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Falde SD, Fussner LA, Tazelaar HD, O'Brien EK, Lamprecht P, Konig MF, Specks U. Proteinase 3-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e314-e327. [PMID: 38574742 DOI: 10.1016/s2665-9913(24)00035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024]
Abstract
Proteinase 3 (PR3)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is one of two major ANCA-associated vasculitis variants and is pathogenically linked to granulomatosis with polyangiitis (GPA). GPA is characterised by necrotising granulomatous inflammation that preferentially affects the respiratory tract. The small vessel vasculitis features of GPA are shared with microscopic polyangiitis. Necrotising granulomatous inflammation of GPA can lead to PR3-ANCA and small vessel vasculitis via activation of neutrophils and monocytes. B cells are central to the pathogenesis of PR3-ANCA-associated vasculitis. They are targeted successfully by remission induction and maintenance therapy with rituximab. Relapses of PR3-ANCA-associated vasculitis and toxicities associated with current standard therapy contribute substantially to remaining mortality and damage-associated morbidity. More effective and less toxic treatments are sought to address this unmet need. Advances with cellular and novel antigen-specific immunotherapies hold promise for application in autoimmune disease, including PR3-ANCA-associated vasculitis. This Series paper describes the inter-related histopathological and clinical features, pathophysiology, as well as current and future targeted treatments for PR3-ANCA-associated vasculitis.
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Affiliation(s)
- Samuel D Falde
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Henry D Tazelaar
- Department of Anatomic Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maximilian F Konig
- Division of Rheumatology, Department of Medicine & Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
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2
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Jansson PS, Lord SJ. A Woman With Shortness of Breath. Ann Emerg Med 2023; 82:756-762. [PMID: 37993221 DOI: 10.1016/j.annemergmed.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Paul S Jansson
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Spencer J Lord
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
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3
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Thomas L, Boatman J. Evaluation of pulmonary abnormalities in recipients of hematopoietic cell transplants and cellular therapies. Transpl Infect Dis 2023; 25 Suppl 1:e14137. [PMID: 37665035 DOI: 10.1111/tid.14137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/28/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
Hematopoietic cell transplant (HCT) and chimeric antigen receptor T-cell (CAR-T) therapy recipients are susceptible to multiple pulmonary complications that are caused by infectious and noninfectious processes. Numerous variables can be associated with specific pulmonary diseases including time from transplantation, presence of graft versus host disease (GVHD), underlying disease, and prolonged neutropenia and lymphocytopenia. Most pulmonary complications are infectious in origin, with bacterial pneumonia remaining the most common pulmonary infection, particularly before neutrophil engraftment. Invasive fungal infections continue to affect this patient population even when antifungal prophylaxis is used. Noninfectious pulmonary complications include a wide differential of pathologies in this population, and as clinical presentations of these various pulmonary disorders often overlap, clinicians frequently will use a multidisciplinary approach in diagnosing these abnormalities. Radiography, particularly with chest computed tomography (CT) imaging, is an essential tool in identifying pulmonary pathology and potential sources. While standard microbiological cultures of respiratory specimens are still utilized, their role is limited by low sensitivity and diagnostic yield. The likelihood of obtaining a diagnosis can be improved by using other microbiological assays, including fungal antigen tests and molecular diagnostic methods, particularly if specimens are collected via bronchoscopy. This review will highlight the more common causes of pulmonary diseases encountered after HCT and CAR-T and will examine the different methods in their diagnosis.
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Affiliation(s)
- Lora Thomas
- Department of Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Julie Boatman
- Department of Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
- Department of Medicine, Veterans Affairs Medical Center, Richmond, Virginia, USA
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4
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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5
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Qanash S, Alamoudi S, Alsuraihi A, Jafri A, Malakah MA, Baghlaf B, Alamoudi M, Althobaiti MM. Lenalidomide-Induced Diffuse Alveolar Hemorrhage in Patient With Multiple Myeloma. Cureus 2023; 15:e43250. [PMID: 37692720 PMCID: PMC10491948 DOI: 10.7759/cureus.43250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
We present a case of multiple myeloma that was treated with a regimen that included lenalidomide. Lenalidomide, a thalidomide analog, is an immunomodulatory drug created synthetically by changing the chemical makeup of thalidomide to increase efficacy and lessen negative effects. It has been authorized for the treatment of relapsed or resistant multiple myeloma. In the case discussed in this report, the patient's lenalidomide dosage was changed to account for her renal impairment. Regardless of this adjustment of the dose, the patient presented with lung infiltrates, hemoptysis, and fever. Unfortunately, she was diagnosed with diffuse alveolar hemorrhage (DAH) secondary to lenalidomide after excluding other causes of hemoptysis. To the best of our knowledge, we believe this is the first case of DAH reported with lenalidomide in Saudi Arabia, which also discusses the possible therapeutic options for such presentations.
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Affiliation(s)
- Sultan Qanash
- Department of Medicine, Ministry of National Guard Health Affairs, Jeddah, SAU
- Department of Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Sameer Alamoudi
- Department of Adult Hematology and Blood and Marrow Transplant (BMT), King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Adult Hematology and Blood and Marrow Transplant (BMT), Ministry of National Guard Health Affairs, Jeddah, SAU
- Department of Adult Hematology and Blood and Marrow Transplant (BMT), King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Anas Alsuraihi
- Department of Adult Hematology and Blood and Marrow Transplant (BMT), Ministry of National Guard Health Affairs, Jeddah, SAU
- Department of Adult Hematology and Blood and Marrow Transplant (BMT), King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Asif Jafri
- Department of Internal Medicine, Ministry of the National Guard Health Affairs, Jeddah, SAU
- Department of Internal Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Manar A Malakah
- Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Bayan Baghlaf
- Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Mulukah Alamoudi
- College of Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Mohammad M Althobaiti
- Department of Adult Hematology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
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6
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Franklin SD, Fierro J, Hysinger EB, Phinizy PA, Piccione J. Hemosiderin-Laden Macrophages in Bronchoalveolar Lavage Samples of Children with Bronchopulmonary Dysplasia. J Pediatr 2023; 253:79-85. [PMID: 36130636 DOI: 10.1016/j.jpeds.2022.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the prevalence of hemosiderin-laden macrophages in children with bronchopulmonary dysplasia (BPD) and assess for an association between hemosiderin-laden macrophages and pulmonary arterial hypertension. STUDY DESIGN Retrospective case-control study of infants and children with and without BPD who underwent bronchoscopy with bronchoalveolar lavage (BAL) the at Children's Hospital of Philadelphia between 2012 and 2021. RESULTS BAL from 205 children with BPD and 106 controls without BPD matched for tracheostomy, infection, and age were reviewed for hemosiderin-laden macrophages. Seventy-one individuals (34.6%) with BPD had a BAL with 10% or more hemosiderin-laden macrophages compared with 3 (2.8%) controls (P < .0001; OR, 18.19; 95% CI, 5.57-59.41). Patients with pulmonary hypertension by echocardiogram (P = .04; OR, 3.69; 95% CI, 1.05-12.96) or an elevated mean pulmonary artery pressure during cardiac catheterization, rs (14) = 0.56, P = .04, were more likely to have elevated hemosiderin-laden macrophages on BAL samples less than 60 days from bronchoscopy. After adjusting for birth weight, gestational age, BPD grade, and age at the time of bronchoscopy using logistic regression, pulmonary hypertension was associated with a higher odds of hemosiderin-laden macrophages of 10% or more (P = .02; OR, 6.37; 95% CI, 1.28-31.87). No association was observed between hemosiderin-laden macrophages and sex, race, gestational age, birth weight, tracheostomy, or infectious studies. CONCLUSIONS This retrospective study revealed increased hemosiderin-laden macrophages in BAL samples from patients with BPD and a significant association with pulmonary arterial hypertension. It is unclear whether elevated hemosiderin-laden macrophages within BPD contributes to the pathogenesis of lung and pulmonary vascular disease or is simply a biomarker of pulmonary arterial hypertension.
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Affiliation(s)
- Stephen D Franklin
- Division of Pulmonary & Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Julie Fierro
- Division of Pulmonary & Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Erik B Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Pelton A Phinizy
- Division of Pulmonary & Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joseph Piccione
- Division of Pulmonary & Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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7
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Martin K, Deleveaux S, Cunningham M, Ramaswamy K, Thomas B, Lerma E, Madariaga H. The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature. Dis Mon 2022; 68:101465. [PMID: 36008166 DOI: 10.1016/j.disamonth.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.
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Affiliation(s)
| | | | | | | | - Beje Thomas
- Medstar Georgetown University Hospital, United States
| | - Edgar Lerma
- Advocate Christ Medical Center, United States
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8
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Sharma A, Upadhyay B, Banjade R, Poudel B, Luitel P, Kharel B. A Case of Diffuse Alveolar Hemorrhage With COVID-19 Vaccination. Cureus 2022; 14:e21665. [PMID: 35233333 PMCID: PMC8881991 DOI: 10.7759/cureus.21665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 12/14/2022] Open
Abstract
With the growing rates of vaccination against coronavirus disease 2019 (COVID-19) across the globe, rare side effects have been increasingly noticed on a post-marketing basis. Cases of myocarditis and pericarditis have been reported in the literature following COVID messenger RNA (mRNA) vaccination. However, diffuse alveolar hemorrhage (DAH) following vaccination has not been reported. DAH is a life-threatening clinicopathological entity characterized by bleeding into the alveolar space from pulmonary microvasculature. It presents a diagnostic challenge in the setting of acute respiratory failure, requiring prompt suspicion and workup. We report a case of a 59-year-old male with a recent COVID-19 infection who presented with DAH within eight hours of the first dose of mRNA vaccination (Moderna, Cambridge, MA). Bronchial alveolar lavage was performed, along with imaging of the chest, to confirm the diagnosis. Immunological workup with rheumatoid factor, anti-citrullinated peptide, anti-neutrophil cytoplasmic antibodies (P-ANCA and C-ANCA), anti-glomerular basement antibodies, Anti-double-stranded DNA, C3 and C4 complement levels, and cryoglobulin were all negative. Infectious workup with cultures and PCR from bronchial lavage was also negative. In the absence of any other causes, the etiology was likely deemed to be vaccine-induced DAH. Herein, we also discuss the possible mechanism of vaccine-related DAH and emphasize the need for further studies on vaccine-related adverse events.
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Affiliation(s)
- Alisha Sharma
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
| | - Binayak Upadhyay
- Internal Medicine, Divison of Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Rabin Banjade
- Internal medicine, AMITA Health Saint Francis hospital, Evanston, USA
| | - Bidhya Poudel
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
| | - Pankaj Luitel
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
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9
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Patel SS, Ahn KW, Khanal M, Bupp C, Allbee-Johnson M, Majhail NS, Hamilton BK, Rotz SJ, Hashem H, Beitinjaneh A, Lazarus HM, Krem MM, Prestidge T, Bhatt NS, Sharma A, Gadalla SM, Murthy HS, Broglie L, Nishihori T, Freytes CO, Hildebrandt GC, Gergis U, Seo S, Wirk B, Pasquini MC, Savani BN, Sorror ML, Stadtmauer EA, Chhabra S. Non-infectious pulmonary toxicity after allogeneic hematopoietic cell transplantation. Transplant Cell Ther 2022; 28:310-320. [DOI: 10.1016/j.jtct.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/08/2022] [Accepted: 03/13/2022] [Indexed: 10/18/2022]
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10
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Zhou P, Li Z, Gao L, Que C, Li H, Ma J, Wang G, Chen M. Pulmonary involvement of ANCA-associated vasculitis in adult Chinese patients. BMC Pulm Med 2022; 22:35. [PMID: 35022009 PMCID: PMC8756656 DOI: 10.1186/s12890-022-01829-y] [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: 10/13/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
The aim of this study was to clarify the clinical characteristics and long-term outcomes of ANCA-associated vasculitis (AAV) patients with pulmonary involvement from a single Chinese cohort.
Methods
Newly diagnosed AAV patients with pulmonary involvement, as defined by CT, were recruited from January 2010 to June 2020. Clinical data and CT images were collected retrospectively. Baseline CTs were evaluated and re-classified into four categories: interstitial lung disease (ILD), airway involvement (AI), alveolar hemorrhage (AH), and pulmonary granuloma (PG).
Results
A total of 719 patients were newly diagnosed with AAV, 366 (50.9%) of whom combined with pulmonary involvement at baseline. Among the AAV cases with pulmonary involvement, 55.7% (204/366) had ILD, 16.7% (61/366) had AI alone, 14.8% (54/366) had PG, and 12.8% (47/366) had AH alone. During follow-up of a median duration of 42.0 months, 66/366 (18.0%) patients died, mainly died from infections. Survival, relapse, and infection were all significantly different based on the radiological features. Specifically, the ILD group tends to have a poor long-term prognosis, the PG group is prone to relapse, and the AI group is apt to infection. The AH group has a high risk of both early infection and relapse, thus a poor short-term prognosis.
Conclusion
AAV patients with diverse radiological features have different clinical characteristics and outcomes. Therefore, the intensity of immunosuppressive therapy must be carefully valued by considering the baseline CT findings among AAV patients with pulmonary involvement.
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11
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Sangli SS, Ryu JH, Baqir M. Diffuse Alveolar Hemorrhage in Primary Versus Secondary Antiphospholipid Syndrome. J Clin Rheumatol 2021; 27:e297-e301. [PMID: 32195850 DOI: 10.1097/rhu.0000000000001358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) occurs in patients with both primary and secondary antiphospholipid antibody syndrome (APS). We sought to determine the differences in clinical presentation, management, and outcomes of DAH in these patients. METHODS We performed a medical records review study and reviewed 30 patients with DAH in the setting of primary and secondary antiphospholipid syndrome seen at our institution between January 1, 1997, and December 31, 2018. We analyzed their demographics, clinical presentation, laboratory values, imaging studies, lung pathology results, management, and outcomes. RESULTS The patients in the secondary APS cohort were younger (median age, 48.5 vs 58 years) and comprised more females (75% vs 17%) compared with those with primary APS (p < 0.05). Two thirds of patients in the secondary APS group were anemic compared with less than one fourth in the primary APS group (p = 0.005). At the time of the first episode of DAH, the patients in the secondary APS required invasive and noninvasive ventilation, antibiotics, and combination immunosuppressive therapy (includes a combination of glucocorticoids with immunosuppressants or intravenous immunoglobulins or plasma exchange) more often compared with those with primary APS. There was only one in-hospital death (3% in-hospital mortality). One-year and 5-year mortality rates were 20% and 27%, respectively, with no significant difference between the primary and secondary APS groups. CONCLUSIONS Diffuse alveolar hemorrhage in the setting of APS, especially secondary APS, can be severe. However, in-hospital mortality is uncommon with current management strategies.
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Affiliation(s)
- Swathi S Sangli
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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12
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Ugajin M, Kani H, Hattori H. Anticoagulant Use as an Independent Risk Factor and Higher In-Hospital Mortality in Patients Showing Alveolar Hemorrhage in Diffuse Lung Disease. ACTA ACUST UNITED AC 2021; 57:medicina57101094. [PMID: 34684131 PMCID: PMC8538906 DOI: 10.3390/medicina57101094] [Citation(s) in RCA: 1] [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: 08/27/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 01/15/2023]
Abstract
Background and objectives: Bronchoalveolar lavage (BAL) is commonly performed to evaluate diffuse lung disease and occasionally to identify alveolar hemorrhage. However, the clinical impact of alveolar hemorrhage and its risk factors in patients with diffuse lung disease have not been clarified. Materials and Methods: We retrospectively analyzed the medical records of all patients who underwent BAL to evaluate diffuse lung disease from January 2017 to December 2020. Alveolar hemorrhage was defined as progressive hemorrhagic BAL fluid or the presence of ≥20% hemosiderin-laden macrophages in the BAL fluid. Logistic regression analysis was performed to assess the association between alveolar hemorrhage and other factors. Results: Sixty subjects were enrolled in this study. Alveolar hemorrhage was observed in 19 subjects (31.7%) with idiopathic interstitial pneumonia, acute respiratory distress syndrome, interstitial pneumonia with autoimmune features, drug-induced lung injury, eosinophilic pneumonia, adenocarcinoma, and systemic lupus erythematosus. The use of anticoagulants was a significant risk factor for alveolar hemorrhage (odds ratio 7.57, p = 0.049). Patients with alveolar hemorrhage required intubated mechanical ventilation more frequently (63.2% vs. 24.4%, p = 0.005) and had higher in-hospital mortality rates (26.3% vs. 4.9%, p = 0.028) than those without alveolar hemorrhage. Conclusions: Alveolar hemorrhage was observed in various etiologies. The use of anticoagulants was a significant risk factor for alveolar hemorrhage. Patients with alveolar hemorrhage showed more severe respiratory failure and had higher in-hospital mortality than those without alveolar hemorrhage.
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Affiliation(s)
- Motoi Ugajin
- Department of Respiratory Medicine, Nagoya Tokushukai General Hospital, 2-52 Kouzouji-cho Kita, Kasugai City 487-0016, Japan
- Department of Respiratory Medicine and Allergology, Aichi Medical University Hospital, Nagakute City 480-1195, Japan
- Correspondence: ; Tel.: +81-568-51-8711; Fax: +81-568-51-7115
| | - Hisanori Kani
- Department of Thoracic Surgery, Nagoya Tokushukai General Hospital, Kasugai City 487-0016, Japan;
| | - Hideo Hattori
- Department of Pathology, Nagoya Tokushukai General Hospital, Kasugai City 487-0016, Japan;
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13
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Rice AJ. Non-neoplastic respiratory fluid cytology including cell differential counts for interstitial lung disease. Cytopathology 2021; 33:44-56. [PMID: 34628692 DOI: 10.1111/cyt.13067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 12/23/2022]
Abstract
Bronchioloalveolar lavage (BAL) is a non-invasive and well-tolerated procedure that plays a key role in the diagnosis of a variety of non-neoplastic pulmonary diseases, including acute respiratory failure, infection, diffuse parenchymal lung disease (DLPD), paediatric and occupational lung disease, and in the evaluation of the lung allograft. A variety of analytic techniques are commonly performed on BAL fluid, including cytology, cell differential count, microbiology and virology, as well as a number of additional techniques in specific circumstances.
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Affiliation(s)
- Alexandra J Rice
- Department of Histopathology, Royal Brompton Hospital, London, UK
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14
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Wang L, Wang J, Xu Y, Jiao J, Xie L, Mo G. A novel therapeutic strategy using extracorporeal membrane oxygenation in patients with anti-neutrophil cytoplasmic antibodies-associated vasculitis: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1267. [PMID: 34532404 PMCID: PMC8421983 DOI: 10.21037/atm-21-3133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/19/2021] [Indexed: 12/20/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) often results in severe respiratory failure which requires emergent management. In patients who are resistant to traditional mechanical respiratory support, extracorporeal membrane oxygenation (ECMO) can be used to maintain gas exchange, thereby providing time for the administration of immunosuppressive therapy to control the inflammation. Herein, we report the application of ECMO to support an adult patient with AAV complicated by severe respiratory failure due to DAH. Similar cases in the literature were identified and discussed. The patient in our case study was successfully treated with ECMO in the acute phase and relieved by immunosuppressive therapy after withdrawal of ECMO. A search in the PubMed database revealed 32 similar cases with DAH, of which 11 cases were microscopic polyangiitis (MPA), 2 cases were eosinophilic granulomatosis with polyangiitis (EGPA), and 19 cases were granulomatosis with polyangiitis (GPA). These patients were all treated with ECMO. Therefore, to date, we identified 33 patients who were effectively treated with ECMO, including 13 (39.4%) males and 20 (60.6%) females, with a ratio of 1:1.54. The average age was 32.4±17.5 and 36.0±16.1 years for males and females, respectively (t=0.610, P=0.547). Most patients received ECMO on the first day of admission to the intensive care unit (ICU) and it appeared that early initiation of ECMO was associated with a shorter duration of ECMO. In general, complications of ECMO in these patients were mild and were not often seen in the clinical setting. This study suggested that early recognition of respiratory failure and referral for ECMO are vital to achieve a satisfactory outcome in AAV patients with DAH.
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Affiliation(s)
- Li Wang
- Department of Critical Care Medicine, The First Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Jiang Wang
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Yi Xu
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Jie Jiao
- Department of Critical Care Medicine, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Lixin Xie
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
| | - Guoxin Mo
- Department of Pulmonary & Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Haidian District, Beijing, China
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Toquet S, Cousson J, Choiselle N, Gozalo C, Giusti D, Bani-Sadr F, N'Guyen Y. Alveolar hemorrhage due to marijuana smoking using water pipe made with plastic bottle: case report and narrative review of the literature. Inhal Toxicol 2021; 33:168-176. [PMID: 34180335 DOI: 10.1080/08958378.2021.1939465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION We described a case of alveolar hemorrhage (AH) after marijuana smoking using a water pipe made with plastic bottle (bong) before making a narrative review of the literature. CASE REPORT A 19-year-old male was admitted for hemoptysis and dyspnea evolving since the previous day. He smoked marijuana ten times a day using bongs. Computed tomography scan of the chest (chest CT-scan) evidenced ground glass opacities involving upper lobes with crazy-paving pattern. Bronchoalveolar lavage (BAL) yielded fluid becoming progressively bloody suggestive of AH. Screening of drug metabolites ruled out the presence of cocaine degradation products. Treatment with prednisone was prescribed and oxygen requirements decreased rapidly. The patient accepted to stop bongs, but kept on smoking marijuana using joints. He was asymptomatic 2 months later; all ground glass opacities had vanished. REVIEW OF THE LITERATURE Four cases described exactly the same circumstances as ours. All were young male patients containing ground glass opacities with diffuse or bilateral pattern in their chest CT-scan. The explanation suggested by the authors of these cases was the potential concomitant inhalation of acid anhydrides derived from use of heated plastic bottle. No acid anhydrides were experimentally evidenced after thermodesorption of heated polyethylene terephthalate (PET) (in which a majority of plastic bottles are made) we performed, but other compounds were. E-cigarette, or vaping, product use-associated lung injuries cases share some chest CT-scan patterns with those of AH following bong use and we tried to draw a parallel between these two latter before discussing a physiopathological hypothesis.
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Affiliation(s)
- Ségolène Toquet
- Service de Médecine Interne, Maladies Infectieuses et Immunologie Clinique, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Joël Cousson
- Unité de Réanimation Polyvalente, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Nathalie Choiselle
- Ecole Nationale Supérieure d'Ingénieurs de Reims ESIREIMS, Université de Reims Champagne Ardennes, Reims, France
| | - Claire Gozalo
- Laboratoire de Pharmacologie, Hôpital Maison Blanche, CHU Reims, Reims, France
| | - Delphine Giusti
- Laboratoire d'Immunologie, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Firouze Bani-Sadr
- Service de Médecine Interne, Maladies Infectieuses et Immunologie Clinique, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Yohan N'Guyen
- Service de Médecine Interne, Maladies Infectieuses et Immunologie Clinique, Hôpital Robert Debré, CHU Reims, Reims, France
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Li S, Sharma N, Kazmierski D, Amjad MA, Dong Y, Wang Y, Sharma N, Ramakrishna S, Ochieng P. Diffuse Alveolar Hemorrhage With Avelumab Maintenance Therapy. Cureus 2021; 13:e15805. [PMID: 34306873 PMCID: PMC8294017 DOI: 10.7759/cureus.15805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint blockade is a rapidly expanding therapeutic modality in oncology. However, its adverse effects extend beyond the cytotoxicity of conventional chemotherapy. Pneumotoxicity associated with immune checkpoint therapy presents a diagnostic conundrum that has been further complicated by the COVID-19 pandemic. We report a case of a patient with metastatic urothelial carcinoma who developed diffuse alveolar hemorrhage (DAH) following treatment with avelumab.
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Affiliation(s)
- Si Li
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Nishant Sharma
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Daniel Kazmierski
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Mohammad Asim Amjad
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Yishan Dong
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, USA
| | - Namita Sharma
- Hematology and Oncology, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | | - Pius Ochieng
- Pulmonary and Critical Care Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
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Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:ijms22020793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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18
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Epidemiology, Risk Factors, and Outcomes of Diffuse Alveolar Hemorrhage After Hematopoietic Stem Cell Transplantation. Chest 2021; 159:2325-2333. [PMID: 33434501 DOI: 10.1016/j.chest.2021.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/02/2020] [Accepted: 01/02/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is an uncommon complication of hematopoietic stem cell transplantation (HCT) that carries high morbidity and mortality. Limited contemporary data are available regarding the incidence, outcomes, and risk factors for DAH. RESEARCH QUESTION What are the incidence, outcomes, and risk factors for DAH developing after HCT? METHODS This was a single-center retrospective cohort study of patients who underwent HCT between January 1, 2005, and December 31, 2016. The incidence and outcomes of DAH development were evaluated. A multivariate logistic regression model was used to analyze differences between survivors and nonsurvivors. RESULTS Of 4,350 patients undergoing first-time HCT, DAH was diagnosed in 99 (2.3%). DAH was seen in 40 of 3,536 autologous HCT recipients (1.1%) and 59 of 814 allogeneic HCT recipients (7.2%). Mean age was 53 ± 13 years, and median time of DAH diagnosis was 126 days (interquartile range, 19-349 days) after HCT. In-hospital mortality and mortality 1 year after DAH diagnosis were 55.6% and 76.8%, respectively. DAH diagnosis more than 30 days after transplantation (OR, 7.06; 95% CI, 1.65-30.14), low platelet count (OR, 0.98; 95% CI, 0.96-1.0; P = .02), elevated international normalized ratio (INR; OR, 4.08; 95% CI, 0.64-25.88; P = .046) and need for invasive mechanical ventilation (OR, 8.18; 95% CI, 1.9-35.21) were associated with higher in-hospital mortality. Steroid treatment did not alter mortality (P = .80) or length of stay (P = .65). However, among those who received steroids, survival was higher in whose who received modest-dose steroids (< 250 mg methylprednisolone equivalent/d) compared with those who received high-dose steroids (≥ 250 mg methylprednisolone equivalent/d; OR, 0.21; 95% CI, 0.07-0.72). INTERPRETATION The mortality of DAH after HCT remains high, and DAH can occur long after transplantation. Later development of DAH (>30 days after HCT), need for invasive mechanical ventilation, thrombocytopenia, and elevated INR are all associated with worse outcomes.
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19
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Risk factors and outcomes of diffuse alveolar haemorrhage after allogeneic haematopoietic stem cell transplantation. Bone Marrow Transplant 2021; 56:2097-2107. [PMID: 33846561 PMCID: PMC8040008 DOI: 10.1038/s41409-021-01293-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/15/2021] [Accepted: 03/29/2021] [Indexed: 02/05/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) is a life-threatening pulmonary complication occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT) without an explicit aetiology or a standard treatment. This study aimed to explore the occurrence and prognosis of DAH after allo-HSCT, in addition to comparing discrepancies in the incidence, clinical characteristics and outcomes of DAH between patients undergoing haploidentical HSCT (HID-HSCT) and matched related donor HSCT (MRD-HSCT). We retrospectively evaluated 92 consecutive patients among 3987 patients with a confirmed diagnosis of DAH following allo-HSCT (HID: 71 patients, MRD: 21 patients). The incidence of DAH after allo-HSCT was 2.3%, 2.4% after HID-HSCT and 2.0% after MRD-HSCT (P = 0.501). The prognosis of patients with DAH after transplantation is extremely poor. The duration of DAH was 7.5 days (range, 1-48 days). The probabilities of overall survival (OS) were significantly different between patients with and without DAH within 2 years after transplantation (P < 0.001). According to the Cox regression analysis, a significant independent risk factor for the occurrence of DAH was delayed platelet engraftment (P < 0.001), and a high D-dimer level (>500 ng/ml) was a significant risk factor for the poor prognosis of DAH. HID-HSCT is similar to MRD-HSCT in terms of the outcomes of DAH.
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20
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Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:1757. [PMID: 33014865 PMCID: PMC7509147 DOI: 10.3389/fonc.2020.01757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
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21
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Sacoto G, Boukhlal S, Specks U, Flores-Suárez LF, Cornec D. Lung involvement in ANCA-associated vasculitis. Presse Med 2020; 49:104039. [PMID: 32650042 DOI: 10.1016/j.lpm.2020.104039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lung involvement is one of the most common clinical features in ANCA-associated vasculitides (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). In this review, we detail the five main presentations of pulmonary involvement in AAV: necrotizing granulomatous inflammation, tracheobronchial inflammation, pulmonary capillaritis, interstitial lung disease (ILD) and asthma with their clinical, radiological and therapeutic characteristics. The prevalence of these manifestations is variable according to the subtype of AAV, necrotizing granulomatous inflammation and tracheobronchial inflammation being defining features of GPA whereas ILD is primarily seen in patients with MPA, especially in association with ANCA directed against myeloperoxydase (MPO-ANCA), and asthma is characteristic of EGPA. Despite recent progresses in the diagnosis and management of these conditions, several questions remain and are discussed here, including local treatments for subglottic stenosis, the uncertain efficacy of plasma exchanges for alveolar hemorrhage, the potential role of antifibrotic agents in ILD associated with MPA, and the use of novel anti-IL-5 strategies in EGPA.
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Affiliation(s)
- Goethe Sacoto
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Calzada de Tlalpan 4502, Col. Sección XVI, CP 14080, Mexico City, Mexico
| | - Sara Boukhlal
- Inserm UMR1227, lymphocytes B et autoimmunité, service de rhumatologie, université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Calzada de Tlalpan 4502, Col. Sección XVI, CP 14080, Mexico City, Mexico
| | - Divi Cornec
- Inserm UMR1227, lymphocytes B et autoimmunité, service de rhumatologie, université de Bretagne Occidentale, CHU de Brest, Brest, France.
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22
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Mondoni M, Rinaldo RF, Carlucci P, Terraneo S, Saderi L, Centanni S, Sotgiu G. Bronchoscopic sampling techniques in the era of technological bronchoscopy. Pulmonology 2020; 28:461-471. [PMID: 32624385 DOI: 10.1016/j.pulmoe.2020.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023] Open
Abstract
Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.
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Affiliation(s)
- M Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - R F Rinaldo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - P Carlucci
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - S Terraneo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - L Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical, Experimental Sciences, University of Sassari, Sassari, Italy
| | - S Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - G Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical, Experimental Sciences, University of Sassari, Sassari, Italy.
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Haider S, Durairajan N, Soubani AO. Noninfectious pulmonary complications of haematopoietic stem cell transplantation. Eur Respir Rev 2020; 29:29/156/190119. [PMID: 32581138 PMCID: PMC9488720 DOI: 10.1183/16000617.0119-2019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) is an established treatment for a variety of malignant and nonmalignant conditions. Pulmonary complications, both infectious and noninfectious, are a major cause of morbidity and mortality in patients who undergo HSCT. Recent advances in prophylaxis and treatment of infectious complications has increased the significance of noninfectious pulmonary conditions. Acute lung injury associated with idiopathic pneumonia syndrome remains a major acute complication with high morbidity and mortality. On the other hand, bronchiolitis obliterans syndrome is the most challenging chronic pulmonary complication facing clinicians who are taking care of allogeneic HSCT recipients. Other noninfectious pulmonary complications following HSCT are less frequent. This review provides a clinical update of the incidence, risk factors, pathogenesis, clinical characteristics and management of the main noninfectious pulmonary complications following HSCT. Noninfectious pulmonary complications following haematopoietic stem cell transplantation is a major cause of morbidity and mortality in this patient population. There are recent advances in the diagnosis and management of these conditions.http://bit.ly/2FgsIYG
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Affiliation(s)
- Samran Haider
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Navin Durairajan
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Higo H, Suzaki N, Nagata T, Togami T, Ohara N, Marukawa M. Pulmonary lymphangitic carcinomatosis from gallbladder cancer mimicking diffuse alveolar haemorrhage. Respirol Case Rep 2020; 8:e00540. [PMID: 32148839 PMCID: PMC7026625 DOI: 10.1002/rcr2.540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 11/19/2022] Open
Abstract
Diagnosis in cases with pulmonary lymphangitic carcinomatosis as a primary manifestation is difficult due to unawareness of the cancer. An 81-year-old man was admitted due to a one-week history of dyspnoea and haemoptysis. Chest computed tomography showed diffuse bilateral ground-grass opacity and partial consolidation. We suspected diffuse alveolar haemorrhage. High-dose methylprednisolone and cyclophosphamide did not improve his condition and he died from respiratory failure. Autopsy revealed pulmonary lymphangitic carcinomatosis of whole lungs and primary gallbladder cancer. We should consider pulmonary lymphangitic carcinomatosis in the differential diagnosis of patients with haemoptysis and diffuse lung opacity of unknown origin.
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Affiliation(s)
- Hisao Higo
- Department of Internal MedicineKagawa Rosai HospitalMarugameJapan
| | - Noriyuki Suzaki
- Department of Internal MedicineKagawa Rosai HospitalMarugameJapan
| | - Takuya Nagata
- Department of Internal MedicineKagawa Rosai HospitalMarugameJapan
| | - Taro Togami
- Department of RadiologyKagawa Rosai HospitalMarugameJapan
| | - Nobuya Ohara
- Department of PathologyKagawa Rosai HospitalMarugameJapan
| | - Masaomi Marukawa
- Department of Internal MedicineKagawa Rosai HospitalMarugameJapan
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Prasad K, Singh P, Kanabar K, Vijayvergiya R. Pulmonary haemorrhage following thrombolysis with streptokinase in myocardial infarction. BMJ Case Rep 2020; 13:13/1/e232308. [PMID: 31980474 DOI: 10.1136/bcr-2019-232308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pulmonary haemorrhage is a rare but a life-threatening complication of thrombolytic therapy in patients with acute ST-elevation myocardial infarction (MI). It usually presents with anaemia, massive haemoptysis, acute-onset respiratory distress and diffuse bilateral lung infiltrates on imaging. We hereby describe two patients, who had pulmonary haemorrhage following streptokinase therapy for acute MI. The first patient improved with conservative treatment, while the second patient died due to respiratory failure. Streptokinase, a fibrin non-specific agent, is a widely used thrombolytic in low-income and middle-income countries. Pulmonary haemorrhage should be suspected in patients who develop sudden respiratory compromise after receiving thrombolytics, especially streptokinase. The management issues related to this uncommon life-threatening complication have been discussed in this article.
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Affiliation(s)
- Krishna Prasad
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parminder Singh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kewal Kanabar
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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What the Intensivists Need to Know About Critically Ill Myeloma Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121630 DOI: 10.1007/978-3-319-74588-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal protein in serum and urine. With the introduction of novel therapies with manageable side effects, this incurable disease has evolved into a chronic disease with an acceptable quality of life for the majority of patients. Accordingly, management of acute complications is fundamental in reducing the morbidity and mortality in MM. MM emergencies include symptoms and signs related directly to the disease and/or to the treatment; many organs may be involved including, but not limited to, renal, cardiovascular, neurologic, hematologic, and infectious complications. This review will focus on the numerous approaches that are aimed at managing these complications.
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27
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What the Intensivist Needs to Know About Hematopoietic Stem Cell Transplantation? ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121262 DOI: 10.1007/978-3-319-74588-6_99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potential curative therapy for some patients with hematologic conditions. There are two main types of HSCT. This includes autologous HSCT, for which the stem cells are obtained from the patient, and allogeneic HSCT, for which the stem cells are obtained from a related or unrelated donor. The most common indications for autologous stem cell transplant are multiple myeloma and relapsed/refractory lymphoma, whereas leukemia and bone marrow failure syndromes remain the most common indications for allogeneic stem cell transplant. This chapter will review the different types, indications, processes, and main complications of HSCT. This chapter will also discuss end-of-life issues that patients and providers face when transplant patients are admitted for the intensive care unit.
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28
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Maillet T, Goletto T, Beltramo G, Dupuy H, Jouneau S, Borie R, Crestani B, Cottin V, Blockmans D, Lazaro E, Naccache JM, Pugnet G, Nunes H, de Menthon M, Devilliers H, Bonniaud P, Puéchal X, Mouthon L, Bonnotte B, Guillevin L, Terrier B, Samson M. Usual interstitial pneumonia in ANCA-associated vasculitis: A poor prognostic factor. J Autoimmun 2019; 106:102338. [PMID: 31570253 DOI: 10.1016/j.jaut.2019.102338] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Progressive fibrosing interstitial lung disease (ILD) is rarely associated with antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). This study focused on the outcomes of ILD patients with associated AAV (AAV-ILD). METHODS AAV-ILD (cases: microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) with ILD) were compared to AAV patients without ILD (controls). ILD was defined as a usual interstitial pneumonia (UIP) or non-specific interstitial pneumonia (NSIP) pattern. Two controls were matched to each case for age (>or ≤65 years), ANCA status (PR3-or MPO-positive) and creatininemia (≥or <150 μmol/L). RESULTS Sixty-two cases (89% MPO-ANCA+) were included. Median age at AAV diagnosis was 66 years. ILD (63% UIP), was diagnosed before (52%) or simultaneously (39%) with AAV. Cases versus 124 controls less frequently had systemic vasculitis symptoms. One-, 3- and 5-year overall survival rates, respectively, were: 96.7%, 80% and 66% for cases versus 93.5%, 89.6% and 83.8% for controls (p = 0.008). Multivariate analyses retained age >65 years (hazard ratio (HR) 4.54; p < 0.001), alveolar haemorrhage (HR 2.25; p = 0.019) and UIP (HR 2.73; p = 0.002), but not immunosuppressant use, as factors independently associated with shorter survival. CONCLUSION For AAV-ILD patients, only UIP was associated with poorer prognosis. Immunosuppressants did not improve the AAV-ILD prognosis. But in analogy to idiopathic pulmonary fibrosis, anti-fibrosing agents might be useful and should be assessed in AAV-ILD patients with a UIP pattern.
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Affiliation(s)
- Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Tiphaine Goletto
- Department of Pulmonology, Hôpital Saint-Louis, APHP, Paris, France
| | - Guillaume Beltramo
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Henry Dupuy
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Stéphane Jouneau
- Department of Pulmonology, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR S, 1085, Rennes, France
| | - Raphael Borie
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Bruno Crestani
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Vincent Cottin
- Department of Pulmonology, Hôpital Louis-Pradel, Bron, France
| | - Daniel Blockmans
- Department of Internal Medicine, UZ Leuven Hospital, Leuven, Belgium
| | - Estibaliz Lazaro
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Jean-Marc Naccache
- Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Tenon, Service de Pneumologie, Site Constitutif Du Centre de Référence des Maladies Pulmonaires Rares OrphaLung, Paris, France
| | - Grégory Pugnet
- Department of Internal Medicine, CHU de Toulouse, Toulouse, France
| | - Hilario Nunes
- Department of Pulmonology, Hôpital Avicenne, APHP, Bobigny, France
| | - Mathilde de Menthon
- Department of Internal Medicine, Hôpital Bicêtre, APHP, Le Kremlin-Bicêtre, France
| | - Hervé Devilliers
- Department of Internal Medicine and Systemic Diseases, CHU Dijon-Bourgogne, Dijon, France
| | - Philippe Bonniaud
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Xavier Puéchal
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Loïc Guillevin
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
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29
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Acute respiratory distress syndrome in leptospirosis. J Crit Care 2019; 51:165-169. [DOI: 10.1016/j.jcrc.2019.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 02/12/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
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30
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Helgeson SA, Heckman AJ, McCain JD, Cowart JB, Maniaci MJ, Garland JL. A 32-year-old man with hypoxemia and bilateral upper-lobe predominant ground-glass infiltrates on chest imaging. Oxf Med Case Reports 2018; 2018:omy072. [PMID: 30302263 PMCID: PMC6169198 DOI: 10.1093/omcr/omy072] [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: 05/02/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 11/27/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare, but potentially fatal, complication of antiphospholipid syndrome, and may present with acute and fulminant symptoms. We report a case of DAH presenting as sudden onset dyspnea in a gentleman with known antiphospholipid syndrome. Chest computed tomography angiography with pulmonary embolism protocol showed right lower lobe segmental filling defects, upper-lobe predominant diffuse ground-glass opacities, and centrilobular nodules bilaterally. The presence of DAH can be confirmed by bronchoalveolar lavage with serial aliquots, but this procedure typically does not elucidate the specific etiology for the hemorrhage. The treatment for patients with severe disease typically consists of a combination of immunosuppressive medications in the form of high-dose intravenous glucocorticoids plus rituximab, cyclophosphamide or mycophenolate; and/or plasma exchange. This case both provides an example of high-quality diagnostic imaging of diffuse alveolar hemorrhage as well as demonstrates the clinical and image-based improvement after treatment.
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31
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Delvino P, Monti S, Balduzzi S, Belliato M, Montecucco C, Caporali R. The role of extra-corporeal membrane oxygenation (ECMO) in the treatment of diffuse alveolar haemorrhage secondary to ANCA-associated vasculitis: report of two cases and review of the literature. Rheumatol Int 2018; 39:367-375. [PMID: 30074077 DOI: 10.1007/s00296-018-4116-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/28/2018] [Indexed: 01/19/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a rare life-threatening condition presenting with severe respiratory failure. The management of AAV-related DAH consists of remission induction immunosuppressive therapy, which requires time to be effective, with significant fatality rates despite appropriate treatment. Extracorporeal membrane oxygenation (ECMO) can support gas exchanges providing the time necessary for immunosuppressive treatment to control the underlying disease in cases refractory to the conventional ventilation techniques. Despite severe preexisting bleeding has been considered a relative contraindication, ECMO has proven to be life-saving in several cases of respiratory failure associated with pulmonary haemorrhage due to various causes, including AAV. We reviewed the clinical presentation and course of two patients affected by AAV-related DAH treated at our Institution between 2012 and 2017, whose management required the use of veno-venous ECMO. We reviewed the current literature on the role of ECMO in the support of these patients. In both patients, ECMO provided life support and allowed disease control, in combination with immunosuppressive treatment. Despite systemic anticoagulation, clinical improvement was achieved without exacerbation of the pulmonary bleeding. We performed a literature review, and summarized available data confirming the effectiveness and safety of ECMO in AAV-related DAH. ECMO has a life-saving role in the management of patients with severe respiratory failure due to ANCA-associated pulmonary capillaritis.
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Affiliation(s)
- Paolo Delvino
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
| | - Sara Monti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.,University of Pavia, Pavia, Italy
| | - Silvia Balduzzi
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Mirko Belliato
- UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione 1, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Roberto Caporali
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
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32
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Severe Maternal Morbidity Associated with Systemic Lupus Erythematosus Flare in the Second Trimester of Pregnancy. Case Rep Obstet Gynecol 2018; 2018:5803479. [PMID: 29862103 PMCID: PMC5971339 DOI: 10.1155/2018/5803479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/05/2018] [Accepted: 04/08/2018] [Indexed: 12/22/2022] Open
Abstract
Pregnancy in women with systemic lupus erythematosus (SLE) is associated with an increased risk of adverse maternal and fetal outcomes. Here, we present a case of severe maternal morbidity in a 23-year-old primigravida with SLE and secondary Sjögren's syndrome who experienced a life-threatening multisystem flare at 17 weeks of gestational age. She presented to the emergency department complaining of cough with hemoptysis and shortness of breath. She developed hypoxic respiratory failure and was admitted to the intensive care unit. Bronchoscopy confirmed diffuse alveolar hemorrhage. Physical exam and laboratory evaluation were consistent with an active SLE flare, pancytopenia, and new-onset lupus nephritis. After counseling regarding disease severity, poor prognosis, and recommendation for therapy with cytotoxic agents, she agreed to interruption of pregnancy which was achieved by medical induction. Her course was further complicated by thrombotic microangiopathy and generalized tonic-clonic seizures attributable to posterior reversible encephalopathy syndrome versus neuropsychiatric SLE. This case represents one of the most extreme manifestations of lupus disease activity associated with pregnancy that has been reported in the literature and emphasizes the importance of preconception evaluation and counseling and a multidisciplinary management approach in cases with a complex and evolving clinical course.
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33
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Mukai Y, Agatsuma T, Ideura G. Early diagnosis of idiopathic pulmonary haemosiderosis: increased haemosiderin-laden macrophages in repeat bronchoscopy. Respirol Case Rep 2018. [PMID: 29541474 PMCID: PMC5838562 DOI: 10.1002/rcr2.304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Idiopathic pulmonary haemosiderosis (IPH) is a diagnosis of exclusion, which is characterized by persistent or recurrent episodes of alveolar haemorrhage. Early diagnosis of IPH, especially in the case of first‐time manifestation, is challenging because previous episodes of alveolar haemorrhage are often difficult to prove. Repeated episodes of alveolar haemorrhage can result in chronic iron‐deficient anaemia and irreversible interstitial fibrosis; thus, early recognition and intervention are desirable in terms of clinical outcome. We report a case of IPH that was diagnosed early by confirming the presence of an increased number of haemosiderin‐laden macrophages with alveolar haemorrhage in repeat bronchoscopy. We wanted to highlight that decreased but sustained attenuation of ground‐glass opacities on high‐resolution computed tomography does not always correlate with successful remission in patients with IPH. Repeat bronchoscopy can be useful in the early recognition of IPH, especially in the case of sustained opacities a few months after alveolar haemorrhage.
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Affiliation(s)
- Yuichi Mukai
- Department of Respiratory Medicine National Hospital Organization Matsumoto Medical Center Nagano Japan.,Department of Respiratory Medicine National Hospital Organization Shinshu Ueda Medical Center Nagano Japan
| | - Toshihiko Agatsuma
- Department of Respiratory Medicine National Hospital Organization Shinshu Ueda Medical Center Nagano Japan
| | - Gen Ideura
- Department of Respiratory Medicine National Hospital Organization Shinshu Ueda Medical Center Nagano Japan
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Abstract
OBJECTIVES Leptospirosis causes reversible multiple organ failure, and its mortality remains high. The aim of this study was to determine the mortality rate of leptospirosis in an ICU offering all types of organ support available nowadays and to compare it with mortality in bacterial sepsis. DESIGN Retrospective, descriptive, and single-center cohort study. SETTINGS The largest ICU of Reunion Island (Indian Ocean) in a teaching hospital. PATIENTS Consecutive patients hospitalized in ICU for leptospirosis from January 2004 to January 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We report 134 cases of patients with leptospirosis hospitalized in ICU. The median age was 40 years (interquartile range, 30-52 yr), with a Simplified Acute Physiology Score II of 38 (27-50) and a Sequential Organ Failure Assessment score of 10 (8-12). Forty-one patients (31%) required mechanical ventilation and 76 (56%) required renal replacement therapy. The door-to-renal replacement therapy time was 0 (0-1) day after admission with a median urea of 25 mmol/L (17-32 mmol/L). Five patients required extracorporeal membrane oxygenation. The mortality rate was 6.0% (95% CI, 2.6-11.4). Among patients hospitalized for sepsis, the standardized mortality ratio of patients with leptospirosis with regards to Simplified Acute Physiology Score II was dramatically low: 0.40 (95% CI, 0.17 - 0.79). CONCLUSIONS The mortality of severe leptospirosis is lower than for other bacterial infection, provided modern resuscitation techniques are available. Prompt organ support ensures very low mortality rates despite high severity scores.
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35
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Vande Vusse LK, Madtes DK. Early Onset Noninfectious Pulmonary Syndromes after Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:233-248. [PMID: 28477636 PMCID: PMC7126669 DOI: 10.1016/j.ccm.2016.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Lisa K Vande Vusse
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - David K Madtes
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA
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36
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Nanjappa S, Jeong DK, Muddaraju M, Jeong K, Hill ED, Greene JN. Diffuse Alveolar Hemorrhage in Acute Myeloid Leukemia. Cancer Control 2017; 23:272-7. [PMID: 27556667 DOI: 10.1177/107327481602300310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Diffuse alveolar hemorrhage is a potentially fatal pulmonary disease syndrome that affects individuals with hematological and nonhematological malignancies. The range of inciting factors is wide for this syndrome and includes thrombocytopenia, underlying infection, coagulopathy, and the frequent use of anticoagulants, given the high incidence of venous thrombosis in this population. Dyspnea, fever, and cough are commonly presenting symptoms. However, clinical manifestations can be variable. Obvious bleeding (hemoptysis) is not always present and can pose a potential diagnostic challenge. Without prompt treatment, hypoxia that rapidly progresses to respiratory failure can occur. Diagnosis is primarily based on radiological and bronchoscopic findings. This syndrome is especially common in patients with hematological malignancies, given an even greater propensity for thrombocytopenia as a result of bone marrow suppression as well as the often prolonged immunosuppression in this patient population. The syndrome also has an increased incidence in individuals with hematological malignancies who have received a bone marrow transplant. We present a case series of 5 patients with acute myeloid leukemia presenting with diffuse alveolar hemorrhage at our institution. A comparison of clinical manifestations, radiographic findings, treatment course, and outcomes are described. A review of the literature and general overview of the diagnostic evaluation, differential diagnoses, pathophysiology, and treatment of this syndrome are discussed.
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Affiliation(s)
- Sowmya Nanjappa
- Departments of Internal Medicine and Infectious Diseases and Tropical Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA. and
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Fukihara J, Taniguchi H, Ando M, Kondoh Y, Kimura T, Kataoka K, Furukawa T, Johkoh T, Fukuoka J, Sakamoto K, Hasegawa Y. Hemosiderin-laden macrophages are an independent factor correlated with pulmonary vascular resistance in idiopathic pulmonary fibrosis: a case control study. BMC Pulm Med 2017; 17:30. [PMID: 28166761 PMCID: PMC5294720 DOI: 10.1186/s12890-017-0376-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/28/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Increases in hemosiderin-laden macrophages (HLM) are reported to be observed in idiopathic pulmonary fibrosis (IPF). According to a recent study, significant correlation between hemosiderin deposition in the lung tissue of IPF and pulmonary hypertension evaluated by echocardiography has been suspected. In this study, we aimed to evaluate whether HLM in bronchoalveolar lavage fluid (BALF) is a factor correlated with pulmonary hemodynamic parameters evaluated by right heart catheterization in patients with IPF. METHODS Initial data from 103 consecutive patients with IPF who underwent surgical lung biopsy between November 2007 and March 2014 were retrospectively analyzed. The "HLM score" of BALF was established by dividing the number of Perls' Prussian blue stain positive macrophages by the total number of macrophages counted. RESULTS BALF showed an elevated HLM score (38.2%). Right heart catheterization revealed mean pulmonary arterial pressure (mPAP) of 16.3 mmHg and pulmonary vascular resistance (PVR) of 1.55 Wood units. HLM score was positively correlated with mPAP (ρ = 0.204; p = 0.038) and PVR (ρ = 0.349, p < 0.001). In multivariate analysis, 6-min walk distance (standardized partial regression coefficient [β], -0.391; p < 0.001), minimum oxygen saturation during 6-min walk distance (β, -0.294; p = 0.001) and HLM score (β, 0.265; p = 0.002) were independently correlated with PVR. CONCLUSIONS HLM score in BALF is an independent factor correlated with PVR in patients with IPF.
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Affiliation(s)
- Jun Fukihara
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan.
| | - Masahiko Ando
- Center of Advanced Medicine and Clinical Research, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, Aichi, 466-0065, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan
| | - Taiki Furukawa
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto-shi, Aichi, 489-8642, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, 3-1 Kurumazuka, Itami-shi, Hyogo, 664-8533, Japan
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki-shi, Nagasaki, Japan
| | - Koji Sakamoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, Aichi, 466-0065, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, Aichi, 466-0065, Japan
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38
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Ryu HS, Park JH, Sheen SS, Kim TH, Han SD, Jung JY, Suh CH, Hwang SC. Cytoplasmic Anti-Neutrophil Cytoplasmic Antibody Positive Diffuse Alveolar Hemorrhage Associated with Methimazole. JOURNAL OF RHEUMATIC DISEASES 2017. [DOI: 10.4078/jrd.2017.24.4.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Han Seok Ryu
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Tae Hwan Kim
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sung Dam Han
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Sung Chul Hwang
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
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39
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Sunjaya DB, Koster MJ, Osborn TG. 61-Year-Old Woman With Systemic Lupus Erythematosus and Chest Pain. Mayo Clin Proc 2017; 92:153-158. [PMID: 27842704 DOI: 10.1016/j.mayocp.2016.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Dharma B Sunjaya
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Matthew J Koster
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Thomas G Osborn
- Advisor to residents and Consultant in Rheumatology, Mayo Clinic, Rochester, MN.
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40
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Abstract
A 39-year-old man treated with dasatinib for chronic myelogenous leukaemia presented to our hospital with haemoptysis, coughing, and dyspnoea. Chest radiography and computed tomography revealed ground-glass opacities and a crazy-paving pattern. Bronchoalveolar lavage was not performed due to serious hypoxemia and bleeding. Significant bleeding from the peripheral bronchi led to a diagnosis of an alveolar haemorrhage. Dasatinib-induced alveolar haemorrhaging was suspected based on the clinical findings. His condition improved immediately after dasatinib withdrawal and initiation of steroid therapy. Reports of alveolar haemorrhaging induced by dasatinib are rare. As such, this is considered an important case.
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Affiliation(s)
- Yoritake Sakoda
- Department of Respiratory Medicine, St. Mary's Hospital, Japan
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41
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Sandur S, Dweik RA, Arroliga AC. Alveolar Hemorrhage. J Intensive Care Med 2016. [DOI: 10.1177/088506669801300603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.
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Affiliation(s)
- Sunder Sandur
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Alejandro C. Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
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42
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Kitajima T, Marumo S, Maeshima Y, Fukui M. Sequential adjuvant chemoradiotherapy-induced diffuse alveolar haemorrhage in a patient with breast cancer successfully treated with corticosteroid plus recombinant human soluble thrombomodulin. BMJ Case Rep 2016; 2016:bcr-2016-217183. [PMID: 27793868 DOI: 10.1136/bcr-2016-217183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The effective treatment for corticosteroid (CS)-refractory sequential chemoradiotherapy (CRT)-induced lung injury has not been established. We report a case of sequential CRT-induced diffuse alveolar haemorrhage (DAH) successfully treated with CS therapy plus recombinant human soluble thrombomodulin (rhTM). A 69-year-old woman was treated with sequential adjuvant CRT for early-stage breast cancer. After sequential CRT, she suffered from progressive dyspnoea. Chest CT scan showed consolidations in the irradiation field and diffuse ground-glass attenuations in the non-irradiation regions. We suspected sequential CRT-induced DAH because of increased haemosiderin-laden macrophages in bronchoalveolar lavage fluid. Her clinical conditions did not improve with high-dose CS therapy. Therefore, rhTM was added, and her disease and serum high-mobility group box-1 levels improved rapidly. Therefore, rhTM plus CS might be a safe and effective treatment for sequential CRT-induced lung injury, although further study is necessary to validate these findings.
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Affiliation(s)
- Takamasa Kitajima
- Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Respiratory Disease Center, Osaka, Japan
| | - Satoshi Marumo
- Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Respiratory Disease Center, Osaka, Japan
| | - Yurina Maeshima
- Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Breast Center, Osaka, Japan
| | - Motonari Fukui
- Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Respiratory Disease Center, Osaka, Japan
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43
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Taniguchi H, Kondoh Y. Acute and subacute idiopathic interstitial pneumonias. Respirology 2016; 21:810-20. [PMID: 27123874 DOI: 10.1111/resp.12786] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
Idiopathic interstitial pneumonias (IIPs) may have an acute or subacute presentation, or acute exacerbation may occur in a previously subclinical or unrecognized chronic IIP. Acute or subacute IIPs include acute interstitial pneumonia (AIP), cryptogenic organizing pneumonia (COP), nonspecific interstitial pneumonia (NSIP), acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) and AE-NSIP. Interstitial lung diseases (ILDs) including connective tissue disease (CTD) associated ILD, hypersensitivity pneumonitis, acute eosinophilic pneumonia, drug-induced lung disease and diffuse alveolar haemorrhage need to be differentiated from acute and subacute IIPs. Despite the severe lack of randomized controlled trials for the treatment of acute and subacute IIPs, the mainstream treatment remains corticosteroid therapy. Other potential therapies reported in the literature include corticosteroids and immunosuppression, antibiotics, anticoagulants, neutrophil elastase inhibitor, autoantibody-targeted treatment, antifibrotics and hemoperfusion therapy. With regard to mechanical ventilation, patients in recent studies with acute and subacute IIPs have shown better survival than those in previous studies. Therefore, a careful value-laden decision about the indications for endotracheal intubation should be made for each patient. Noninvasive ventilation may be beneficial to reduce ventilator associated pneumonia.
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Affiliation(s)
- Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
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Epelbaum O, Go R, Patel G, Braman S. Pulmonary Kaposi's Sarcoma and Its Complications in the HAART Era: A Contemporary Case-Based Review. Lung 2016; 194:163-9. [PMID: 26826066 DOI: 10.1007/s00408-015-9830-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/07/2015] [Indexed: 11/26/2022]
Abstract
The early years of the acquired immunodeficiency syndrome (AIDS) epidemic introduced the global medical community to Kaposi's sarcoma (KS), a heretofore seldom encountered angiosarcomatous neoplasm associated with human herpesvirus-8. At that time, clinicians treating these KS patients were routinely exposed to the pulmonary manifestations of this malignancy, including characteristic airway lesions, peribronchovascular opacities, and the typically hemorrhagic pleural effusions. They also witnessed uncommon complications of pulmonary KS such as chylous effusions, diffuse alveolar hemorrhage, and immune reconstitution inflammatory syndrome. Since the advent of highly active antiretroviral therapy, the incidence of KS has steadily declined and with that so has clinician familiarity with this disease. Herein, we present four KS cases recently encountered at our institution that illustrate both typical manifestations of pulmonary KS as well as its thoracic complications. The case descriptions are followed by a review of these clinical entities with the aim of restoring awareness among frontline physicians of what is now a rare but not quite extinct AIDS-defining neoplasm.
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Affiliation(s)
- Oleg Epelbaum
- Division of Pulmonary and Critical Care Medicine, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Box D6-4, Elmhurst, NY, 11373, USA
| | - Ronaldo Go
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, 7 Dazian Building, First Avenue at 16 Street, New York, NY, 10003, USA
| | - Geminikumar Patel
- Department of Medicine, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Room A1-16, Elmhurst, NY, 11373, USA
| | - Sidney Braman
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY, 10029-6754, USA.
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Iida Y, Takano Y, Ishiwatari Y, Yoshida A, Shimizu T, Ito R, Hattori T, Takahashi N, Hashimoto S. Diffuse Alveolar Hemorrhage Associated with Makyo-kanseki-to Administration. Intern Med 2016; 55:3321-3323. [PMID: 27853076 PMCID: PMC5173501 DOI: 10.2169/internalmedicine.55.6986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We herein describe the first known case of diffuse alveolar hemorrhage (DAH) associated with the administration of Makyo-kanseki-to, a Chinese herbal drug. A 64-year-old man with bronchial asthma presented with persistent cough. Makyo-kanseki-to was prescribed as an adjunctive treatment for bronchial asthma. Immediately after drug ingestion, the patient expectorated bloody sputum. DAH was diagnosed based on the presence of bilateral ground-glass opacity which was identified on chest computed tomography and bloody bronchoalveolar lavage fluid. We diagnosed that the administration of Makyo-kanseki-to was the responsible medication because the hemorrhage developed immediately after drug ingestion and resolved after the cessation of such medication with no subsequent recurrence.
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Affiliation(s)
- Yuko Iida
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
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Ljungman P, Snydman D, Boeckh M. Pneumonia After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7153442 DOI: 10.1007/978-3-319-28797-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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Hematopoietic Stem Cell Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7124099 DOI: 10.1007/978-3-319-29683-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Role of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in immunocompromised patients. Curr Opin Infect Dis 2015; 27:322-8. [PMID: 24977681 DOI: 10.1097/qco.0000000000000072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe the role of bronchoalveolar lavage (BAL) in the evaluation of pulmonary disease in immunocompromised patients. RECENT FINDINGS Recent discoveries in this field are largely in two areas: the array of diagnostic testing performed on BAL fluid and technical details that can enhance the yield from this procedure. Regarding diagnostic testing, the addition of new assays, including Aspergillus galactomannan antigen assay, respiratory viral panels, and Pneumocystis jirovecii PCR, has improved the diagnostic yield of BAL over conventional cultures and stains. To improve the diagnostic yield of the procedure itself, it should be done early in the clinical course, with the BAL in the anatomic area most affected, and with a preprocedural computed tomography of the chest to properly plan the procedure. SUMMARY Bronchoscopic evaluation with BAL can provide important diagnostic information in immunocompromised patients with pulmonary diseases and should be routinely performed when clinically indicated and able to be completed safely.
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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Balsat M, Xhaard A, Lengline E, Tavernier E, Cornillon J, Guyotat D, Darmon M. Worsening of Respiratory Status during Neutropenia Recovery in Noncritically Ill Hematological Patients: Results of a Prospective Multicenter Study. Respiration 2015; 90:229-34. [DOI: 10.1159/000433556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 05/25/2015] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Neutropenia recovery (NR) has been associated with worsening preexisting lung injury in up to 50% of critically ill cancer patients. However, only limited relevant data exist in the general population of hematological patients. <b><i>Objectives:</i></b> To assess the incidence of acute respiratory deterioration during NR in patients with hematological malignancies. <b><i>Methods:</i></b> Adult patients with neutropenia expected to last more than 7 days were included. Worsening of respiratory status (WRS) was defined as a decrease in oxygen saturation of ≥5%, the need for oxygen therapy for ≥24 h, an increase in oxygen flow of ≥50% in patients previously treated with oxygen, or the need for mechanical ventilation. NR was defined as the 3 days preceding or following a neutrophil count of >0.5 × 10<sup>9</sup>/l. <b><i>Results:</i></b> A total of 16 of 50 patients included in this pilot study experienced WRS during NR (32%), and 13 patients had WRS during neutropenia (26%). The incidence density of WRS was 0.53 (±0.79) episodes per 10 days during NR and 0.20 (±0.39) episodes per 10 days during neutropenia (p = 0.004). Sepsis, stem cell transplantation, preexisting pneumonia, or the use of granulocyte colony-stimulating factor were not associated with WRS during NR. <b><i>Conclusion:</i></b> Up to one third of noncritically ill hematological patients with expected neutropenia of more than 7 days experience WRS during NR. Clinical consequences and risk factors for WRS during NR remain to be evaluated.
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