrent IDA with any pulmonary symptoms may be the only presenting feature of IPH.
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Affiliation(s)
- İrem Eldem
- Departments of *Pediatrics †Pediatric Hematology ‡Pathology, Ankara University School of Medicine, Dikimevi, Ankara, Turkey
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Mushtaq A, Khatoon S, Qureshi MA. Use of Corticosteroids in the management of Idiopathic Pulmonary Haemosiderosis: Do we have enough evidence. Pak J Med Sci 2015; 31:487-9. [PMID: 26101518 PMCID: PMC4476369 DOI: 10.12669/pjms.312.7135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 12/24/2014] [Accepted: 02/01/2015] [Indexed: 11/15/2022] Open
Abstract
Idiopathic Pulmonary Haemosiderosis (IPH) is a rare disease commonly affecting the paediatric population with approximately 500 globally reported cases in the literature. The disease usually presentswith a symptom triad consisting of ferropenic anaemia, cough with haemoptysis and diffuse bilateral alveolar infiltrates. Therapeutic options for this disorder are not only limited but also not fully effective. Moreover, corticosteroids remain the mainstay of IPH treatment. This communication reviews the available evidence in support of corticosteriod usage in the treatment of IPH. We conclude that the use of corticosteroid in IPH treatment is unfathomed and demands further investigation.
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Affiliation(s)
- Ammara Mushtaq
- Ammara Mushtaq, Final Year Medical Student, Dow Medical College, Dow University of Health Sciences, Karachi - Pakistan
| | - Subika Khatoon
- Subika Khatoon, Final Year Medical Student, Dow Medical College, Dow University of Health Sciences, Karachi - Pakistan
| | - Muhammad Asif Qureshi
- Dr. Muhammad Asif Qureshi, MBBS, PhD Assistant Professor Immunology, Dow Medical College, Dow University of Health Sciences, Karachi - Pakistan
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42
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Khorashadi L, Wu CC, Betancourt SL, Carter BW. Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient. Clin Radiol 2015; 70:459-65. [PMID: 25515792 DOI: 10.1016/j.crad.2014.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/06/2014] [Accepted: 11/10/2014] [Indexed: 11/30/2022]
Abstract
Idiopathic pulmonary haemosiderosis (IPH) is a rare disease characterized by alveolar capillary haemorrhage resulting in deposition and accumulation of haemosiderin in the lungs. Although its precise pathophysiology remains unclear, several hypotheses have been proposed to explain the aetiology of the disorder, including autoimmune, environmental, allergic, and genetic theories. IPH is typically diagnosed in childhood, usually before the age of 10 years; however, this entity may be encountered in older patients given the greater awareness of the diagnosis, availability and utilization of advanced imaging techniques, and improved treatment and survival. The classic presentation of IPH consists of the triad of haemoptysis, iron-deficiency anaemia, and pulmonary opacities on chest radiography. The diagnosis is usually confirmed via bronchoscopy with bronchoalveolar lavage (BAL), at which time haemosiderin-laden macrophages referred to as siderophages, considered pathognomonic for IPH, may be identified. However, lung biopsy may ultimately be necessary to exclude other disease processes. For children with IPH, the disease course is severe and the prognosis is poor. However, adults generally have a longer disease course with milder symptoms and the prognosis is more favourable. Specific imaging features, although non-specific in isolation, may be identified on thoracic imaging studies, principally chest radiography and CT, depending on the phase of disease (acute or chronic). Recognition of these findings is important to guide appropriate clinical management.
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Affiliation(s)
- L Khorashadi
- Department of Radiology, Mount Auburn Hospital, Cambridge, MA 02138, USA
| | - C C Wu
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - S L Betancourt
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - B W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Bakalli I, Kota L, Sala D, Celaj E, Kola E, Lluka R, Sallabanda S. Idiopathic pulmonary hemosiderosis - a diagnostic challenge. Ital J Pediatr 2014; 40:35. [PMID: 24708654 PMCID: PMC3999482 DOI: 10.1186/1824-7288-40-35] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 03/28/2014] [Indexed: 11/10/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis is a rare disorder that can occur at any age and is characterized by the triad of hemoptysis, iron deficiency anemia and diffuse pulmonary infiltrates. The clinical course is exceedingly variable especially in children and a substantial proportion of this age group is undiagnosed. It is probably due to the fact that iron deficiency anemia may be the first and the only manifestation of IPH, preceding other symptoms and signs by several months and IPH is not considered as a rare cause of anemia, unless the typical triad is present. We present a case of IPH in a 13-year-old girl, treated for several months with persistent iron deficiency anemia, without response to therapy.
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Affiliation(s)
- Ilirjana Bakalli
- PICU, University Hospital Center “Mother Theresa”, Tirana, Albania
| | - Luljeta Kota
- Paediatric Pneumology, University Hospital Center “Mother Theresa”, Tirana, Albania
| | - Durim Sala
- PICU, University Hospital Center “Mother Theresa”, Tirana, Albania
| | - Ermela Celaj
- PICU, University Hospital Center “Mother Theresa”, Tirana, Albania
| | - Elmira Kola
- PICU, University Hospital Center “Mother Theresa”, Tirana, Albania
| | - Robert Lluka
- PICU, University Hospital Center “Mother Theresa”, Tirana, Albania
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Doi T, Ohga S, Ishimura M, Takada H, Ishii K, Ihara K, Nagai H, Hara T. Long-term liposteroid therapy for idiopathic pulmonary hemosiderosis. Eur J Pediatr 2013; 172:1475-81. [PMID: 23812505 DOI: 10.1007/s00431-013-2065-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 06/07/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Control of refractory bleeding in idiopathic pulmonary hemosiderosis (IPH) is challenging. Based on the effect of liposteroid (dexamethasone palmitate) for acute bleeding in two reported cases, the long-term utility was assessed in all nine IPH children (including the first two cases) treated in a tertiary center for 20 years. The median at disease onset was 2.3 years (range, 1.2 to 8.6). All had life-threatening and/or repetitive bleeding on prednisolone (PSL) therapy. Liposteroid was intravenously infused at 0.8 mg/kg/day for three consecutive days at the time of acute bleeding. Single infusion was followed by a longer interval from weekly to monthly accompanied by low-dose PSL (less than 0.3 mg/kg/day). Monthly infusion as maintenance therapy was continued for prophylaxis of bleeding. Treatment outcomes were retrospectively analyzed. During the observation period of a median of 11.0 years (range 2.4-16.9 years), no one died. Five patients were weaned and the other one was being weaned from liposteroid for the cure or long remission (median, 5.5 years). Three others were on liposteroid therapy because of active disease. Neither patient had respiratory symptoms, although three showed subnormal %vital capacity. Serum levels of KL-6 and ferritin were normal in all and all but one patient(s), respectively. Four patients (three on liposteroid therapy) showed low bone mineral density. There were no obese patients. Height SD score did not significantly decrease except for one patient. CONCLUSION The liposteroid therapy might improve the survival of IPH patients with reducing the adverse effects of steroids, although prospective control studies are needed.
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Affiliation(s)
- Takehiko Doi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Taytard J, Nathan N, de Blic J, Fayon M, Epaud R, Deschildre A, Troussier F, Lubrano M, Chiron R, Reix P, Cros P, Mahloul M, Michon D, Clement A, Corvol H. New insights into pediatric idiopathic pulmonary hemosiderosis: the French RespiRare(®) cohort. Orphanet J Rare Dis 2013; 8:161. [PMID: 24125570 PMCID: PMC3852822 DOI: 10.1186/1750-1172-8-161] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 10/11/2013] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of alveolar hemorrhage in children and its pathophysiology remains obscure. Classically, diagnosis is based on a triad including hemoptysis, diffuse parenchymal infiltrates on chest X-rays, and iron-deficiency anemia. We present the French pediatric cohort of IPH collected through the French Reference Center for Rare Lung Diseases (RespiRare®, http://www.respirare.fr). METHODS Since 2008, a national network/web-linked RespiRare® database has been set up in 12 French pediatric respiratory centres. It is structured as a medical recording tool with extended disease-specific datasets containing clinical information relevant to all forms of rare lung diseases including IPH. RESULTS We identified 25 reported cases of IPH in children from the database (20 females and 5 males). Among them, 5 presented with Down syndrome. Upon diagnosis, median age was 4.3 [0.8-14.0] yrs, and the main manifestations were: dyspnea (n = 17, 68%), anemia (n = 16, 64%), cough (n = 12, 48%), febrile pneumonia (n = 11, 44%) and hemoptysis (n = 11, 44%). Half of the patients demonstrated diffuse parenchymal infiltrates on chest imaging, and diagnosis was ascertained either by broncho-alveolar lavage indicating the presence of hemosiderin-laden macrophages (19/25 cases), or lung biopsy (6/25). In screened patients, initial auto-immune screening revealed positive antineutrophilic cytoplasmic antibodies (ANCA) (n = 6, 40%), antinuclear antibodies (ANA) (n = 5, 45%) and specific coeliac disease antibodies (n = 4, 28%). All the patients were initially treated by corticosteroids. In 13 cases, immunosuppressants were introduced due to corticoresistance and/or major side effects. Median length of follow-up was 5.5 yrs, with a satisfactory respiratory outcome in 23/25 patients. One patient developed severe pulmonary fibrosis, and another with Down syndrome died as a result of severe pulmonary hemorrhage. CONCLUSION The present cohort provides substantial information on clinical expression and outcomes of pediatric IPH. Analysis of potential contributors supports a role of auto-immunity in disease development and highlights the importance of genetic factors.
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Affiliation(s)
- Jessica Taytard
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
| | - Nadia Nathan
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
| | - Jacques de Blic
- Pediatric Pulmonary Department, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Mickael Fayon
- CHU de Bordeaux, Centre d’Investigation Clinique (CIC 0005), F-33076 Bordeaux, France
| | - Ralph Epaud
- Pediatric Department, Centre Hospitalier Inter-communal de Créteil, Créteil, France
| | - Antoine Deschildre
- Pediatric Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Françoise Troussier
- Pediatric Department, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Marc Lubrano
- Pediatric Department, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Raphaël Chiron
- Pediatric Department, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Philippe Reix
- Pediatric Pulmonary Department, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Pierrick Cros
- Pediatric Department, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Malika Mahloul
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
| | - Delphine Michon
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
| | - Annick Clement
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
| | - Harriet Corvol
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France
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Taytard J, Nathan N, de Blic J, Fayon M, Epaud R, Deschildre A, Troussier F, Lubrano M, Chiron R, Reix P, Cros P, Mahloul M, Michon D, Clement A, Corvol H. New insights into pediatric idiopathic pulmonary hemosiderosis: the French RespiRare(®) cohort. Orphanet J Rare Dis 2013. [PMID: 24125570 DOI: 10.1186/1750-1172-9-161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of alveolar hemorrhage in children and its pathophysiology remains obscure. Classically, diagnosis is based on a triad including hemoptysis, diffuse parenchymal infiltrates on chest X-rays, and iron-deficiency anemia. We present the French pediatric cohort of IPH collected through the French Reference Center for Rare Lung Diseases (RespiRare®, http://www.respirare.fr). METHODS Since 2008, a national network/web-linked RespiRare® database has been set up in 12 French pediatric respiratory centres. It is structured as a medical recording tool with extended disease-specific datasets containing clinical information relevant to all forms of rare lung diseases including IPH. RESULTS We identified 25 reported cases of IPH in children from the database (20 females and 5 males). Among them, 5 presented with Down syndrome. Upon diagnosis, median age was 4.3 [0.8-14.0] yrs, and the main manifestations were: dyspnea (n = 17, 68%), anemia (n = 16, 64%), cough (n = 12, 48%), febrile pneumonia (n = 11, 44%) and hemoptysis (n = 11, 44%). Half of the patients demonstrated diffuse parenchymal infiltrates on chest imaging, and diagnosis was ascertained either by broncho-alveolar lavage indicating the presence of hemosiderin-laden macrophages (19/25 cases), or lung biopsy (6/25). In screened patients, initial auto-immune screening revealed positive antineutrophilic cytoplasmic antibodies (ANCA) (n = 6, 40%), antinuclear antibodies (ANA) (n = 5, 45%) and specific coeliac disease antibodies (n = 4, 28%). All the patients were initially treated by corticosteroids. In 13 cases, immunosuppressants were introduced due to corticoresistance and/or major side effects. Median length of follow-up was 5.5 yrs, with a satisfactory respiratory outcome in 23/25 patients. One patient developed severe pulmonary fibrosis, and another with Down syndrome died as a result of severe pulmonary hemorrhage. CONCLUSION The present cohort provides substantial information on clinical expression and outcomes of pediatric IPH. Analysis of potential contributors supports a role of auto-immunity in disease development and highlights the importance of genetic factors.
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Affiliation(s)
- Jessica Taytard
- Pediatric Pulmonary Department, AP-HP, Hôpital Trousseau, Université Pierre et Marie Curie-Paris6, Inserm U938, 26, avenue du Docteur Arnold-Netter, 75012 Paris, France.
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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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Abstract
PURPOSE OF REVIEW Advances in genetics and clinical diagnostics, along with recently described clinical entities and refined classification schemes, have improved our understanding of diffuse and interstitial lung diseases in children. This review presents recent updates in these disorders in the context of systemic inflammatory conditions. RECENT FINDINGS Classification of childhood diffuse lung disease (DLD) using adult paradigms is not useful. Distinct clinical-pathologic entities exist in children. Infants are more likely to present with genetic and developmental disorders, and older children with inflammatory and immune-mediated conditions. A combination of clinical evaluation, high-resolution computed tomography scanning, pulmonary function testing and serology, with bronchoscopy and surgical lung biopsy in selected cases, is most useful in the evaluation of DLD in the context of rheumatologic conditions. Common causes of DLD, such as infection, especially in the setting of immunodeficiency, must be ruled out. Optimal therapy for specific disorders will require careful analysis of data from national registries. Emerging use of biomarkers and high-throughput molecular analysis will yield novel insight into these disorders. SUMMARY In the setting of known or suspected rheumatologic disorders, diagnosis and management of DLD are challenging, and require close collaboration among rheumatologists, pulmonologists, and other specialists.
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Idiopathic pulmonary hemosiderosis in adults: a case report and review of the literature. Case Rep Med 2012; 2012:267857. [PMID: 22851975 PMCID: PMC3407666 DOI: 10.1155/2012/267857] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 06/20/2012] [Indexed: 11/17/2022] Open
Abstract
Idiopathic pulmonary hemosiderosis is a very rare condition rarely affecting adults and causing recurrent episodes of diffuse alveolar haemorrhage that may lead to lung fibrosis. Due to lack of pathognomonic findings, IPH diagnosis is established upon exclusion of all other possible causes of DAH in combination with specific pathologic findings revealing bland alveolar haemorrhage with absence of vasculitis and/or accumulation of immune complexes within lung parenchyma. Here we describe a rare case of idiopathic pulmonary hemosiderosis in an otherwise healthy 27-year-old Greek male patient with relapsing episodes of fever accompanied by general fatigue and discomfort. He was at this time point a light smoker and had been hospitalised once in the past for similar symptoms. His iron deficiency anemia coupled with chest high-resolution computed tomography and bronchoalveolar lavage revealed findings compatible with diffuse alveolar hemorrhage. After excluding all other sources of bleeding through extensive gastrointestinal workup and thorough immunologic profile, video-assisted thoracic lung biopsy was performed and the diagnosis of Idiopathic Pulmonary Hemosiderosis was established. Patient was treated with high doses of oral corticosteroids, leading to clinical response. We highlight the need for vigilance by the respiratory physician for the presence of DAH, a challenging, acute condition requiring early recognition along with identification of the underlying syndrome and appropriate treatment to achieve optimal results.
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Kahraman H, Köksal N, Ozkan F. Eight Years Follow-up of a Case with Idiopathic Pulmonary Hemosiderosis After Corticosteroid Therapy. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 4:49-51. [PMID: 22393549 PMCID: PMC3289491 DOI: 10.4103/1947-2714.92907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Idiopathic pulmonary hemosiderosis is characterized by recurrent episodes of alveolar hemorrhage, hemoptysis, and secondary iron deficiency anemia with unknown etiology. It generally emerges in childhood and adolescence periods but rarely found in adulthood. Definite diagnosis is established by appearing the hemosiderin-laden macrophages at sputum, bronchoalveolar lavage, or open lung biopsy. We reported a male patient who was born in 1975, expectorated blood since 1995, and was diagnosed in 1998. He received many blood replacements. He admitted to our clinic in 2003 with complaints of coughing up blood, shortness of breath, and tiredness. We gave the corticosteroid therapy to patient for 6-month period. After treatment, the patient did not have any complaints. Clinicians should keep in mind that idiopathic pulmonary hemosiderosis may differ in localization on chest X-ray and corticosteroid treatment should be started when diagnosis is established.
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Affiliation(s)
- Hasan Kahraman
- Department of Chest Diseases, Kahramanmaraş Sutcuimam University, Kahramanmaraş, Turkey
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