Diffuse Alveolar Hemorrhage

Aka: Diffuse Alveolar Hemorrhage, Pulmonary Alveolar Hemorrhage

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II. Pathophysiology

  1. Acute life-threatening diffuse Pulmonary Hemorrhage often due to Vasculitis
  2. Bleeding into the alveoli due to disrupted capillary-alveolar basement membrane

III. Symptoms

  1. Cough
  2. Hemoptysis (66% of patients)
  3. Dyspnea
  4. Chest Pain or chest tightness
  5. Fever

IV. Signs

  1. Anemia (variably present)
  2. Diffuse lung infiltration (may be unilateral)
  3. Acute Respiratory Failure

V. Causes: Pathologic Capillaritis or Vasculitis

  1. Primary ideopathic Small Vessel Vasculitis
    1. Churg-Strauss Syndrome (Allergic Granulomatosis)
    2. Granulomatosis with Polyangiitis (Wegener's Granulomatosis)
    3. Microscopic Polyangiitis
  2. Primary Immune complex mediated Vasculitis
    1. Goodpasture Syndrome
    2. Hemoch-Schonlein Purpura
  3. Secondary Vasculitis
    1. Antiphospholipid Antibody Syndrome
    2. Polymyositis or Dermatomyositis
    3. Rheumatoid Arthritis
    4. Systemic Lupus Erythematosus
  4. Drug-Induced
    1. Chemotherapy
    2. Propylthiouracil
    3. Autologous Bone Marrow Transplant
  5. Miscellaneous causes
    1. Acute lung Transplant Rejection
    2. Behcet Syndrome
    3. Essential Cryoglobulinemia

VI. Causes Non-Pathologic Capillaritis (Bland Pulmonary Hemorrhage)

  1. Inhalational Injury
    1. Crack Cocaine
    2. Retinoic Acid
    3. Sevoflurane (Volatile Organic Anesthetic)
      1. Ahmed-Khan (2023) Arch Clin Cases 10(1): 29-31 [PubMed]
    4. Isocyanates
      1. https://en.wikipedia.org/wiki/Bhopal_disaster
  2. Coagulopathy
    1. Anticoagulants
    2. Anti-Platelet Agents
    3. Disseminated Intravascular Coagulation (DIC)
    4. Thrombolytics
  3. Drug-Induced
    1. Amiodarone
    2. Penicillamine
    3. Nitrofurantoin
  4. Oncologic Management
    1. Bone Marrow Transplant
    2. Cytotoxic Drug Therapy
    3. Radiation Therapy
  5. MIscellaneous
    1. Acute Respiratory Distress Syndrome (ARDS)

VII. Differential Diagnosis

  1. See Hemoptysis Causes

VIII. Labs

  1. Initial Labs
    1. Complete Blood Count with Platelet Count
    2. Comprehensive Metabolic Panel
    3. Blood Cultures
    4. C-Reactive Protein
    5. Urinalysis
  2. Vasculitis-Related Labs
    1. Serum ANCA
    2. Ant-GBM Antibodies
    3. Antinuclear Antibody (ANA)
    4. Antiphospholipid Antibody Panel
    5. Consider other rheumatologic and autoimmune Antibody testing

IX. Imaging

  1. Chest XRay
    1. Patchy or diffuse Alveolar Infiltrates
  2. CT Chest
    1. Regions of ground-glass attenuation

X. Diagnostics

  1. Bronchoscopy
    1. Indicated in most cases of acute Diffuse Alveolar Hemorrhage
    2. Send aspirate cultures for Bacterial, fungal and viral organisms

XI. Management

  1. ABC Management
    1. Supplemental Oxygen
    2. Non-Invasive Positive Pressure Ventilation or Mechanical Ventilation as needed
    3. Empiric Antibiotic management for infectious cause
  2. High Dose Corticosteroids
    1. Methylprednisolone IV 125 to 250 mg every 6 hours for 4 to 5 days
    2. Consider continued oral Corticosteroids (e.g. Prednisone) for a 5 day course
  3. Immunosuppressants
    1. Cyclophosphamide, Azathioprine, Methotrexate, Mycophenolate and Etanercept have been used
  4. Plasmapheresis
    1. May be indicated in Vasculitis (e.g. Goodpasture's Syndrome)

XII. References

  1. Park (2013) Tuberc Respir Dis 74:151-62 [PubMed]

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