29 Sep 2020

8/12/20 Diffuse Alveolar Hemorrhage

PGY2 Daniel Aldea presented a case of a 45 y/o M with history of SLE (diagnosed 1996 c/b lupus nephritis, previously on HD, pleurisy, pericarditis and protein C deficiency with history of RLE DVT), aortic regurgitation and HTN who presents with RUQ abdominal pain x1 day and worsening SOB x5 days. Patient reports RUQ pain that started earlier in the day, constant, not associated with PO intake. He also reports worsening SOB and DOE x5 days, associated with mild orthopnea and cough with production of white phlegm. He has noted b/l LE edema and decreased UOP. Home medications include acyclovir, amlodipine, carvedilol, losartan, prednisone, mycophenolate, sevelamer, sodium bicarbonate, darbepoetin alfa, and pantoprazole. Denies tobacco/ethanol/drugs. Vitals significant for temp of 36.4, HR 112, RR 20, BP 147/90 and satting 88% on RA. Exam significant for tachypnea, diminished lung sounds In b/l lower lung fields and 1-2+ pitting edema to b/l knees.

CBC: WBC 7.7>Hb 4.4/Hct 12.6<Plt 316 (*of note: 3 months prior, H/H at 8.4/24)
CMP:
Na 135/K 3.4/Cl 98/HCO3 17/BUN 109/Cr 7.44 <Glucose 123
ALP 69>T.protein 5.1/Albumin 3.5/AST 20/ALT 21/Tbili 0.2/Dbili <0.2

CXR:
DA1

Acid-Base workup:

  • Lactate 1.2
  • ABG: pH 7.46/pCO2 25/pO2 79/HCO3 18 on 33% FiO2

Cardiac workup:

  • Troponin: 0.03 >0.03>0.04
  • BNP: 29740 (normal <125)
  • TTE with EF of 64%, Grade 2 diastolic dysfunction RVSP 50mmHg, L atrium dilated, moderate aortic regurgitation and mild mitral regurgitation

Renal workup:

  • UA with negative leuk/nitrite, small blood (4-5 RBC)
  • FeNa: 14.1%
  • FeUrea: 59.8%
  • Urine protein/cr: 3.54
  • Renal US: kidneys are very increased in echogenicity consistent with renal parenchymal disease. No hydronephrosis.

Infectious workup:

  • BCx negative x2
  • Procal 0.72
  • Flu panel negative
  • HIV non-reactive
  • AFB: MTB PCR negative x2, AFB smear/culture negative x3
  • Respiratory culture negative
  • PCP DFA negative
  • Aspergillus EIA negative
  • Blasto Ab negative
  • Cocci Ab negative
  • Serum crypto Ag negative
  • Urine histo negative
  • 1-3bD glucan <21 pg/mL
  • CMV PCR not detected
  • EBV PCR <200 copies/mL

 

Rheum workup:

  • ESR: 119 (normal 0-22)
  • CRP: 42 (normal <4.9)
  • ANA negative
  • C3: 115 (normal 90-180)
  • C4: 23.6 (normal 10-40)

CT Thorax with multifocal airspace opacities in b/l lower lobes and RML:

Bronch with BAL done showing progressively bloodier on subsequent lavages consistent with diffuse alveolar hemorrhage.

DA4

Treatment: Patient was upgraded to the MICU due to worsening acute hypoxic respiratory failure with hemoptysis and he was intubated. Given bronch results, he was started on solumedrol 16mg q8H. He was also started on HD due to renal failure. Patient was able to be extubated after 2 days and was started on a steroid taper for discharge.

NEJM CPC:
Case 38-2019: A 20-Year-Old Man with Dyspnea and Abnormalities on Chest Imaging

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