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Correspondence |

Diffuse Alveolar Hemorrhage in Infectious Diseases FREE TO VIEW

Edson Marchiori, MD, PhD; Gláucia Zanetti, MD, PhD; Bruno Hochhegger, MD
Author and Funding Information

From the Department of Radiology, Federal University of Rio de Janeiro.

Correspondence to: Edson Marchiori, MD, PhD, Rua Thomaz Cameron, 438. Valparaiso, CEP 25685.120, Petrópolis, Rio de Janeiro, Brazil; e-mail: edmarchiori@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(1):228. doi:10.1378/chest.10-1627
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To the Editor:

We read with great interest the article by Lara and Schwarz1 in a recent issue of CHEST (May 2010), in which they discuss the diagnosis of the underlying histologic and clinical entities responsible for diffuse alveolar hemorrhage (DAH) as well as treatment options. The authors reviewed the different causes of DAH, but they did not mention the infectious diseases that can lead to this manifestation. Thus, we would like to report the case of a patient with 2009 influenza A(H1N1) (A[H1N1]) who presented with DAH.

A 59-year-old man was admitted with a 2-day history of fever and headache followed by dry cough and progressive dyspnea. He also reported an episode of hemoptysis 6 h earlier. Physical examination revealed fever, oxygen saturation on room air of 91%, and crackles in both lungs. Laboratory tests revealed a WBC count of 3,400/mm3 with absolute lymphopenia, a C-reactive protein level of 7.0 mg/dL, and a lactate dehydrogenase level of 600 IU/L; HIV serologic results were negative. High-resolution CT scans performed 3 h after admission showed diffuse ground-glass opacities bilaterally. Bronchofibroscopy revealed blood-tinged secretion coming from both lungs. BAL results were negative for mycobacteria, fungi, and malignancy. Real-time polymerase chain reaction tests confirmed infection with A(H1N1) virus. The patient was treated with oseltamivir and was discharged on the seventh day.

DAH is a clinical syndrome that often leads to respiratory failure. Once the diagnosis is made, the underlying cause must be established in order to initiate treatment.1 Pulmonary infections have been unusually associated with DAH. The etiologic diagnosis of the infection relies upon clinical history, chest imaging, BAL, microbiologic and serologic tests, and histopathologic exams. The pulmonary infections with which DAH has been associated include those caused by viruses (dengue fever, Cytomegalovirus, Hantavirus, A[H1N1]), bacteria (leptospirosis, TB), fungi (invasive aspergillosis), and others agents (Mycoplasma, Legionella, Strongyloides).2,3

Gilbert et al4 described pulmonary hemorrhage as a complication of A(H1N1) viral infection. They have suspected that severe cases of A(H1N1) pneumonia had a higher incidence of alveolar hemorrhage than previously reported. This suspicion is supported by the findings of Mauad et al,5 who found an intense hemorrhagic component in five of 21 patients with A(H1N1) infection who had undergone autopsy.

In conclusion, infectious causes should be considered in the diagnostic work-up of DAH cases because of the obvious therapeutic implications. In the current context of the A(H1N1) outbreak, this infection should be particularly included in the differential diagnosis of DAH.

Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010;1375:1164-1171. [CrossRef] [PubMed]
 
Marchiori E, Ferreira JL, Bittencourt CN, et al. Pulmonary hemorrhage syndrome associated with dengue fever, high-resolution computed tomography findings: a case report. Orphanet J Rare Dis. 2009;4:8. [CrossRef] [PubMed]
 
Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;754:258-280. [CrossRef] [PubMed]
 
Gilbert CR, Vipul K, Baram M. Novel H1N1 influenza A viral infection complicated by alveolar hemorrhage. Respir Care. 2010;555:623-625. [PubMed]
 
Mauad T, Hajjar LA, Callegari GD, et al. Lung pathology in fatal novel human influenza A (H1N1) infection. Am J Respir Crit Care Med. 2010;1811:72-79. [CrossRef] [PubMed]
 

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References

Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010;1375:1164-1171. [CrossRef] [PubMed]
 
Marchiori E, Ferreira JL, Bittencourt CN, et al. Pulmonary hemorrhage syndrome associated with dengue fever, high-resolution computed tomography findings: a case report. Orphanet J Rare Dis. 2009;4:8. [CrossRef] [PubMed]
 
Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;754:258-280. [CrossRef] [PubMed]
 
Gilbert CR, Vipul K, Baram M. Novel H1N1 influenza A viral infection complicated by alveolar hemorrhage. Respir Care. 2010;555:623-625. [PubMed]
 
Mauad T, Hajjar LA, Callegari GD, et al. Lung pathology in fatal novel human influenza A (H1N1) infection. Am J Respir Crit Care Med. 2010;1811:72-79. [CrossRef] [PubMed]
 
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