Pulmonary capillaritis and alveolar hemorrhage. Update on diagnosis and management

Fat emboli-Related diffuse alveolar haemorrhage (FEDAH) an acronym to remember-Case series

Fat embolism syndrome (FES) is a rare but potentially fatal complication of trauma or orthopaedic surgery, which presents predominantly with pulmonary symptoms. The rapid worsening respiratory failure in a previously normal orthopaedic surgery or trauma patients usually get evaluated for pulmonary embolism, fat-embolism-related acute respiratory distress or transfusion related acute lung injury. Orthopaedic surgeons and clinicians need to be aware of related entity termed 'Fat Embolism related Diffuse Alveolar Haemorrhage' (FEDAH). The clinical presentation in an orthopaedic surgery of trauma patient with FEDAH are haemoptysis, worsening type 1 respiratory failure and oxygen requirement, drop in haemoglobin levels with chest x-ray/computed tomography suggestive of Diffuse alveolar haemorrhage (DAH). Early bronchoscopy and bronchoalveolar lavage (BAL) confirmation of DAH, presence of BAL haemosiderophages and lipid-laden macrophages are the pointers in the early diagnosis of FEDAH. It needs a high clinical suspicion and interdepartmental collaborative measures. Timely referral from orthopaedic surgeons, early bronchoscopy and treatment with steroids is key in diagnosis and management.

Clinical Dilemmas in Immune Thrombocytopenic Purpura With Diffuse Alveolar Hemorrhage: Diagnosis, Treatment, and Outcomes

This report elucidates a unique case of a 39-year-old female with immune thrombocytopenic purpura (ITP) who developed a rare and severe complication: diffuse alveolar hemorrhage (DAH). Despite initial treatments for ITP, the patient experienced fluctuating platelet (PLT) counts and shortness of breath, which were later identified as symptoms of DAH. An urgent splenectomy improved the patient's platelet counts and overall condition. This case underscores the imperative to recognize DAH as a possible ITP complication, requiring clinicians' vigilance for prompt diagnosis and intervention. The intricate nature of ITP in adults necessitates individualized, patient-centered treatment approaches to enhance outcomes. This report provides invaluable insights into the clinical understanding and management of ITP and its complications through detailed analysis and documentation of the patient's treatment journey.

Post thrombolytic alveolar hemorrhage: a case report

Alveolar hemorrhage following thrombolytic agents administration is an extremely rare entity that has only been reported in twenty two patients in the medical literature. We herein report a case of a 60-year old male with an acute ST-elevation myocardial infarction who was treated with Streptokinase. Twelve hours after streptokinase adminstration, the patient developed severe hemoptysis and dyspnea and radiological studies were highly suggestive for acute alveolar hemorrhage. His past medical history is significant for severe chest trauma ten months prior to presentation. . Conservative therapy in addition to anti-coagulants withdrawal has led to gradual improvement in the next six days. We also discussed the aspects of our patient in comparison with published cases.

Diagnostic value of "hyperdense consolidation sign" as a characteristic new computed tomography sign of diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is an uncommon but life-threatening condition. Although DAH must be distinguished from other lung diseases, no specific computed tomography (CT) signs of DAH have been reported. This study aimed to evaluate the diagnostic value of "hyperdense consolidation" CT sign. We retrospectively evaluated non-contrast CT findings of 25 DAH patients and age- (≤ 2 years) and sex-matched controls with symptoms of dyspnea and hypoxemia. Two radiologists compared the two groups for the presence of hyperdense consolidation signs in lung parenchyma, defined as consolidation that visually contains areas with higher density than the aorta in the specific narrow window setting (window level = 35 Hounsfield units [HU], width = 80 HU) with a mediastinal filter. The sensitivity, specificity, positive- and negative-predictive values of the hyperdense consolidation sign for detection of DAH were 32.0%, 100%, 100%, and 59.5% with perfect interobserver agreement (к = 1.00). The hyperdense consolidation sign was found to be a highly specific sign for DAH.

A 49-year-old man with ischemic cardiomyopathy and persistent hemoptysis for eighteen months

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of recurrent episodes of diffuse alveolar hemorrhage (DAH). IPH commonly manifests with hemoptysis, radiologic chest infiltrates and anemia. The etiology of IPH is unknown, but an immunologic mechanism is widely speculated. The definitive diagnosis of IPH requires a thorough exclusion of other causes of DAH, such as infections, inflammation, malignancy, cardiac diseases, drug and toxin exposure, and medications. Due to the rarity of the disease, a diagnosis is often delayed by years. We present the case of a 49-year-old man with ischemic cardiomyopathy who presented with hemoptysis for eighteen months. Serologic workup was negative for vasculitides and autoimmune diseases. Bronchoscopy revealed DAH. A surgical lung biopsy showed 'bland pulmonary hemorrhage.' A right heart catheterization ruled out cardiac causes of DAH. The patient was diagnosed with IPH and started on systemic corticosteroids with rapid improvement of hemoptysis.

Alveolar Hemorrhage Caused by the Combination of Immune Checkpoint Inhibitors (ICIs) and Angiogenesis Inhibitors: The Underlying Long-Term Vascular Endothelial Growth Factor (VEGF) Inhibition

The combination of immune checkpoint inhibitors (ICIs) and other anticancer agents is the standard of care for various cancers. Bevacizumab, an anti-angiogenesis inhibitor, causes serious adverse events such as pulmonary hemorrhage (PH). Here, we present a case of drug-induced diffuse alveolar hemorrhage (DAH), an adverse event, in a patient with hepatocellular carcinoma who was treated with a combination of ICIs and anti-angiogenesis inhibitors after long-term use of lenvatinib, which inhibits vascular endothelial growth factor (VEGF). An 85-year-old man with hepatocellular carcinoma initially received lenvatinib, a multi-kinase inhibitor, but the drug was later switched to bevacizumab-atezolizumab combination therapy owing to disease progression. After five cycles, he developed dyspnea and diffuse ground-glass opacities, which improved with discontinuation of the combination therapy and initiation of steroid pulse therapy. Our case findings indicate that both ICIs and anti-angiogenesis inhibitors cause drug-induced DAH, and their combination may increase the severity of DAH. Moreover, long-term VEGF inhibition may induce the development of DAH. Clinicians need to be aware that long-term VEGF inhibition may be associated with DAH and should consider the risk management of such adverse events while using this combination therapy.

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

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

Lung transplant to manage end-stage lung disease due to idiopathic pulmonary hemosiderosis: A review of the literature

Idiopathic pulmonary hemosiderosis (IPH) is a rare immunological disease with a genetic predisposition. It is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH). Timely use of immunosuppressive medications has significantly improved overall outcomes, including mortality. Still, uncontrolled and frequent episodes of DAH can eventually cause pulmonary fibrosis, leading to end-stage lung disease (ESLD). The objective of the present project was to scrutinize the literature and summarize the demographic, clinical, radiological, and histopathological features, as well as the overall outcomes, in this patient population following lung transplant. The Medline database was searched using the PubMed platform. Articles published in English between 1960 and 2020 were included in the search. Different search terms were used to identify all patients who underwent lung transplantation to manage ESLD due to IPH. Only four cases of lung transplantation have been reported in the literature in patients with IPH. All but one of these underwent deceased donor lung transplant; recurrence was reported in two of these patients and suspected in the third. One patient received living donor lung transplant and had no recurrence during a five-year follow-up. Patients with IPH should not be excluded from lung transplantation because the disease may not recur in all patients, and even when it does recur it can be promptly treated by increasing immunosuppression.

Alveolar Hemorrhage Following Thrombolytic Therapy for Acute Myocardial Infarction: Two Case Reports and Literature Review

Alveolar hemorrhage (AH) is a heterogeneous clinical syndrome with a high mortality rate, characterized by extensive bleeding into the alveolar spaces. AH secondary to systemic thrombolysis treatment in the setting of acute myocardial infarction is an uncommon complication, but potentially fatal and can lead to acute respiratory failure. This entity is rarely reported in the literature. We report two cases of acute AH after intravenous thrombolysis for acute myocardial infarction, which could contribute to the literature on the subject, and discuss the risk factors as well as the clinical and radiological findings supporting the diagnosis. We overview also the rare previous published case reports in this context, and we contrast our findings with those reported in the literature.

Diffuse alveolar haemorrhage secondary to haemophilus influenzae in a vaping patient

Diffuse alveolar haemorrhage (DAH) is known to occur from several infectious and non-infectious aetiologies. Among the infectious aetiologies, Haemophilus influenzae, an organism known to cause community-acquired pneumonia, has not been reported in association with DAH prior to this case. On the other hand, vaping, an evolving epidemic concern, has been linked to various types of lung injury, including DAH. However, DAH related to vaping is only limited to several case reports. Our case describes H. influenzae pneumonia with DAH in a patient known to have vaped until the night prior to elective lobectomy for lung cancer and developed DAH within 24 hours of hospitalisation. He subsequently recovered with treatment. DAH requires immediate recognition, and healthcare providers need to be aware that neither haemoptysis nor decrease in haemoglobin level is necessarily associated. Prior to diagnosis, empirical treatment with intravenous steroids and antibiotics can be life-saving.

Anti-neutrophil cytoplasmic antibody-associated vasculitis complicated with diffuse alveolar haemorrhage and central nervous system vasculitis

Diffuse alveolar haemorrhage and central nervous system vasculitis are life-threatening complications of anti-neutrophil cytoplasmic antibody-associated vasculitis. The simultaneous occurrence of diffuse alveolar haemorrhage and central nervous system vasculitis is a rare presentation of antibody-associated vasculitis. Its diagnosis by histopathology is difficult because biopsy is difficult to perform, and urgent treatment is needed. We report a case of a Japanese man with diffuse alveolar haemorrhage and central nervous system vasculitis associated with antibody-associated vasculitis. New classification criteria may be needed for diffuse alveolar haemorrhage and central nervous system vasculitis associated with systemic vasculitis. When antibiotic-resistant atypical bilateral pneumonia is noted in the acute phase of a cerebral stroke, with elements suggestive of vasculitis, clinicians should be aware that diffuse alveolar haemorrhage and central nervous system vasculitis may occur simultaneously.

Diffuse Alveolar Hemorrhage in Cardiac Diseases

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

Idiopathic pulmonary hemosiderosis: A state of the art review

Idiopathic pulmonary hemosiderosis (IPH) is an uncommon cause of diffuse alveolar hemorrhage (DAH). Patients with IPH usually present with hemoptysis, and the diagnosis is often delayed by years. Patients often present with intermittent episodes of hemoptysis interspersed between periods of relative normalcy. However, massive hemorrhage resulting in acute respiratory failure and non-remitting hemoptysis have also been described. The classic triad includes hemoptysis, radiologic lung infiltrate, and iron deficiency anemia. Several hypotheses regarding the pathogenesis of IPH have been proposed. These risk factors include an autoimmune, allergic or genetic predisposition, and possible environmental exposure. Since IPH appears to be responsive to corticosteroids, the autoimmune hypothesis is considered to play a crucial role. A diagnosis of IPH requires exclusion of other etiologies of DAH, including infection, medications, toxic inhalation, vasculitis, and anti-glomerular basement membrane disease, among others. Histologically, IPH is characterized by the presence of hemosiderin-laden macrophages in the alveolar space without any evidence of vasculitis or immunocomplex deposition. Corticosteroid therapy represents the primary modality of treatment. Other immunosuppressive medications have also been used with varying success, especially in the setting of steroid-refractory disease. The prognosis of IPH in adults is somewhat better compared to the pediatric population. The severity of the initial presentation does not predict future outcomes. Which risk factors and patient characteristics are associated with a poor outcome are also unknown. More research is necessary to elucidate the pathophysiology and appropriate treatment.

Flexible Fiberoptic Bronchoscopy: Indications, Diagnostic Yield and Complications

Objective

Flexible fiberoptic bronchoscopy (FFB) has become an essential procedure for diagnosing and managing various respiratory conditions. We aimed to assess the main indications, diagnostic yield, and safety of FFB in our institute.

Methods

A total of 216 patients who underwent FFB between July 2009 and June 2012 at King Abdul-Aziz Medical City, Jeddah, Saudi Arabia, were reviewed retrospectively. Indications of the procedure, the diagnostic yield of variable respiratory diseases, and complications were reported.

Result

Out of 216 patients, 210 (97.2%) completed FFB. One hundred and ninety-eight (91.7%) bronchoscopies were for diagnostic purposes, and the remaining 12 (5.6%) were for therapeutic aim. The mean age of patients was 50 years ± 20 years and patients. Respiratory infection, malignancy, pulmonary infiltrate in febrile neutropenia (FN), and hemoptysis in order of frequency were the main indications. The overall diagnostic yield was 46%. Mycobacterium tuberculosis (MTB) was the most common indication (26.8%) and was identified in 37.7%, whereas pneumonia was confirmed in 46.3% of the patients. Malignancy was established in 35.3% of suspected cases, while eosinophilic pneumonia was diagnosed in 100%. The diagnostic yield in pulmonary infiltrates of human immunodeficiency viral (HIV) was 85.7%. Alveolar hemorrhage was the most common cause of hemoptysis. Out of therapeutic bronchoscopy, lung collapse was the main indication. There is no mortality and complications occurred in 1.5% of the cases.

Conclusion

MTB was the most common indication of FFB, followed by malignancy. It has a high diagnostic yield in eosinophilic pneumonia and pulmonary infiltrates in HIV patients. FFB is shown to be a safe modality for diagnostic and therapeutic purposes.   

Diffuse alveolar hemorrhage with histopathologic manifestations of pulmonary capillaritis: Three case reports

BACKGROUND

Diffuse alveolar hemorrhage (DAH) is a multicause pulmonary capillary hemorrhage or pulmonary vascular small vessel injury (mainly capillaries, including arteries and veins), causing pulmonary microcirculation blood to accumulate in the alveolar space. DAH is classified by the histological absence or presence of pulmonary capillaritis (PC) and is rarely reported in the literature.

CASE SUMMARY

This is a report of three girls aged 6-11 years with DAH and PC. Two patients had decreased hemoglobin and one had increased erythrocyte sedimentation rate. High-resolution computed tomography showed bilateral diffuse pulmonary infiltrate, and diagnosis of PC was confirmed by lung biopsy. Immunofluorescence test in one case showed granular IgG and a small amount of granular IgA deposit on the alveolar walls, and was negative in the other two cases, describing isolated pauci-immune PC. Treatment was with glucocorticoid alone or combination with immunosuppressants, and the symptoms resolved in all patients.

CONCLUSION

PC is classified as isolated and immune-mediated PC associated with systemic disease. It can be controlled in most children with glucocorticoid alone or combined with immunosuppressants.

Henoch-Schönlein Purpura in children: not only kidney but also lung

BACKGROUND

Henoch-Schönlein Purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels. Pulmonary involvement is a rare complication of HSP and diffuse alveolar hemorrhage (DAH) is the most frequent clinical presentation. Little is known about the real incidence of lung involvement during HSP in the pediatric age and about its diagnosis, management and outcome.

METHODS

In order to discuss the main clinical findings and the diagnosis and management of lung involvement in children with HSP, we performed a review of the literature of the last 40 years.

RESULTS

We identified 23 pediatric cases of HSP with lung involvement. DAH was the most frequent clinical presentation of the disease. Although it can be identified by chest x-ray (CXR), bronchoalveolar lavage (BAL) is the gold standard for diagnosis. Pulse methylprednisolone is the first-line of therapy in children with DAH. An immunosuppressive regimen consisting of cyclophosphamide or azathioprine plus corticosteroids is required when respiratory failure occurs. Four of the twenty-three patients died, while 18 children had a resolution of the pulmonary involvement.

CONCLUSIONS

DAH is a life-threatening complication of HSP. Prompt diagnosis and adequate treatment are essential in order to achieve the best outcome.

Onset of granulomatosis with polyangiitis obscured by heart disease in an elderly man

We describe a case of 85-year-old man who presented to the Emergency Department with sudden dyspnea. He had a past medical history of cardiomyopathy and radiography and nonenhanced computed tomography (CT) of the chest showed pulmonary edema. Despite intravenous diuretic therapy, there was no clinical improvement. Cardiac CT was then performed showing a solid pulmonary nodular lesion with intralesional cavitations, ground-glass opacities, and peripheral vascularization. CT-guided needle lung biopsy yielded a diagnosis of granulomatosis with polyangiitis (Wegener granulomatosis). Medical treatment with cyclophosphamide and prednisone produced rapid symptomatic improvement and complete resolution of the radiological findings. This case demonstrates the challenges in making this diagnosis in an elderly patient with heart disease. We found very few documented cases where there was onset of granulomatosis with polyangiitis at this age.

Infective endocarditis presenting as diffuse alveolar hemorrhage: A case report

An 80-year-old man was admitted to the hospital because of fever, bloody sputum and exertional dyspnea of 3 days. Laboratory tests showed anemia and increase of the C-reactive protein level. A chest computed tomography scan revealed diffuse bilateral ground-glass opacities. Bronchoalveolar lavage confirmed the clinical diagnosis of diffuse alveolar hemorrhage (DAH). After methylprednisolone pulse therapy, Enterococcus faecalis was detected in the blood cultures. A diagnosis of infective endocarditis was made according to the Modified Duke's criteria. The causes of DAH are certainly diverse; however, we should consider infective endocarditis as one of the etiologies of DAH.

[A rare and severe complication related to acenocoumarol therapy: intra-alveolar bleeding]

L'hémorragie intra-alvéolaire est une urgence médicale rare et grave ayant de nombreuses étiologies. Nous rapportons ainsi le cas clinique d'un patient qui pourrait contribuer à élargir la littérature sur ce sujet. Le patient est un homme âgé de 62 ans ayant un antécédent de fibrillation auriculaire sous anti-vitamines K et admis dans un tableau de dyspnée d'apparition brutale avec hémoptysie et notion d'automédication par anti-inflammatoires non stéroïdiens. La radiographie et le scanner thoracique ont montré des opacités alvéolaires bilatérales diffuses. Au bilan d'hémostase de l'admission, l'INR était incoagulable. Le diagnostic d'hémorragie intra-alvéolaire était suspecté cliniquement et radiologiquement puis confirmé par l'endoscopie bronchique avec lavage broncho-alvéolaire (LBA) retrouvant un liquide uniformément hémorragique. Les études précédentes présentant des cas similaires secondaires à la prise d'anti-vitamines K sont rares. En conclusion, Il parait très important de souligner l'intérêt d'une surveillance stricte et optimale clinico-biologique des patients traités en anti-vitamines K afin d'éviter un surdosage pouvant contribuer à un accident hémorragique grave engageant le pronostic vital.

[Lung involvement in hematologic systemic diseases]

Pulmonary diseases can occur across the entire disease spectrum of malignant hematologic systemic diseases. Although infectious processes of the lungs are common in these immunosuppressed patient collectives, noninfectious causes account for up to half of the pulmonary manifestations found in hematologic malignancies. Besides the frequent infections including opportunistic pathogens, a broad differential diagnosis including drug-induced lung injury by cytostatic substances, cytokines, and innovative immunotherapeutic agents, rarer transfusion of blood products and intrathoracic manifestations of the hematologic malignancy itself, have to be kept in mind. Finally, vascular complications can also lead to pulmonary reactions. Early and consistent diagnostics and treatment of the bronchopulmonary, intrathoracic and vascular complications within the framwework of hematologic systemic diseases can be essential for the patient's prognosis.

Systemic lupus erythematosus-associated diffuse alveolar haemorrhage: a single-centre experience in Han Chinese patients

OBJECTIVE

Despite aggressive therapeutic regimens, diffuse alveolar haemorrhage (DAH) is still associated with a high mortality rate in systemic lupus erythematosus (SLE). This study was carried out in patients with SLE-associated DAH with a focus on their therapeutic modality.

METHOD

A retrospective review was performed in 839 Han Chinese lupus patients hospitalized for their DAH manifestation from May 2006 to December 2016.

RESULTS

There were 24 episodes in 17 cases (2.0% incidence), 15 females and two males aged 19-67 years (mean ± sd 38.2 ± 15.1 years). High disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) 12-31, 19.8 ± 5.6] was found at the onset of DAH. All patients were treated with high-dose corticosteroid, followed by pulse methylprednisolone (70.6%), plasmapheresis (41.2%), pulse cyclophosphamide (35.3%), and rituximab (23.5%). Six patients (35.3%), including three with extracorporeal membrane oxygenation, died owing to acute respiratory failure. All patients receiving rituximab treatment survived with a follow-up period of 12-58 months (40.8 ± 21.1 months), and no further relapse was noted in three cases with a history of recurrent DAH episodes. In addition, there was a significant decrease in their lupus activity (SLEDAI-2K 21.5 ± 6.0 to 6.3 ± 1.7, p = 0.0286).

CONCLUSION

In this single-centre series with SLE-associated DAH in Han Chinese patients, a beneficial effect of rituximab therapy was observed.

Severe Progressive Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus

Diffuse alveolar hemorrhage (DAH) refers to the effusion of blood into the alveoli due to damaged pulmonary microvasculature. The ensuing alveolar collapse can lead to severe hypoxemia with poor prognosis. In these cases, it is crucial to provide respiratory care for hypoxemia in addition to treating the underlying disease. Here, we describe our experience with a case involving a 46-year-old woman with severe DAH-induced hypoxemia accompanying systemic lupus erythematosus (SLE). Mechanical ventilation was managed using airway pressure release ventilation (APRV) after intubation. Through APRV-based respiratory care and treatment of the underlying disease, hemoptysis was eliminated and oxygenation improved. The patient did not experience significant barotrauma and was successfully weaned from mechanical ventilation after 25 days in the intensive care unit. This case demonstrates that APRV-based control for respiratory management can inhibit the effusion of blood into the alveoli and achieve mechanical hemostasis, as well as mitigate alveolar collapse. APRV may be a useful method for respiratory care in patients with severe DAH-induced hypoxemia.

Mediastinal angiosarcoma presenting as diffuse alveolar hemorrhage

Angiosarcomas are malignant vascular tumors. Angiosarcomas arising in the thorax such as angiosarcoma of the lungs, heart and mediastinum are extremely rare. There are no reports of mediastinal angiosarcomas presenting with diffuse alveolar hemorrhage, which is a clinical syndrome characterized by the presence of hemoptysis, dyspnea, hypoxia, diffuse lung infiltrates and anemia. Usually, diffuse alveolar hemorrhage is caused by pulmonary capillaritis. Local invasion is more common with these tumors than distant metastasis. These tumors are very aggressive and have a poor response to treatment modalities including surgical resection, chemotherapy, and radiation. Consequently, they carry a poor prognosis. Due to the rarity of these tumors, no standard chemotherapy or radiation protocol exists. We report a case of diffuse alveolar hemorrhage caused by a previously unreported entity: angiosarcoma of the mediastinum.

Methylprednisolone pulse therapy rescued life-threatening pulmonary hemorrhage due to idiopathic pulmonary hemosiderosis

Idiopathic pulmonary hemosiderosis (IPH) is an extremely rare cause of massive pulmonary hemorrhage in children. During the acute phase, death due to massive alveolar hemorrhage and subsequent severe respiratory failure. We report two cases of IPH children who developed hypoxemic respiratory failure and massive pulmonary hemorrhage. One case of a 10-year-old boy was treated with methylprednisolone pulse therapy (10mg/kg/d) for the first three days and followed by systemic steroid therapy, he successfully decannulated 10days later and discharged with a favorable quality of life. Another case of a 4year-old female child with Down's syndrome diagnosed as IPH for over one year and treated with oral corticosteroids for maintenance therapy. She sudden suffered severe hypoxemia with rapid falls in the hemoglobin level. We applied methylprednisolone pulse therapy (10mg/kg/d) for three days and other supportive therapies, the girl survived through complicated with oxygen dependence. We suggest that methylprednisolone pulse therapy provides a chance of recovery and survival for patients with IPH at the acute phase, even if accompanied by severe pulmonary hemorrhage.

A Case of Rare Diffuse Alveolar Hemorrhage and Review of Literature

It is well known that some disorders can cause concomitant kidney dysfunction with lung involvement. These syndromes, characterized by the simultaneous presence of intra-alveolar hemorrhage and acute glomerulonephritis, are caused by numerous and variable disorders. The most frequent are the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis and Goodpasture syndrome. A quick discerning of the underlying causes and initiation of adequate treatment is crucial to prevent acute respiratory failure and irreversible loss of renal function. We reported the case of a 33-year-old man having hemorrhagic alveolitis presenting a picture consistent with Goodpasture syndrome in the absence of anti-glomerular basement membrane (anti-GBM) antibodies or ANCA at lab test and a review of literature. This case highlights the need to consider the chances of falsely seronegative cases of anti-GBM disease, as well as the importance of using all available assay routine tests. These cases would appear indeed more common than before if just taken into consideration their existence. Several reports have shown false seronegatives especially in patients with relapses, in smokers, and in patients with predominantly pulmonary symptoms.

Pathology of Antineutrophil Cytoplasmic Antibody–Associated Pulmonary and Renal Disease

Context.—Antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis commonly presents with pulmonary and renal involvement that may present diagnostic challenges.

Objectives.—To highlight the updates in the classification of small vessel vasculitis, present the patterns of pulmonary and renal pathology in which ANCA-associated vasculitis is included in the differential diagnosis, analyze the screening and specific antineutrophil cytoplasmic antibody testing methods in the clinical laboratory, compare and contrast the 3 major ANCA-associated vasculitis diseases, and review the pathophysiologic mechanisms of tissue injury in this setting.

Data Sources.—Data are derived from published literature and clinical experience.

Conclusions.—Although rare, ANCA-associated vasculitis diseases are often considered in the differential diagnosis of many pathologic patterns of pulmonary and renal disease. Histopathologic diagnosis of specific entities in this context nearly always requires correlation of the pathology with clinical and serologic data.

A Suspected Case of an Alveolar Haemorrhage Caused by Dasatinib

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.

Antineutrophilic cytoplasmic antibody-associated vasculitis with hypocomplementemia has a higher incidence of serious organ damage and a poor prognosis

A relationship between antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and complement has been shown, and complement has an important role in the pathogenesis of AAV. The clinical characteristics of AAV with hypocomplementemia still remain unclear.We conducted an observational study of 81 patients with AAV (median onset age 71 years; 58% female). Using medical records, we analyzed the patients' baseline variables, laboratory data, clinical symptoms, and therapeutic outcomes after treatments including episodes of relapses, initiation of dialysis, and death. We defined hypocomplementemia as the state in which at least one of the following was lower than the lower limit of the normal range: complement 3 (C3), complement 4 (C4), and total complement activity (CH50).Sixteen patients (20%) had hypocomplementemia at their diagnosis of AAV. Compared to the AAV patients without hypocomplementemia (n = 65), those with hypocomplementemia had significantly higher rates of the occurrence of skin lesions (8 [50%] vs. 8 [12%], P = 0.002), diffuse alveolar hemorrhage (DAH) (6 [38%] vs. 5 [8%], P = 0.006), and thrombotic microangiopathy (TMA) (3 [19%] vs. 0 [0%], P = 0.007). The AAV patients with hypocomplementemia had significantly lower platelet levels (16.5 × 10 vs. 24.9 × 10 cells/μL, P = 0.023) compared to those without hypocomplementemia. More positive immune complex deposits in renal biopsy specimens were seen in the AAV patients with hypocomplementemia than in those without hypocomplementemia (4 [80%] vs. 2 [18%], P = 0.036). Assessed by a log-rank test, hypocomplementemia at disease onset was significantly associated with death (P = 0.033).Hypocomplementemia in AAV at the disease onset was a risk factor for the serious organ damage, and a life prognostic factor. It is thus very important to pay attention to the levels of complement at the diagnosis of AAV.

Cor triatriatum sinister: a rare underlying cause of pulmonary hemosiderosis

Pulmonary hemosiderosis is a disorder with unknown cause and characterized by hemosiderin appreciation in alveolar interstitium from decomposed hemoglobin following alveolar capillary bleeding, which finally leads to pulmonary fibrosis. It can be divided into primary and secondary types in terms of its etiology. While primary types are related to autoimmunity, secondary types can be associated with cardiovascular and pulmonary causes such as mitral stenosis leading to pulmonary congestion. We report a case of cor triatriatum sinister in a child who presented with hemoptysis as a main clinical manifestation and had been previously diagnosed with idiopathic pulmonary hemosiderosis. Based on clinical signs and imaging examinations, we considered the hemoptysis was most likely due to cor triatriatum. The child underwent corrective surgery with uneventful recovery. The hemoptysis has not recurred any more after operation. Cardiovascular disease including cor triatriatum should be considered with regards to the etiology of pulmonary hemosiderosis.

Diffuse Alveolar Hemorrhage Due to Malignant Arterial Hypertension – an Unusual Manifestation of a Common Disease

Diffuse alveolar hemorrhage is a clinicopathological syndrome that often leads to respiratory failure, with associated hemoptysis and anemia. Chest radiograph presents non-specific findings of perihilar infiltrates, while computed tomography shows ground-glass attenuation or areas of consolidation with interlobular septal thickening. Bronchoalveolar lavage is used to confirm the clinical and radiological suspicion.

While vasculitis and other causes of pulmonary renal syndrome are the most common causes of diffuse alveolar hemorrhage, malignant hypertension should be considered in the proper clinical setting. We present a case report of a 51-year-old previously healthy patient that was diagnosed with diffuse alveolar hemorrhage and acute renal failure due to malignant hypertension, through clinical and radiological findings.

The lung in systemic vasculitis: radiological patterns and differential diagnosis

The respiratory system may be involved in all systemic vasculitides, although with a variable frequency. The aim of our review is to describe radiographic and high-resolution CT (HRCT) findings of pulmonary vasculitides and to correlate radiological findings with pathological results. Lung disease is a common feature of antineutrophil cytoplasmic autoantibody-associated small-vessel vasculitides, including granulomatosis with polyangiitis (Wegener's), eosinophilic granulomatosis with polyangiitis (Churg-Strauss) and microscopic polyangiitis. Pulmonary involvement is less frequent in immune-complex-mediated small-vessel vasculitides, such as Behçet's disease and Goodpasture's syndrome. Pulmonary involvement associated to large-vessel (gigantocellular arteritis and Takayasu's disease) or medium-vessel (nodose polyarteritis and Kawasaki's disease) vasculitides is extremely rare. The present review describes the main clinical and radiological features of pulmonary vasculitides with major purpose to correlate HRCT findings (solitary or multiple nodules, cavitary lesions, micronodules with centrilobular or peribronchial distribution, airspace consolidations, "crazy paving", tracheobronchial involvement, interstitial disease) with pathological results paying particular attention to the description of acute life-threatening manifestations. A thorough medical history, careful clinical examination and the knowledge of radiological patterns are mandatory for a correct and early diagnosis.

Alveolar hemorrhage in systemic lupus erythematosus: a cohort review

Diffuse alveolar hemorrhage (DAH) is a rare but potentially catastrophic manifestation with a high mortality. Among rheumatologic diseases, it occurs most frequently in patients with systemic lupus erythematosus (SLE) and systemic vasculitis. Despite new diagnostic tools and therapies, it remains a diagnostic and therapeutic challenge. The aim of this work was to characterize the SLE patients with an episode of alveolar hemorrhage followed in our Clinical Immunology Unit (CIU). A retrospective chart review was carried out for all patients with SLE followed in CIU between 1984 and the end of 2013. We reviewed the following data: demographic characteristics, clinical and laboratory data, radiologic investigations, histologic studies, treatment, and outcome. We identified 10 episodes of DAH, corresponding to seven patients, all female. These represent 1.6% of SLE patients followed in our Unit. The age at DAH attack was 42.75 ± 18.9 years. The average time between diagnosis of SLE and the onset of DAH was 7.1 years. Three patients had the diagnosis of SLE and the DAH attack at the same time. Disease activity according to SLEDAI was high, ranging from 15 to 41. All patients were treated with methylprednisolone, 37.5% cyclophosphamide and 28.6% plasmapheresis. The overall mortality rate was 28.6%.

Idiopathic pulmonary hemosiderosis presenting in an adult: A case report and review of the literature

Diffuse alveolar hemorrhage (DAH) is characterized by the presence of hemoptysis, anemia, and the presence of diffuse parenchymal infiltrates on imaging studies. Idiopathic pulmonary hemosiderosis (IPH) is an uncommon cause of diffuse alveolar hemorrhage (DAH) and is classically known to present in childhood. Adult-onset IPH is extremely rare. We report the case of a 48-year-old female patient who presented with hemoptysis and acute hypoxic respiratory failure, requiring intubation and mechanical ventilation. Imaging studies showed diffuse bilateral patchy infiltrates. Bronchoalveolar lavage (BAL) confirmed the diagnosis of DAH. Extensive workup including video-assisted thoracoscopic surgical lung biopsy (VATS) failed to reveal any vasculitis, infectious, immunological or connective tissue disorder, as the underlying cause for DAH. The patient was successfully treated with high-dose steroid therapy.

Rituximab: an emerging treatment for recurrent diffuse alveolar hemorrhage in systemic lupus erythematosus

Diffuse alveolar hemorrhage (DAH) is a rare manifestation of systemic lupus erythematosus (SLE) and is associated with high mortality rates. Treatment typically consists of aggressive immunosuppression with pulse-dose steroids, cyclophosphamide, and plasma exchange therapy. Mortality rates remain high despite use of multiple medical therapies. We present a case of recurrent DAH in a 52-year-old female with SLE after a deceased donor renal transplant who was successfully treated with rituximab. Our report highlights the pathophysiologic importance of B-cell-mediated immunosuppression in SLE-associated DAH and suggests that rituximab may represent a viable alternative to cyclophosphamide in the treatment of this disease. We also review eight other reported cases of rituximab use in SLE-associated DAH.

Pulmonary hemorrhage with capillaritis secondary to mycophenolate mofetil in a heart-transplant patient

Immunosuppressive drugs are an integral part of therapy in organ transplantation. However, they are not without side effects, and although rare, these agents should be considered in the differential diagnosis of pulmonary complications in patients receiving transplants. We present a case of a patient who developed acute respiratory failure 7 days after orthotopic heart transplantation and who had been on both mycophenolate mofetil (MMF) and tacrolimus agents. Lung biopsy revealed features of pulmonary hemorrhage with capillaritis. Considered as a possible etiology, MMF was withdrawn. There was immediate improvement of the patient's symptoms. The temporal relationship between MMF exposure and onset of pulmonary symptoms in the absence of other possible etiologies strongly suggests a causal relationship. Previously published reports of pulmonary toxicity from MMF included interstitial fibrosis. To the best of our knowledge, this is the first reported case of pulmonary hemorrhage with capillaritis because of administration of MMF.

[The pulmonary-renal syndrome: a diagnostic and therapeutic emergency for the internist and the intensivist]

The pulmonary-renal syndrome is a rare and life-threatening condition. It is defined as the association of a diffuse alveolar hemorrhage and a rapidly progressive glomerulonephritis. The characteristic histological lesion common to all underlying diseases is a necrotizing and crescentic glomerulonephritis. The pulmonary-renal syndrome is a diagnostic and therapeutic emergency: any delay in its management will lead to death or serious functional damage as pulmonary and renal impairment. ANCA-associated vasculitis and Goodpasture's disease are the main disorders associated to pulmonary-renal syndrome. More rarely systemic lupus, cryoglobulinaemia, Henoch-Schonlein purpura or subacute endocarditis may induce a pulmonary-renal syndrome. Differential diagnosis can sometimes be difficult, highlighting some ambiguity in the definition of the syndrome. Initial treatment usually associates systemic corticosteroid, cyclophosphamide and plasma exchange. The role of biotherapy as first line therapy remains to be determined.

[Alveolar haemorrhage associated with the primary antiphospholipid syndrome]

INTRODUCTION

Thrombotic events, particularly pulmonary embolism, are well known presentations of the antiphospholipid syndrome. Other pulmonary manifestations of the disease like alveolar haemorrhage are rare but can represent a catastrophic aspect of this disease. Alveolar haemorrhage in this context is important to recognize since it can be either a complication of anticoagulation therapy or a manifestation of the disease. The therapeutic implications are then very different.

CASE PRESENTATION

We present the case of a woman with massive pulmonary embolism treated with thrombolytic therapy. This was complicated by alveolar hemorrhage initially attributed to thrombolytics and recurrent bleeding considered to be a manifestation of the antiphospholipid syndrome. The complicated course necessitated a protracted stay in the intensive care unit, mechanical ventilation, and treatment with intravenous corticosteroids and plasmapheresis.

CONCLUSION

Alveolar haemorrhage associated with the antiphospholipid syndrome can be catastrophic and require prompt and aggressive therapy. Plasmapheresis, usually reserved for the catastrophic aspects of this condition, was felt to be useful in this case.