Pulmonary Manifestations of Systemic Disease: Pulmonary Manifestations of Systemic Disease |

A Rare Case of Focal Alveolar Hemorrhage With Microscopic Polyangiitis FREE TO VIEW

Van Derick Mangulabnan, MD; Ching-Fei Chang, MD
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University of Southern California, Keck School of Medicine, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A457. doi:10.1016/j.chest.2016.02.476
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SESSION TITLE: Pulmonary Manifestations of Systemic Disease

SESSION TYPE: Case Report Slide

PRESENTED ON: Saturday, April 16, 2016 at 09:45 AM - 11:15 AM

INTRODUCTION: Classic diffuse alveolar hemorrhage (DAH) is usually suspected in a patient with known autoimmune disease who presents with severe hypoxemia and bilateral pulmonary infiltrates, with or without frank hemoptysis. It is rarely considered in a previously healthy patient who suddenly presents with hemoptysis and a focal infiltrate. We present an unusual case of a patient who sought medical attention after six days of coughing up blood and was found to have DAH secondary to microscopic polyangiitis, despite having only a unilateral infiltrate on chest imaging.

CASE PRESENTATION: A 59-year-old male ex-smoker presents with six days of hemoptysis and a past medical history significant only for hypothyroidism. He was otherwise asymptomatic. Chest radiographs revealed a left mid-lung infiltrate which was initially interpreted as a possible arteriovenous malformation or pneumonia. Bronchoscopy detected only scant blood in the left upper lobe initially, but then sequential aliquots of lavage fluid demonstrated increasingly hemorrhagic fluid. A clinical diagnosis of alveolar hemorrhage was made, and ensuing workup revealed unexplained anemia and renal insufficiency. Subsequent serologic testing was positive for p-ANCA and MPA-Ab. A renal biopsy was performed and confirmed the presence of capillaritis and perivenular infiltrates consistent with microscopic polyangiitis. The patient was started on immunosuppressives, and within one week of treatment, the hemoptysis resolved.

DISCUSSION: Diffuse alveolar hemorrhage is defined as a life-threatening condition in which bleeding occurs throughout the entire lung at the alveolar level. In autoimmune diseases, this usually results from alveolar capillaritis, whereas other forms may be seen as a result of drugs and infections. Traditionally, the diagnosis is made when patients in the correct clinical setting present with findings of diffuse bilateral alveolar infiltrates and severe hypoxemia, with increasingly bloody return on bronchoalveolar lavage. When patients present with hemoptysis and only a focal infiltrate, however, DAH is usually not considered because it is considered a bilateral process. Although the possibility of this phenomenon has been raised in the literature, we could not find any case reports of actual unilateral DAH. Whether our patient represents a unique subgroup of DAH, or just a rare detection of the disease at its earliest stage is still unclear, but as with all other cases, treatment of the underlying autoimmune condition is the key to recovery.

CONCLUSIONS: This is a rare case of diffuse alveolar hemorrhage presenting in a very focal manner. Clinicians should be aware that this condition may present as a unilateral infiltrate, but early detection and diagnosis through bronchoscopy can be life-saving.

Reference #1: Franks et al. Curr Opin Pulm Med 2000

Reference #2: Lichtenberger et al. Curr Probl Diagn Radiol 2014

DISCLOSURE: The following authors have nothing to disclose: Van Derick Mangulabnan, Ching-Fei Chang

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