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Diffuse Alveolar Hemorrhage

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Diffuse Alveolar Hemorrhage, Pulmonary Alveolar Hemorrhage

  • See Also
  1. Hemoptysis
  2. Hemoptysis Causes
  3. Massive Hemoptysis
  • Pathophysiology
  1. Acute life-threatening diffuse Pulmonary Hemorrhage often due to Vasculitis
  2. Bleeding into the alveoli due to disrupted capillary-alveolar basement membrane
  • Symptoms
  1. Cough
  2. Hemoptysis (66% of patients)
  3. Dyspnea
  4. Chest Pain or chest tightness
  5. Fever
  • Signs
  1. Anemia (variably present)
  2. Diffuse lung infiltration (may be unilateral)
  3. Acute Respiratory Failure
  1. Primary ideopathic Small Vessel Vasculitis
    1. Churg-Strauss Syndrome (Allergic Granulomatosis)
    2. Granulomatosis with Polyangiitis (Wegener's Granulomatosis)
    3. Microscopic Polyangiitis
  2. Primary Immune complex mediated Vasculitis
    1. Goodpasture Syndrome
    2. Hemoch-Schonlein Purpura
  3. Secondary Vasculitis
    1. Antiphospholipid Antibody Syndrome
    2. Polymyositis or Dermatomyositis
    3. Rheumatoid Arthritis
    4. Systemic Lupus Erythematosus
  4. Drug-Induced
    1. Chemotherapy
    2. Propylthiouracil
    3. Autologous Bone Marrow Transplant
  5. Miscellaneous causes
    1. Acute lung Transplant Rejection
    2. Behcet Syndrome
    3. Essential Cryoglobulinemia
  • Causes Non-Pathologic Capillaritis (Bland Pulmonary Hemorrhage)
  1. Inhalational Injury
    1. Crack Cocaine
    2. Retinoic Acid
    3. Sevoflurane (Volatile Organic Anesthetic)
      1. Ahmed-Khan (2023) Arch Clin Cases 10(1): 29-31 [PubMed]
    4. Isocyanates
      1. https://en.wikipedia.org/wiki/Bhopal_disaster
  2. Coagulopathy
    1. Anticoagulants
    2. Anti-Platelet Agents
    3. Disseminated Intravascular Coagulation (DIC)
    4. Thrombolytics
  3. Drug-Induced
    1. Amiodarone
    2. Penicillamine
    3. Nitrofurantoin
  4. Oncologic Management
    1. Bone Marrow Transplant
    2. Cytotoxic Drug Therapy
    3. Radiation Therapy
  5. MIscellaneous
    1. Acute Respiratory Distress Syndrome (ARDS)
  • Differential Diagnosis
  1. See Hemoptysis Causes
  • Labs
  1. Initial Labs
    1. Complete Blood Count with Platelet Count
    2. Comprehensive Metabolic Panel
    3. Blood Cultures
    4. C-Reactive Protein
    5. Urinalysis
  2. Vasculitis-Related Labs
    1. Serum ANCA
    2. Ant-GBM Antibodies
    3. Antinuclear Antibody (ANA)
    4. Antiphospholipid Antibody Panel
    5. Consider other rheumatologic and autoimmune Antibody testing
  • Imaging
  1. Chest XRay
    1. Patchy or diffuse Alveolar Infiltrates
  2. CT Chest
    1. Regions of ground-glass attenuation
  • Diagnostics
  1. Bronchoscopy
    1. Indicated in most cases of acute Diffuse Alveolar Hemorrhage
    2. Send aspirate cultures for Bacterial, fungal and viral organisms
  • Management
  1. ABC Management
    1. Supplemental Oxygen
    2. Non-Invasive Positive Pressure Ventilation or Mechanical Ventilation as needed
    3. Empiric Antibiotic management for infectious cause
  2. High Dose Corticosteroids
    1. Methylprednisolone IV 125 to 250 mg every 6 hours for 4 to 5 days
    2. Consider continued oral Corticosteroids (e.g. Prednisone) for a 5 day course
  3. Immunosuppressants
    1. Cyclophosphamide, Azathioprine, Methotrexate, Mycophenolate and Etanercept have been used
  4. Plasmapheresis
    1. May be indicated in Vasculitis (e.g. Goodpasture's Syndrome)
  • References
  1. Park (2013) Tuberc Respir Dis 74:151-62 [PubMed]