Diffuse Lung Disease: Student/Resident Case Report Poster - Diffuse Lung Disease |

A Unique Case of Diffuse Alveolar Hemorrhage Associated With Methimazole Use FREE TO VIEW

Jonathan Vignes, MD; Mehdi Khosravi, MD
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University of Kentucky, Lexington, KY

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

Chest. 2016;150(4_S):520A. doi:10.1016/j.chest.2016.08.534
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SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Diffuse alveolar hemorrhage is a rare but documented side effect of treatment with antithyroid medication. Several cases have been reported, but we believe that our case represents a unique combination of clinical and laboratory findings that has not been previously documented.

CASE PRESENTATION: A 48 year-old female with a history of hyperthyroidism presented to the ER after a suicide attempt with an overdose of Hydroxyzine. She developed atrial fibrillation with rapid ventricular response shortly after admission and was diagnosed with thyroid storm. She was started on Methimazole therapy with improvement in symptoms. Within two days of initiation of therapy, her oxygenation worsened and she developed small-volume hemoptysis. A chest x-ray demonstrated new right perihilar and basal opacities compared to admission x-rays. A PE protocol CT scan of the chest demonstrated no pulmonary embolus, but showed bilateral patchy airspace disease in a central peribronchial distribution with no nodules or cavitary lung lesions. She underwent bronchoscopy that confirmed diffuse alveolar hemorrhage (DAH) with sequentially more bloody return on repeated bronchoalveolar lavage (BAL) aliquots. The remainder of her BAL studies demonstrated no infectious etiology, including no growth on fungal cultures at 6 weeks. An autoimmune workup was completed, which was also negative for MPO-ANCA. MMI therapy was withdrawn and she was transitioned to therapy with corticosteroids and beta blockers. Her hemoptysis and acute hypoxic respiratory failure resolved. She was discharged home several days later, at which time she was asymptomatic.

DISCUSSION: Diffuse alveolar hemorrhage is a documented side effect of treatment with antithyroid medications, albeit a rare one. A literature review demonstrated two documented cases of methimazole induced diffuse alveolar hemorrhage. In the case reported above, infectious studies including fungal culture, bacterial culture, viral panel, influenza, acid fast stain, and KOH stain were negative. Autoimmue workup, as is customary in cases of DAH, including MPO-ANCA, were also negative. The previous two reported cases of MMI induced DAH were associated with MPO-ANCA positivity.

CONCLUSIONS: DAH associated with Methimazole therapy is a rare disease. To our knowledge, this case represents a unique combination of clinical and laboratory findings, with no evidence of ANCA positivity, that has not previously been documented in the available literature.

Reference #1: Lau EY, So SY, Chan E, Kwok J, Ma J, Kung AW. Methimazole-induced antineutrophil cytoplasmic antibody-associated diffuse alveolar haemorrhage in a Chinese woman with Graves’ disease. Hong Kong Med J. 2009 Jun;15(3):209-12.

Reference #2: Ming-Han Tsai, Yih-Leong Chang, Vin-Cent Wu, Ching-Chung Chang, and Tien-Shang Huang. Methimazole Induced Pulmonary Hemorrhage Associated with Antimyeloperoxidase-Antineutrophil Cytoplasmic Antibody: A Case Report. J Formos Med Assoc 2001;100:772-5.

DISCLOSURE: The following authors have nothing to disclose: Jonathan Vignes, Mehdi Khosravi

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