Diffuse Alveolar Hemorrhage Due to Rheumatic Fever

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a potentially devastating complication of myriad pulmonary and cardiovascular diseases. CASE PRESENTATION: A 43 year-old woman presented with fever, dyspnea and polyarthralgias for several weeks. Physical exam was notable for temperature 102.7, IV/VI systolic murmur at the apex, and right-sided crackles. There was tender synovitis of the bilateral wrists and knees. Chest radiograph showed diffuse infiltrates, right greater than left. Electrocardiogram showed PR-interval prolongation (0.25ms). She was treated with antibiotics for pneumonia, but developed hypoxic respiratory failure requiring mechanical ventilation. Bronchoscopy revealed progressively bloody return. Echocardiography revealed severe mitral regurgitation with ruptured chordae tendinae of anterior and posterior leaflets. Sedimentation rate was 124 and antistreptolysin-O titer was >2300 IU/ml. Respiratory cultures, respiratory viral panel, and mycoplasma, legionella, and HIV tests were negative. Antinuclear antibodies, antineutrophil cytoplasmic antibodies, and antiglomerular basement membrane antibodies were negative. She was diagnosed with DAH due to rheumatic fever with mitral valve involvement. Penicillin therapy was begun and she was taken for urgent mitral valve replacement. Pathologic evaluation demonstrated severe acute and chronic inflammation of the anterior and posterior leaflets consistent with rheumatic valve disease. DISCUSSION: DAH is a potentially life-threatening condition resulting from a wide array of pathology. It can be categorized into three distinct DAH syndromes: vasculitis/capillaritis, “bland” pulmonary hemorrhage, DAH due to another process or condition.1The pathogenesis of DAH from valvulopathy falls into the “bland” category, as alveolar bleeding occurs through increased mechanical pressure, rather than inflammation of the pulmonary vasculature. Right upper lobe predominant bleeding is characteristic in mitral regurgitation because the regurgitant jet is toward the right pulmonary venous system. Transesophageal studies show that the flow velocity and pressure gradient are highest at the orifice of the right pulmonary venous system.2 CONCLUSIONS: While not as prevalent in more developed countries, acute rheumatic fever and rheumatic heart disease are still prominent global health concerns with potentially life-threatening complications. This case serves to remind clinicians to consider rheumatic valvulopathy as a possible etiology when alveolar hemorrhage is diagnosed, and to consider DAH as a cause of respiratory failure in patients with rheumatic and non-rheumatic mitral regurgitation. Reference #1: Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;75:258, 260, 264-5. Reference #2: Roach JM, Stajduhar KC, Torrington KG. Right upper lobe pulmonary edema caused by acute mitral regurgitation: diagnosis by transesophageal echocardiography. Chest. 1993;103:1286-1288. DISCLOSURE: The following authors have nothing to disclose: Steven Register, Stephanie Taylor, Brice Taylor No Product/Research Disclosure Information