(P31) A Case of Diffuse Alveolar Hemorrhage

Chief Complaint : Hemotypsis, cough, shortness of breath

History of Present Illness : 42 year old female with past medical history of Takayasu arteritis status post (s/p) ascending aortic aneurysm repair and mechanical aortic valve replacement on warfarin, coronary artery aneurysms s/p percutaneous intervention (PCI) and coiling of right coronary artery (RCA) aneurysms on aspirin and clopidogrel, left hip avascular necrosis s/p left hip replacement presents with hemoptysis since yesterday. Symptoms started three days ago with cough and rhinorrhea. Developed small amount of hemoptysis yesterday and worsening this morning. Associated with shortness of breath. Denies fever, chills, sick contacts, sore throat, chest pain, nausea, vomiting, diarrhea, abdominal pain, lightheadedness, syncope. Denies lower leg swelling.

Of note, patient had recent admission and was discharged 2 weeks before presentation. During admission, noted to have coronary artery aneurysms. Underwent PCI with placement of two drug eluting stents and coiling of mid RCA aneurysms. Patient was discharged on warfarin, aspirin, and clopidogrel.

Pertinent Physical Exam: Vital signs: BP- 165/90, Temp- 98.9 F, Pulse -84, RR- 20, SpO2- 94% on 2L nasal cannula
General: not in acute distress, well developed, not-ill appearing
Cardiovascular: regular rate and rhythm, no murmurs appreciated
Pulmonary: not in respiratory distress, mildly tachypneic, rales present throughout the lung fields, no wheezing noted, no decreased breath sounds
Abdominal: no pain to palpation, abdomen is soft
Musculoskeletal: no lower leg edema
Neurological: alert and oriented x 3

Point of care ultrasound: B-lines bilaterally, dilated IVC, mildly decreased ejection fraction

Pertinent Laboratory Data: Hemoglobin: 8.0 (1 week prior, 9.8)
Hematocrit: 26.8 (1 week prior, 32.0)
INR: 3.4
PTT: 32.9
Platelets: 239
Troponin: 0.57
BNP: 2,114 (2 weeks prior, 981)
pH 7.34/pCO2 55.80/HCO3 26/lactate 3.0
WBC: 11.2

Case Discussion: Diffuse alveolar hemorrhage (DAH) is a life-threatening condition and must be recognized early in evaluation as patients may quickly decompensate. Cases requiring hospitalization have a hospital mortality rate of 25% and delay in treatment worsens prognosis. DAH may be a complication of systemic lupus erythematosus, antiphospholipid syndrome, systemic vasculitis (e.g. Takayasu arteritis, granulomatosis with polyangiitis, microscopic polyangiitis), systemic sclerosis, and coagulopathies. Patients will normally present with acute shortness of breath and cough. The classical triad is hemoptysis, pulmonary infiltrates on chest radiograph, and a decrease in hemoglobin. Diagnosis is confirmed typically with bronchoalveolar lavage (BAL). Although, this is usually completed after admission so suspicion must be high to begin treatment in the emergency room. Treatment of DAH depends on the underlying cause but typically includes high dose steroids, correction of any coagulopathy, and nebulized tranexamic acid (TXA). Many of these patients require intubation.

In our case, patient presented mildly tachypneic and required 2 liters of oxygen via nasal cannula initially. Within 3 hours of presentation, patient required non-invasive ventilation. Patient continued to decompensate and 3.5 hours from presentation required intubation. BAL was completed post-intubation which confirmed the diagnosis of DAH. Patient was admitted to the ICU and started on high dose steroids and nebulized TXA. Warfarin, plavix, and aspirin were held for a day. Patient required 2 units of fresh frozen plasma and 2 units of packed red blood cells. Given high risk of stent thrombosis and history of mechanical valve replacement, On day 2, patient was started on heparin drip and plavix. Patient was extubated on day 5 and respiratory status continued to improve.

Our patient’s cause of DAH was multifactorial given history of Takayasu arteritis and recent stent and valve replacement requiring triple therapy. This case highlights the importance of early diagnosis as patients may quickly decompensate.

References and Acknowledgements (Optional): 1. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline D. Tintinalli’s Emergency Medicine : a Comprehensive Study Guide, 9e. 9th ed. McGraw-Hill Education LLC; 2017.