INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is an uncommon but life threatening cause of respiratory failure. Commonly, a secondary cause for DAH is discovered and treated. Vocal cord polyps are not a usual cause of diffuse alveolar hemorrhage.
CASE PRESENTATION: The patient was a 50 year old woman with diffuse abdominal and bilateral flank pain for 2 days, vomiting, fevers, chills, and one episode of loose brown stool for one day. She had a similar episode a few months earlier and was given a diagnosis of diverticulitis. She had a history of heavy smoking, chronic obstructive lung disease, hypertension, hepatitis C, an appendectomy, and a cholecystectomy. She had hoarseness but no recent increase in dyspnea. She had used cocaine till 3 years ago. Physical examination showed a temperature of 99.5F, heart rate of 122/min, blood pressure of 74/54 mm Hg, and mild abdominal tenderness. Her white blood cell count was 26,300/mm3 with 83% segmented neutrophillic leukocytes and 4% band forms, lactate 2.8 mmol/L, and creatinine 2.1 mg/dL. Urine drug screen was negative for cocaine or other drugs, and her chest radiograph was normal. Computed tomography of the abdomen and pelvis confirmed diverticulitis. She was admitted to the intensive care unit with a diagnosis of severe sepsis. She received 5 L of intravenous (IV) normal saline, IV norepinephrine, and IV antibiotics. Over the next day her blood pressure improved, norepinephrine was discontinued, and her creatinine decreased to 1.0 mg/dL. However, the patient had increasing dyspnea with increasing O2 requirements. She was given furosemide and her IV fluids were discontinued, resulting in a net fluid loss of 4.5L. However, her hypoxemia worsened and her chest radiograph showed progression of diffuse bilateral interstitial opacities. Fiberoptic bronchoscopy showed a large pedunculated right vocal cord polyp that nearly completely occluded the glottis during inspiration, resulting in a ball valve-like effect (see image/video). In the presence of an otolaryngologist the bronchoscope was carefully advanced past the polyp and into the trachea, where bloody secretions were seen. Repeated bronchoalveolar lavage showed progressively bloody fluid, with red blood cell counts of 10,675, 22,225, and 27,300/mm3 on three successive lavages, consistent with DAH . She then underwent immediate resection of the polyp and remained endotracheally intubated and mechanically ventilated. IV methylprednisolone was started for DAH. Autoimmune evaluation, which included ANA, anti-dsDNA, C3, C4, RA, and ANCAs MPO, PR3, was negative, and methylprednisolone was discontinued. The radiographic opacities resolved, her oxygenation improved, and she was liberated from mechanical ventilation on the 10th post-operative day. She was discharged from the hospital. When she was seen as an outpatient at 10 weeks postoperatively, all her symptoms had resolved.
DISCUSSION: This patient had both DAH and variable extra-thoracic upper airway obstruction (UAO) due to a large pedunculated vocal cord polyp. The DAH resolved after the polyp was removed. We suggest that the DAH was, indeed, caused by the obstructing polyp. UAO that results in a Müller maneuver is a well established cause of pulmonary edema. However, UAO may also be a cause of DAH. The mechanism for both UAO-induced pulmonary edema and DAH may be the same, namely, a marked decrease in alveolar pressure relative to pulmonary capillary pressure.
CONCLUSIONS: Diffuse alveolar hemorrhage is an acutely life-threatening condition. This case illustrates that vocal cord polyp may be an unusual cause of diffuse alveolar hemorrhage.
Reference #1 Negative pressure pulmonary hemorrhage, Schwartz DR et al. Chest 1999;115:1194-1197
Reference #2 Negative pressure acute tracheobronchial hemorrhage and pulmonary edema, Papaioannou V et al. J Anesth 2009; 23:417-420
DISCLOSURE: The following authors have nothing to disclose: Rami Zebian, Robert Lodato
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