A 24-year-old pregnant woman was admitted at 33 weeks-gestation due to dyspnea of two-week duration. She had a mild dry cough, denied chest pain, fever, hemoptysis or night sweats. She had no joint pains, rashes, anorexia, abdominal pain, nausea or vomiting.
The patient was complaint with regular antenatal care and she was treated for Staphylococcus aureus UTI two-weeks prior to admission. Gestational history revealed multiple spontaneous abortions due to cervical incompetence and she had prophylactic cerclage this pregnancy. She denied toxic habits or travel history; her tuberculin test was negative six months earlier. On initial evaluation she was tachycardic, normotensive and afebrile. Her respiratory rate was 28 breaths per minute and her oxygen saturation was 95% in ambient air. There was no jugular venous distension. Rales were heard at lung bases. The abdomen was soft, gravid, and not tender. No skin lesions were noted.Initial laboratory results are shown in table 1.Chest-x-ray on admission showed bilateral diffuse nodular infiltrates (Figure 1). She was transferred to ICU for acute hypoxic respiratory failure and treated with antibiotics for community acquired pneumonia and suspected infective endocarditis. Her respiratory status worsened requiring high FiO2. Intravenous steroids were initiated for fetal maturity. On day three of hospitalization she developed worsening infiltrates and was electively intubated followed by hemoptysis. Fiberoptic Bronchoscopy (FOB) revealed diffuse alveolar hemorrhage (DAH). (Table 2) Elective caesarian section with delivery of viable fetus was performed. Her hospital course was complicated by ARDS, septic shock and multiple organ failure. Work up for vasculitis was negative. Beta HCG declined post delivery. Cytology and microbiology of bronchoalveolar lavage specimens was negative. Echocardiogram showed no vegetations and normal heart function. Open lung biopsy could not be done due to high oxygen and PEEP requirements. Patient continued to have DAH, refractory ARDS and shock and expired on day 13. Autopsy revealed metastatic choriocarcinoma to the lungs. Placenta revealed a microscopic focus of Choriocarcinoma.
ARDS in a pregnant patient is a diagnostic challenge. This can be classified as causes unaffected by pregnancy (pneumonias, sepsis, acute pancreatitis), modified by pregnancy ( pyelonephritis, aspiration) and unique to pregnancy (obstetric hemorrhage, severe preeclampsia, chorioamnionitis, endometritis, trophoblastic embolism and amniotic fluid embolism 1. Choriocarcinoma is a rare tumor with an incidence of 1 in 25,000 to 40,000 pregnancies. It may develop after an abortion, a term or preterm pregnancy, an ectopic pregnancy, or a hydatidiform mole. It is estimated that the lesion is preceded by a normal pregnancy in 22.5% of the cases. Choriocarcinoma associated with a viable pregnancy is rare but has been reported in literature. This condition is suspected in gravid patients with pulmonary lesions and failure of beta HCG to decline after delivery. DAH has been described in primary pulmonary choriocarcinoma 2 but not in metastatic choriocarcinoma.In our case initial diagnostic consideration for ARDS included infection and vasculitis and extensive work up was negative. Placental gross exam was normal and beta HCG trended down. Our case represents a rare manifestation of choriocarcinoma without vaginal bleeding presenting with ARDS and DAH with declining beta HCG after delivery.
Metastatic choriocarcinoma should be considered in the differential of ARDS in pregnant patients with DAH. A careful review of placental tissue and consideration to lung biopsy should be done in pregnant patients with unclear lung pathology.
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