Diffuse Alveolar Hemorrhage
Pulmonary renal syndromes are uncommon but serious conditions that may lead to serious complications such as end-stage renal disease and pulmonary compromise. Serologic testing for these syndromes assists with diagnosis although tissue biopsy is preferabl
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Joshua Smith and Mark Daren Williams
Case Presentation A 43-year-old Hispanic male originally from Honduras presented to the Emergency room with cough producing yellow sputum for 1 month, with recent change to blood tinged over the previous days. His past medical history was pertinent for hypertension and end stage renal disease requiring thrice weekly hemodialysis. He had missed dialysis for the previous week prior to presentation due to bad weather. He also reported fever, chills, and sore throat with the onset of hemoptysis. Of note, the patient had presented to another local hospital 2 months prior with similar symptoms of hemoptysis. He was evaluated by gastroenterology and otolaryngology and an endoscopy and laryngoscopy were performed. There were no obvious signs of bleeding but endoscopy did note blood emanating from the larynx. At presentation, his physical exam was notable for bilateral inspiratory rales with normal vital signs including oxygen saturation of 98 % on room air.
J. Smith, MD Internal Medicine – Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA M.D. Williams, MD, FCCP (*) Pulmonary/Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA e-mail: [email protected]
He was initially diagnosed with end-stage renal failure 18 months prior following a motor vehicle accident. The patient was uninjured but was noted to have a serum creatinine of 21 mg/dl. A renal ultrasound showed moderate to marked cortical hyperechoic texture suggesting renal parenchymal disease attributed to long-standing hypertension. He was started on hemodialysis and remained compliant despite some logistical challenges regarding his immigrant status. The patient had lived in the United States for the previous 10 years with no recent travel or sick contacts. He denied any use of tobacco, alcohol, or illicit drug use. He previously worked as a roofer, but was currently unemployed due to his dialysis dependence. At the time of presentation, his laboratory data was notable for anemia with hemoglobin of 5.9 g/dl, Potassium 6.6 mmol/L, BNP 2092 pg/ml and serum creatinine 23 mg/dl. A chest x-ray showed multifocal bilateral alveolar opacities (Figs. 34.1 and 34.2). The patient was initially treated with hemodialysis, broad spectrum antibiotics, and placed in respiratory isolation for evaluation of tuberculosis. The patient reported that his hemoptysis improved significantly following serial sessions of dialysis, yet chest imaging remained unchanged. Sputum culture, respiratory viral antigen panel, and AFB smears were negative. A bronchoscopy was performed 4 days after admission and revealed a progressively bloody bronchoalveolar lavage (Fig. 34.3) consistent with a diagno-
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_34
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J. Smith and M.D. Williams
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sis of diffuse alveolar hemorrhage. Serologic analysis confirmed the diagnosis. Question
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