Diffuse alveolar hemorrhage (DAH) is a rare presentation of solid tumor. DAH usually occurs prior to the discovery of the tumor and the cause is often recognized only at open lung biopsy.We report a case of renal cell carcinoma presenting with diffuse alveolar hemorrhage as the initial manifestation.
An 80-year-old non-smoking white male presented with a two week history of hemoptysis. One week prior,he was treated with a course of amoxicillin for presumed bronchitis. The patient denied any history of chest pain, shortness of breath, fever, chills, or weight loss. Denied use of warfarin or non-steroidal anti-inflammatory medications. On physical examination, his nasal passages and oropharynx were normal, and his lungs were clear to auscultation. Heart examination revealed no murmurs, and he had no skin rash, joint swelling, or clubbing. The patient’s initial white blood cell count was 9.0 x 10ˆ3/microl, hemoglobin 13.7 g/dl (hematocrit 40.4), and platelet count 247 x 10ˆ3 cells/microl. His coagulation profile was normal, serum electrolytes and creatinine were within normal limits. Urine analysis was normal at that time. Sputum gram stain revealed no organisms or inflammatory cells. Initial chest radiograph showed diffuse bilateral infiltrates and CT (computerised tomography)scan of the chest revealed bilateral, diffuse ground glass opacities. (See Graphic 1) The patient subsequently underwent a bronchoscopy. The diagnosis of diffuse alveolar hemorrhage was made on the basis of increasingly bloody return on serial bronchoalveolar lavages of the right middle lobe (60 cc x 3). Serological tests including ANA, rheumatoid Factor, ANCA, Anti-GBM and ESR were within normal limits. Echocardiogram revealed normal LV function with no evidence of mitral stenosis. Repeat CBC on the day of bronchoscopy revealed a falling hematocrit (32%), and urine analysis was now quite bloody with rare crenated red blood cells but no red cell casts. Gram stain, cultures and cytology from bronchoalveolar lavage were negative. The patient was started on high dose steroids ( 1000mg/day x 3 days). Renal biopsy was performed.There was no evidence of glomerulonehritis. Incidentally an abnormal appearing area of malignant cells were identified compatible with renal cell carcinoma. Subsequently a lung biopsy was performed by Video assisted thoracoscopic surgery which revealed foci of metastaic tumor compatible with renal cell carcinoma infiltrating the pulmonary vasculature and lymphatics causing alveolar hemorrhage. (Graphic 2)
We present a case of renal cell carcinoma metastatic to the lung initially presenting as diffuse alveolar hemorrhage. DAH as a presenting sign of solid organ malignancy is rare though has been reported previously. Discovery of the tumor in this setting occurs only after open lung. DAH has many etiologies including systemic vasculitis, collagen vascular disorders, drugs, and mitral stenosis. Malignancy is a far less common cause of DAH as compared to the above mentioned causes. Supervia et al reported a case of pulmonary metastases from renal cell carcinoma causing alveolar haemorrhage. Carter et al reported a case of epithelioid hemangioendothelioma (formerly known as intravascular sclerosing bronchoalveolar tumor, IVBAT) a rare pulmonary vascular malignancy presenting as alveolar hemorrhage. Open lung biopsy in this case revealed hemorrhage secondary to growth of neoplastic cells originating from capillary walls and protruding into vessel lumina. High volume choriocarcinoma (a germ cell tumor) has been reported to cause pulmonary hemorrhage. Beneditt et al presented a series of three cases where high volume choricarcinoma caused pulmonary hemorrhage.
We present a case of Metastatic renal Cell carcinoma presenting with diffuse alveolar hemorrhage as an initial manifestation proven by lung biopsy.
K.D. Ganatra, None.