Diffuse alveolar hemorrhage with an unknown etiology

SESSION TITLE: Diffuse Lung Disease Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a life-threatening condition caused by widespread damage of small pulmonary vessels leading to bleeding inside the alveolar space. It is caused by multiple etiologies: infectious, inflammatory, rheumatologic, toxic, traumatic, medication, and radiation. Combination of history and physical exam, serologic, radiographic studies, BAL/bronchoscopy, and biopsy help to establish the diagnosis. We present a case of DAH with an unknown etiology. CASE PRESENTATION: A 50 y/o woman with a history of smoking, alcohol dependence, liver cirrhosis with ascites, gastric varices s/p balloon-occluded retrograde transvenous obliteration, active HIV (on HAART, positive viral load, CD4 > 200), active hepatitis B, HTN, DM2, hypothyroidism, presented to the ER with dyspnea, cough, hemoptysis, and melena. Vitals: stable. PE: bilaterally decreased breath sounds and finger clubbing. Labs: Hb 9.7 g/dL, INR 2.3. CT: patchy peribronchial ground glass opacities (GGO) in RLL, LUL. Broad-spectrum antibiotics were started for pneumonia as she was febrile. +ANA 1:640, negative ENA, low complements, +cryoglobulin, serum IgM/IgG/IgA elevated, +p ANCA 1:80, +PR3. All infectious w/u, including Quantiferon, viral panel, and COVID were negative. She left AMA and was readmitted two days later with increasing abdominal distention with pain in the left upper quadrant. Multiple regions of ecchymosis were noted- mainly the anterior abdominal wall. INR 1.9. CT angiography abd/pelvis: left rectus sheath hematoma, cirrhosis, and splenomegaly. CT chest: worsening GGO involving all lobes. She was intubated for bronchoscopy, which showed diffuse erythema and bloody secretions in the upper and lower lobes. RUL BAL was consistent with DAH, as lavage was progressively more hemorrhagic. Extubation was complicated, with acute hypoxemic respiratory failure requiring emergent re-intubation. Suspicion for vasculitis was high, and pulse solumedrol was started. A skin biopsy showed pathology of anetoderma (macular atrophy) and no evidence of vasculitis. Her overall symptoms improved with IV steroids. It was changed to PO steroids before discharge home. DISCUSSION: Finding underlying etiology is critical for the directed treatment. However, this is only sometimes possible. Extensive infectious workup must be obtained before steroids or other immunosuppressants are started. Rheumatic diseases, including systemic vasculitis, are usually the last to suspect when most other etiologies are ruled out. A biopsy (1) is often pursued when the diagnosis remains uncertain by choosing the least invasive approach. Our case was challenging since the patient had multiple antibodies associated with vasculitis (2) and uncontrolled HIV and HBV. A lung biopsy was not pursued due to elevated INR. Receiving steroids was the only option to stabilize the bleeding. No other immunosuppressive therapy is considered safe for uncontrolled HIV and HBV. CONCLUSIONS: DAH is an infrequent but severe condition that must be considered in a patient with hemoptysis. Early prompt diagnosis could change prognosis and outcomes (3). Also, a trial of steroids could be used with close monitoring of symptoms; this was beneficial to our patient. REFERENCE #1: Travis WD, Colby TV, Lombard C, Carpenter HA. A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Surg Pathol. 1990 Dec;14(12):1112-25. doi: 10.1097/00000478-199012000-00003. PMID: 2252102. REFERENCE #2: Jennings CA, King TE Jr, Tuder R, Cherniack RM, Schwarz MI. Diffuse alveolar hemorrhage with underlying isolated, pauciimmune pulmonary capillaritis. Am J Respir Crit Care Med. 1997 Mar;155(3):1101-9. doi: 10.1164/ajrccm.155.3.9116994. PMID: 9116994. REFERENCE #3: Franks TJ, Koss MN. Pulmonary capillaritis. Curr Opin Pulm Med. 2000 Sep;6(5):430-5. doi: 10.1097/00063198-200009000-00008. PMID: 10958235. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Davina Chen No relevant relationships by Zin Min Htet No relevant relationships by Zinobia Khan No relevant relationships by Zin Thawdar Oo No relevant relationships by Milena Vukelic