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A1786 - A Silent Culprit of Diffuse Alveolar Hemorrhage
Author Block: E. L. Altschul1, H. Liao2, B. A. Mina1; 1Pulmonary and Critical Care Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 2Wyckoff Heights Medical Center, Brooklyn, NY, United States.
Introduction Diffuse alveolar hemorrhage (DAH) is characterized by bleeding into the alveolar spaces of the lung due to disruption of alveolar-capillary basement membrane. DAH can arise from a broad range of etiologies such as vasculitis, drugs, infections, or cardiac causes. We describe a case of diffuse alveolar hemorrhage caused by pulmonary edema due to severe mitral regurgitation (MR).Case Presentation A 66 year-old male with a past medical history of stroke, hypertension, end-stage renal disease on hemodialysis presented to the emergency department complaining of chest pain and dyspnea. Physical examination was remarkable for a blood pressure of 92/66 mmHg, respiratory rate 20 per minute, and pulse oximetry of 90%, which markedly improved with oxygen. EKG revealed new-onset atrial fibrillation and his troponin was elevated to 7.986 ng/mL requiring admission to the CCU for NSTEMI. During hospitalization he developed a fever to 38.6C and empirical antibiotics for pneumonia were started. Cardiac catheterization revealed triple vessel disease and he was transferred to our hospital for coronary artery bypass grafting (CABG). On arrival, he complained of dyspnea associated with hypoxia despite consistent dialysis sessions. He was placed on high-flow nasal cannula for increased work of breathing. Additionally, his hemoglobin decreased and he was transfused 2 units of packed red blood cells. Echocardiogram was significant for severe MR and CT scan of the chest revealed moderate to severe diffuse bilateral ground glass opacities. To confirm the etiology of the opacities, bronchoscopy was performed and demonstrated significant blood in trachea and bilateral segmental airways consistent with diffuse alveolar hemorrhage. Further laboratory workup for vasculitis was negative. After three hemodialysis sessions post bronchoscopy his respiratory status improved and he underwent a successful CABG.Discussion DAH is described as clinical constellation of hemoptysis, anemia, diffuse bilateral pulmonary infiltrates on chest x-ray, and hypoxemic respiratory failure. Hemoptysis can be absent at presentation in up to 33% of patients with DAH from any cause. Bronchoalveolar lavage reveals progressively more hemorrhagic effluent and is the usual method for diagnosis of DAH. In this patient, the abrupt increase in left atrial pressure from volume overload led to the pulmonary edema and disruption of alveolar capillary membrane. His MR improved with daily sessions of dialysis. It has been well known that mitral stenosis causes DAH. Our case illustrates that acute severe MR can be a rare cause of DAH with only a few case reports described.