3/1/17 Resident Morning Report – Diffuse Alveolar Hemorrhage, ANCA Vasculitis

CC: shortness of breath

ID: 59 yo female with HTN initially presents with joint swelling and extremity swelling.  She was diagnosed with p-ANCA vasculitis and was started on pulse steroids, rituximab and plasmaphresis.  Her hospital course was complicated by melena (she was found to have multiple small gastric ulcers, a large duodenal ulcer, and candida esophagitis on EGD) and shortness of breath (TTE and coronary angiogram was demonstrated Takotsubo’s cardiomyopathy with symptom improvement with therapy).  She again began to feel short of breath on HD #24 with symptoms of lightheadedness and weakness.  Exam was notable for decreased breath sounds to bilateral bases and CXR performed at the time revealed bilateral patchy disease.  An ABG performed revealed pH 7.47, pCO2 24, pO2 50, HCO3  18 with an anion gap of 15.  Bronchoscopy was performed with serial lavages and findings were consistent with diffuse alveolar hemorrhage.

Don’t forget:

  • There are many, many causes of DAH, but think of the main etiologies of DAH in 5 broad categories:
    1. vasculitidies (ex: MPA, GPA, EGPA)
    2. other autoimmune disorders, esp pulmonary-renal syndromes (ex: Goodpasture’s)
    3. medications (ex: PTU, anticoagulants)
    4. infections (ex: endocarditis, leptospirosis)
    5. idiopathic pulmonary hemosiderosis/pulmonary endometriosis

Pearls from morning report:

  • 30% of patients with DAH will NOT present with hemoptysis.
  • The diagnostic yield of bronchoscopy in DAH is higher if performed within the first 48 hours of symptoms .
  • A DLCO > 100% predicted is a sensitive marker for DAH, though impractical as patients are likely too unstable to get a pulmonary function test.

Random trivia:

Cocaine laced with levamisole can induce vasculitis and diffuse alveolar hemorrhage.  It is estimated that up to 70-80% of cocaine entering the United States since 2005 is adulterated with levamisole.


Want to read more?

Diffuse Alveolar Hemorrhage (Chest)


References: 

Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;75(4):258, 260, 264-5.

Schwarz MI, King TE, Hollingsworth H. The diffuse alveolar hemorrhage syndromes. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 1, 2017)

 

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