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Resident PGY 3
Henry Ford Macomb
Diffuse alveolar hemorrhage (DAH) is the process of bleeding into the alveolar spaces of the lungs due to disruption of the alveolar-capillary basement membrane. It can be caused by many disease processes, including rheumatic diseases, vasculitis, infection, drugs, etc4. DAH is a rare, but a serious pulmonary complication of systematic lupus erythematosus1. Cough, hemoptysis, fever, and dyspnea are common initial symptoms, however, hemoptysis can be absent in up to one third of patients3. In the absence of hemoptysis, new radiographic opacities, decreasing hemoglobin level, and the finding of hemorrhagic fluid on bronchoalveolar lavage favor the diagnosis5. A 22-year-old female G1P0, 14 weeks pregnant presented to the emergency department with chief complaint of fevers, myalgia, lesions on the hand and in the mouth x2 weeks. Patient was diagnosed with hand-foot-mouth disease two weeks ago, however still having high fevers and cough. Initial vitals showed tachycardia and fever. Physical examination showed maculopapular rash on face, lesions on bilateral palms and blisters in posterior pharynx. A septic work up and cardiac work up was done in the emergency department. Initial CXR was negative. After receiving 30cc/kg fluid bolus, patient was hypoxic at 88% and a repeat CXR showed pulmonary infiltrate on the right lung field. Patient was treated with Rocephin and Azithromycin and admitted for further evaluation. On day two of admission, patient continued to have fevers with tachycardia, with increasing work of breathing despite different regiment of antibiotics. Patient was transferred to Henry Ford Main for escalation of care and required a multidisciplinary approach. A diagnosis of Lupus was made and the patient was started on systemic steroids. Patient’s respiratory status deteriorated, requiring intubation and bronchoscopy, which demonstrated diffuse alveolar hemorrhage –patient was treated with six rounds of plasmapheresis. Given the patient’s severe symptoms secondary to SLE, Cytoxan was initiated along with prophylactic Bactrim. Patient tolerated the treatment well.DAH is a difficult diagnosis; clinical suspicion needs to be high. DAH accounts for only for 1.5 to 3.7% of hospital admission due to SLE2. This case was particularly difficult, as patient did not present with hemoptysis, she did not have a known diagnosis of SLE, she was pregnant, and had a complicated clinical course. DAH has a high mortality rate, 25-50%, therefore, it is imperative to diagnosis and treat early4. Treatment for DAH related to SLE includes a combination of systemic glucocorticoids and immunosuppressive therapy, rituximab, or plasmapheresis, and support care3.
Patel, Shama and Sipp, Scott, "A Case of Diffuse Alveolar Hemorrhage" (2019). Case Reports. 109.