DIFFUSE ALVEOLAR HEMORRHAGE WITH LATE PRESENTING RIGHT VENTRICULAR THROMBI

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diffuse alveolar hemorrhage is a life threatening emergency that can be caused by multiple etiologies. Pulmonary capillaritis, one common etiology, is particularly associated with autoimmune or inflammatory diseases. We present a challenging case of diffuse alveolar hemorrhage with associated acute hypoxic respiratory failure due to isolated pulmonary capillaritis with multiple late presenting intracardiac thrombi. CASE PRESENTATION: A 20 year-old woman presented with four days of myalgias, fever, and shortness of breath. Testing for pulmonary embolism and SARS-CoV2 was negative. She was diagnosed with pneumonia and treated with ceftriaxone and azithromycin. She then developed blood tinged mucous which was concerning for diffuse alveolar hemorrhage and received three days of pulse dose steroids. Seven days after initial presentation, she required escalation to intensive care. Her oxygen saturation was 96% on 70% FiO2 and 50 liters of pressure and subsequently required intubation for hypoxic respiratory failure. Imaging revealed diffuse bilateral infiltrates and bronchoscopy with lavage yielded mild endobronchial bleeding, but no overt hemorrhage. Pathology demonstrated neutrophilic capillaritis with diffuse alveolar damage. Prior outpatient autoimmune workup was significant only for mildly positive anti-nuclear antibody (speckled pattern 1:80). Transthoracic echocardiogram performed after intubation revealed two right ventricular thrombi that were not present on prior echocardiogram from admission. We initiated a heparin infusion in the setting of her alveolar bleeding and continued treatment with methylprednisolone. She then developed acute hemodynamic changes concerning for pulmonary embolism but stabilized without further intervention. The patient's oxygenation improved and she was successfully extubated. An antiphospholipid syndrome screen returned positive for a Dilute Russell Viper Venom Time (though notably value was 1.25 and upper limit of normal is 1.24) and anticoagulation was transitioned to warfarin prior to discharge home. DISCUSSION: Concurrent hemorrhage and hypercoagulability is a difficult management dilemma that many clinicians will face in the hospital setting. This case highlights the degree of suspicion required to evaluate for thromboembolic phenomena even in a patient with hemorrhage. In this young patient with no significant past medical history, autoimmune etiologies must be considered for her presentation of diffuse alveolar hemorrhage, which can also cause a concurrent hypercoagulable state. Despite mildly positive lupus anticoagulant screen, remainder of autoimmune workup was negative and suspicion low for systemic autoimmune disease. CONCLUSIONS: Bedside clinical judgement must drive decision making in the balance between worsening bleeding with anticoagulation or considering intervention for hemodynamically significant thromboembolic events. REFERENCE #1: Stoots SA, Lief L, Erkan D. Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome. Curr Rheumatol Rep. 2019;21(10):56. Published 2019 Sep 6. doi:10.1007/s11926-019-0852-7 REFERENCE #2: Park MS. Diffuse alveolar hemorrhage. Tuberc Respir Dis (Seoul). 2013;74(4):151-162. doi:10.4046/trd.2013.74.4.151 DISCLOSURES: No relevant relationships by Micah Fisher, source=Web Response No relevant relationships by David Wilhoite, source=Web Response