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Diffuse Alveolar Hemorrhage in a Lupus Patient With Systemic Cryptococcosis FREE TO VIEW

Abhishek Singla, MD; Pranjal Sharma, MBBS; Jayanth Adusumalli, MBBS; Tammy Wichman, MD
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Department of Internal Medicine, Creighton University Medical Center, Omaha, NE

Chest. 2013;144(4_MeetingAbstracts):62A. doi:10.1378/chest.1704835
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SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: A case of diffuse alveolar hemorrhage (DAH) in a patient with Systemic Lupus Erythematosus (SLE) and Cryptococcus Pneumonia.

CASE PRESENTATION: An 18 year old female from Burma with a history of SLE diagnosed 2 years ago, on prednisone, presented with fever and confusion. Lab work revealed methicillin sensitive staphylococcus aureus (MSSA) bacteremia as well as hypocomplementemia [C3- 40 mg/dL (normal 90-180), C4- 8 mg/dL (normal: 8- 36)]. MRI of brain was obtained that showed basal ganglia and periventricular white matter intensities suggestive of lupus vasculitis. Cerebro Spinal Fluid (CSF) analysis was normal. Patient was treated with cefazolin and started on methylprednisolone 1 gm/day for 3 days followed by prednisone taper, on which she showed neurological improvement. However, on 6th hospital day, she developed rapidly progressive respiratory distress with dry cough (no hemoptysis) and hypoxemic respiratory failure requiring 10 L Oxygen via Oxymizer. Chest X-ray & CT-scan chest showed bilateral alveolar infiltrates. Bronchoscopy with Broncho Alveolar Lavage (BAL) revealed hemorrhagic fluid which progressively increased in subsequent aliquots. Culture of the BAL revealed Cryptococcus neoformans which was subsequently also found in blood culture. Patient was also treated with Amphotericin B (0.7 mg/kg per day) plus flucytosine (100 mg/kg per day) for 2 weeks followed by fluconazole for 1 year.

DISCUSSION: A large spectrum of pulmonary manifestations can occur in SLE. DAH is an infrequent but potentially serious complication of SLE. Up to a third of patients with diffuse alveolar hemorrhage may not have hemoptysis. We present a rare case of alveolar hemorrhage in a lupus patient who was also found to have systemic cryptococossis. Cryptoccal infections can infect immunocompromised hosts but has not been reported to cause DAH. Patients with severe pulmonary or disseminated cryptococcal disease should be managed as for central nervous system disease, even in the setting of normal findings on spinal fluid examination.

CONCLUSIONS: Early BAL is necessary in DAH to rule out infections in addition to establishing the diagnoses.

Reference #1: Lara, Abigail R., and Marvin I. Schwarz. "Diffuse alveolar hemorrhage." CHEST Journal 137.5 (2010): 1164-1171.

Reference #2: Carmier, D., et al. "Respiratory involvement in systemic lupus erythematosus." Revue des Maladies Respiratoires 27.8 (2010): e66-e78.

Reference #3: Kamen, Diane L., and Charlie Strange. "Pulmonary manifestations of systemic lupus erythematosus." Clinics in chest medicine 31.3 (2010): 479.

DISCLOSURE: The following authors have nothing to disclose: Abhishek Singla, Pranjal Sharma, Jayanth Adusumalli, Tammy Wichman

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