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A Patient With Diffuse Alveolar Hemorrhage Secondary to Generalized Tonic-Clonic Seizures FREE TO VIEW

Brett Collander, MD; Rishi Raj, MBBS
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Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL

Chest. 2013;144(4_MeetingAbstracts):913A. doi:10.1378/chest.1704849
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SESSION TITLE: Miscellaneous Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

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

INTRODUCTION: We present a rare case of generalized tonic-clonic seizure causing diffuse alveolar hemorrhage.

CASE PRESENTATION: A 57 year woman presented to an outside facility with hemoptysis. CT chest then showed bilateral diffuse ground glass opacities and bronchoscopy was consistent with diffuse alveolar hemorrhage. The patient presented to the same facility three months later with recurrent hemoptysis and diffuse alveolar hemorrhage. The treating physician at the outside institution decided to proceed with a surgical lung biopsy during her second admission. The patient received corticosteroids on both these occasions and was discharged home. The patient was transferred to our facility for further treatment after she presented to the other facility with a third episode of hemoptysis one month later. CT chest at our institution confirmed the bilateral diffuse ground glass opacities. Bronchoscopy was consistent with alveolar hemorrhage bilaterally. Review of the surgical biopsy performed outside showed bland alveolar hemorrhage without any capillaritis, vasculitis or any other abnormalities. Workup for infections, vasculitis and all other causes for pulmonary hemorrhage was negative. Further questioning revealed that the patient recently started having seizures and that all these episodes of hemoptysis were preceded by prolonged generalized tonic-clonic seizure activity. The patient never had any hemoptysis episode that was not preceded by prolonged seizure activity. A detailed workup for secondary causes for seizures was negative. A diagnosis of seizure related hemoptysis was made. She was started on anti-seizure medications and has not had any seizures or hemoptysis six months later on follow-up.

DISCUSSION: Diffuse alveolar hemorrhage associated with seizures is a diagnosis of exclusion in the appropriate clinical setting. The mechanism is not well understood. Neurogenic pulmonary edema, autonomic dysfunction, increased capillary hydrostatic pressure and negative intra-thoracic pressure from a collapsed upper airway during the seizures likely contribute (1-3). Treatment for diffuse alveolar hemorrhage induced by seizures consists of antiepileptics to control seizures and supportive respiratory care.

CONCLUSIONS: Diffuse alveolar hemorrhage is a rare, but serious complication of seizures. Failure to recognize seizures as the cause for the hemoptysis can lead to unnecessary diagnostic procedures and potentially harmful treatment, as was the case in our patient.

Reference #1: Terrence CF, et al. Neurogenic pulmonary edema in unexpected, unexplained death of epileptic patients. Ann Neurol. 1981;9(5):458-464.

Reference #2: Fontes RB, et al. Acute neurogenic pulmonary edema: case reports and literature review. J Neurosurg Anesthesiol. 2003;15(2):144-50.

Reference #3: Davison DL, et al. Neurogenic pulmonary edema. Crit Care. 2012;12;16(2):212.

DISCLOSURE: The following authors have nothing to disclose: Brett Collander, Rishi Raj

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