Downstate Medical Center, New Hyde Park, NY
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Systemic Disease
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM
INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is characterized by widespread bleeding into the alveoli due to microvascular injury1. Most patients present with bilateral involvement, unilateral involvement is usually rare. There are several disease processes associated with DAH one of which is severe mitral regurgitation 2, 3. DAH and pulmonary edema secondary to MR have a Right upper lobe predilection. Diffuse alveolar hemorrhage is diagnosed by sequential bronchoalveolar lavage revealing increasing hemorrhagic lavage returns2.
CASE PRESENTATION: 38 yo F with PMH of CHF, Endocarditis, Severe MR & AR, Pulm and systolic HTN who present with acute respiratory decompensation requiring mechanical ventilation. CTA showed Evidence of Left Upper and Lower lobe infiltrates with air bronchograms and septal thickening. PT underwent bronchoscopy. Left upper lobe Bronchoalveolar Lavage was performed with hemorrhagic return on each subsequent return on all three attempts. All cultures were negative for infectious etiologies. Cytology was positive for hemosiderin laden macrophages. TEE showed regurgitant jet was eccentric towards the left lateral atrial wall.
DISCUSSION: Diffuse alveolar hemorrhage is characterized by widespread bleeding into the alveoli due to microvascular injury. In the limited studies/case reports on MR related DAH the site of hemorrhage was predominantly RUL. This is explained by the anatomy of the pulmonary veins in relation to the mitral valve apparatus. The plane of the mitral valve is inclined posterosuperiorly and to the right enabling the regurgitant jets to penetrate the origin of the pulmonary vein in the right upper lobe1. But in the case above, pt developed unilateral, left sided DAH supported by BAL and TEE findings showing the regurgitant jet towards the left lateral atrial wall which is the origination site of the left pulmonary veins. Two of the possible reasons for developing DAH in this pt could be: 1) Chronic MR and LA dilatation might have resulted in anatomical changes placing the regurgitant jet towards the left atrial wall. 2) The increased after load (systolic HTN) in this patient at the time of admission acutely increased the degree of regurgitation and therefore abrupt increase in Left atrial volume and pressure reflecting into the pulmonary vasculature and causing microvascular injury.
CONCLUSIONS: This case reinforces the importance of considering Mitral regurgitation as an etiology of DAH in case of Left Upper Lobe opacity.
Reference #1: Creticus P. Marak et al. “Diffuse Alveolar Hemorrhage due to Acute Mitral Valve Regurgitation,” Case Reports in Pulmonology, vol. 2013, Article ID 179587, 5 pages, 2013.
Reference #2: Woolley K, Stark P.“Pulmonary parenchymal manifestations of mitral valve disease.” Radiographics. 1999 Jul-Aug;19(4):965-72.
Reference #3: P. A. Schnyder et al. “Pulmonary edema associated with mitral regurgitation: prevalence of predominant involvement of the right upper lobe,” The American Journal of Roentgenology, vol. 161, no. 1, pp. 33-36, 1993.
DISCLOSURE: The following authors have nothing to disclose: Khushboo Chokshi, Rosa Arancibia, James Mahoney, Padmanabhan Krishnan
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