The perplexity of pulmonary infiltrates in the intensive care unit.
Avasarala S, Gorgis S, and Ouellette D. The perplexity of pulmonary infiltrates in the intensive care unit. Chest 2015; 148(4).
Respiratory failure with diffuse pulmonary infiltrates in the intensive care unit (ICU) patient has a broad differential. We report a case of recurrent mantle cell lymphoma presenting with diffuse alveolar hemorrhage (DAH). CASE PRESENTATION: A 74-year-old male with a history of stage IV mantle cell lymphoma presented with a productive cough and a chest radiograph demonstrating multifocal infiltrates with bilateral pleural effusions. Remission of his lymphoma was induced four years prior to this presentation with bendamustine and rituximab, but recurrence was suggested by recent outpatient imaging that showed splenomegaly and lymphadenopathy. He was started on antibiotics and underwent a thoracentesis. On his fourth day of hospitalization, he was transferred to the ICU for worsening hypoxemia, tachypnea, and evidence of respiratory failure. The chest radiograph demonstrated worsening of the infiltrates (Figure 1); an echocardiogram showed an ejection fraction of 51%. Bronchoscopy with bronchoalveolar lavage revealed progressive hemorrhage in sequential aliquots; cytology of the bronchoalveolar lavage fluid was negative for malignant cells. Cytological examination of the patient's pleural fluid and peripheral smear demonstrated cells that were consistent with malignant lymphoma. Corticosteroids were initiated, but the patient deteriorated and he succumbed to respiratory failure. DISCUSSION: Respiratory failure and diffuse pulmonary infiltrates among critically ill patients has a broad differential diagnosis; it is further complicated in a patient with a known malignancy.1 We have presented a patient with DAH, which is a syndrome characterized by hypoxemia, diffuse pulmonary infiltrates, dropping hemoglobin, and evidence of hemorrhage on bronchoscopy. DAH can occur in patients with hematological malignancies or in any cause of acute respiratory distress syndrome.2,3 This case highlights the importance of a bronchoscopy with bronchoalveolar lavage to aid in the diagnosis of DAH in an ICU patient with hypoxia and bilateral pulmonary infiltrates. Conclusions: This case exemplifies DAH mimicking acute respiratory distress syndrome in a patient with recurrent lymphoma. DAH is one of many conditions that can imitate acute respiratory distress syndrome. In this circumstance, corroborative evidence from a bronchoscopy was essential towards reaching a diagnosis.