Title: A Case of Diffuse Alveolar Hemorrhage in the Absence of Vasculitis

Author: Clarissa Castanon, MD Division of Hospital Medicine

Introduction

Diffuse alveolar hemorrhage (DAH) is a life threatening condition of the lung usually associated with vasculitic disorders and connective tissue diseases. It is less commonly seen in infections. DAH is the result of injury to the alveolar capillaries, venules and arterioles where red blood cells accumulate in the alveoli. Clinically, DAH is comprised of hemoptysis, anemia, diffuse pulmonary infiltrates and acute hypoxic respiratory failure. Diagnosis is made via bronchoscopy and Broncheoalveolar lavage. We report a case of influenza Pneumonia complicated by diffuse alveolar hemorrhage. Case:

A 72 year old African American male presented with fever, chills, cough and altered mental status. Medical history was significant for metastatic prostate cancer and hypertension. Home medications included Zytiga, Lisinopril, Morphine and Prednisone. On admission patient was febrile to 104 degrees Fahrenheit and tachycardic to 123 beats per minute. Physical exam revealed a lethargic male with diffuse rhonchi on lung auscultation and 2+ pitting edema bilateral lower extremities. Chest X-ray revealed increased bibasilar interstitial opacifications. Patient was started on broad-spectrum antibiotics and placed on supplemental oxygen. Patient was found to be influenza A positive and was started on Oseltamivir. CT chest was later done which showed diffuse bilateral airspace disease. During this hospitalization patient developed increased oxygen requirements and worsening anemia requiring blood transfusion. Patient’s tachypnea and hypoxia worsened. Repeat chest x-ray showed worsening diffuse interstitial infiltrates and nodular densities. Diuretics and Bilevel positive pressure did not improve patient’s conditions. He was electively intubated and transferred to the intensive care unit. Acute Respiratory Distress Syndrome Network protocol was initiated at 6mL/kg. Bronchoscopy revealed diffuse pinpoint petechiae in the airways and blood return in lingual and right middle lobe without clearance after multiple aliquots. Samples were sent for bacterial and viral cultures. Cell count showed 700 WBC (50% neutrophils, 16% lymphocytes and 34%monocytes) and 150,000 RBC. Bronchial cultures were negative for bacteria and fungi. Viral culture is still in transit. Rheumatologic workup including Antinuclear antibody, Anti-double stranded DNA, Proteinase antibody and Myeloperoxidase antibody were negative. Patient was successfully extubated but developed supraventricular tachycardia likely from persistent hypoxia and was reintubated 7 days later.

Discussion

Influenza is a common viral syndrome affecting millions of people every year. Those especially susceptible are cancer patients. Even with early administration of antiviral, steroids and empiric antibiotics these patient’s carried a higher rate of mortality according to a report by Hajjar et. al. Influenza A infection is known to be associated with complications like viral or bacterial pneumonia however, diffuse alveolar hemorrhage is a less common association. Although, Mussi von Ranke et. al. conclude that influenza A is one of the more common infectious diseases causing diffuse alveolar hemorrhage, many medical professionals still only associate autoimmune and vasculitic disorders with DAH. According to an article by Lara et al. common etiologies of DAH include isolated pauci immune pulmonary capillaritis, idiopathic pulmonary hemosiderosis, ANCA associated granulomatous vasculitis, systemic lupus erythematous, good pasture syndrome and microscopic polyangiitis. Gilbert et. al. describes a fatal case of H1N1 pneumonia complicated by alveolar hemorrhage during the 2007-2009 pandemic. Marchiori et. al. also describes a case of Influenza complicated by DAH where intervention and treatment were started early and the patient was safely discharged. Our intention is to shed light on the connection between influenza A and DAH so that appropriate treatment can be initiated early in order to reduce morbidity and mortality associated with this disease.