Cause Of Diffuse Alveolar Hemorrhage Research Articles

Clinical features, paraclinical characteristics, and etiology of mediastinal bleeding diffusion in children at the Vietnam National Children’s Hospital from 2018 to 2023

Background: In modern life, diffuse alveolar haemorrhage (DAH) is a serious and rare condition in children. Due to the subtle clinical manifestations and diverse causes of the disease, it is easy to be missed or diagnosed late. This study describes clinical and paraclinical characteristics, with the aim to find signs suggesting early diagnosis as well as determine the cause of DAH in children. Objects and methods: Case series. Results: From January 2018 to March 2023, there were 14 children diagnosed with DAH. The age of onset is 4.08 (1.58-5.41) years old, but most patients are diagnosed late with age at diagnosis being 5.25 (1.67-6.16) years old, male/female ratio is 1:1.8. The most common symptoms reported were anaemia (100%), hemoptysis (57.1%), shortness of breath (71.4%), and respiratory failure (85.7%). The common X-ray finding was diffuse infiltrates in both lungs (92.9%). On chest computed tomography scans, 92.9% of patients exhibited images of blurred opacity spreading, 57.1% showed interlobar pleural thickening, and 28.6% presented with images of lung consolidation. 3 patients (22%) had milk allergy, 2 patients (14%) had ANCA (Anti-neutrophil cytoplasmic antibody) vasculitis, and 9 patients (64%) had idiopathic pulmonary haemosiderosis (IPH).

Systemic lupus erythematosus with diffuse alveolar hemorrhage.

Systemic lupus erythematosus with diffuse alveolar hemorrhage.

Abstract 13671: A Case of Diffuse Alveolar Hemorrhage While on Systemic Anticoagulation for Impella

A 57 year old male with PMH of non-ischemic cardiomyopathy (EF 30%), atrial fibrillation, and VT s/p ICD was admitted to the cardiac intensive care unit for cardiogenic shock. His condition deteriorated necessitating Impella 5.5 implantation as bridge to cardiac transplant. Systemic heparin was started per Impella protocol with a lower anti-Xa goal of 0.2 - 0.3 given post-op bleeding at the R axillary Impella site. Five days post Impella placement he developed bloody secretions from the endotracheal tube requiring multiple blood transfusions and discontinuation of systemic heparin, while maintaining heparin purge. Labs were notable for anti-Xa 0.22, hemoglobin 9.7, and platelets 221. CT Chest demonstrated parenchymal opacities concerning for diffuse alveolar hemorrhage (DAH) which was confirmed via bronchoalveolar lavage; he had no known history of lung disease. High-dose corticosteroids were administered as a high ANA titer (1:128) and low C3 suggested capillaritis. However, decreasing ANA (1: 320) and a negative autoimmune workup decreased the likelihood of a rheumatologic cause for DAH and steroids were discontinued. DAH secondary to acquired von Willebrand syndrome (aVWS) was considered, but factor VIII and vWF activity levels were normal. The bloody secretions improved with inhaled thromboxane and systemic heparin was restarted. Orthotopic heart and kidney transplant was performed with subsequent Impella removal 104 days after Impella placement. Discussion: We present the first documented case of DAH with isolated Impella 5.5 support. Previously reported cases of DAH post-Impella were observed in patients with concurrent ECMO or RVAD. As autoimmune and coagulopathic causes of DAH were excluded, bland DAH secondary to systemic anticoagulation is most likely in this case. This raises a question about how to balance the risk of bleeding with the risk of device thrombosis, stroke and embolic events and when to switch from heparin to sodium bicarbonate purge.

Idiopathic Pulmonary Hemosiderosis in Pediatric in Patients: Report of Four Cases in Rabat, Morrocco

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage. Patients with IPH usually present with the classical triad: hemoptysis, and iron deficiency anemia, and pulmonary infiltrates on chest imaging, the diagnosis is often delayed by years.
 We report four IPH pediatrics cases of children diagnosed at the children’s hospital of Rabat, Morocco. The aim of this study is to review the clinical manifestations, diagnostic tools and treatment of this affection.
 All the four patients were presented with the classical triad, the diagnosis was based on the Clinical, radiologic and biologic findings. Bronchoalveolar lavage was performed to all the patients and confirmed the diagnosis by the identification of siderophages.
 High doses of Corticosteroids, by an induction therapy with an intravenous methylprednisolone (20 mg/kg/day for 3 days) followed by oral prednisone (1 mg/kg/day) had shown a good therapeutic response. One patient was treated first with oral corticosteroid and switched over to synthetic antimalarial drugs, because he had side effects from long-term cortico therapy. Then the clinical condition has been improved. The evaluation of response to the therapy included the clinical symptoms and signs, laboratory data and chest x ray. The prognosis of IPH is influenced by several factors, including the time of diagnosis, early initiation of treatment, and the presence of comorbidities.

Diffuse alveolar hemorrhage (DAH): a rare presentation of metastatic angiosarcoma

BackgroundAngiosarcoma is an uncommon and highly aggressive malignant tumor. Angiosarcoma presenting as diffuse alveolar hemorrhage (DAH) is rare.Case presentationA young female who presented with history of dyspnea was found to have features of DAH on radiological evaluation. Angiosarcoma was confirmed from the histopathological examination of the underlying lung nodule. Management with the palliative chemotherapy showed clinical improvement, and resolution of changes of DAH on imaging.ConclusionAngiosarcomas are not usually listed in the causes of DAH. It must be considered in the differentials of DAH after ruling out the common causes.

Diffuse alveolar hemorrhage secondary to sarcoidosis.

Diffuse alveolar hemorrhage (DAH) is a pulmonary condition that can be caused by autoimmune disorders such as lupus, small vessel vasculitis, and antiphospholipid syndrome. Sarcoidosis as a cause of DAH has been reported; however, the literature remains limited. We performed a chart review for patients with a diagnosis of both sarcoidosis and DAH. Seven patients met inclusion criteria. Mean (range) patient age was 54years (39-72), and 3 patients had a history of tobacco use. Diagnosis of DAH and sarcoidosis were concurrent for 3 patients. Corticosteroids were used for treatment of DAH in all patients; 2 (including 1 with refractory DAH) were successfully treated with rituximab. We believe sarcoidosis-associated DAH is more common than previously reported. It is essential to consider sarcoidosis in the differential diagnosis of immune-mediated DAH. Key Points • Sarcoidosis can cause diffuse alveolar hemorrhage (DAH); more extensive studies are needed to estimate this condition's prevalence. • BMI of 25 or higher appears to be a risk factor for the development of sarcoidosis-associated DAH.

SMALL VESSELS, BIG PROBLEMS: MICROSCOPIC POLYANGIITIS PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE

SMALL VESSELS, BIG PROBLEMS: MICROSCOPIC POLYANGIITIS PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE

Clinical Presentation of Legionella pneumophila Serogroup 1-Associated Pneumonia and Diffuse Alveolar Hemorrhage: A Case Report and Literature Review

Patient: Female, 44-year-old Final Diagnosis: Legionella pneumophila serogroup 1-associated pneumonia and diffuse alveolar hemorrhage Symptoms: Dyspnea Medication:— Clinical Procedure: Bronchoalveolar lavage Specialty: Infectious Diseases Objective: Rare disease Background:We report a case of diffuse alveolar hemorrhage (DAH) caused by Legionella pneumophila serogroup (SG) 1 and review the existing literature to identify risk factors and determine the prognosis of patients with Legionella pneumonia-associated DAH.Case Report:A 44-year-old woman was admitted to our hospital following the presentation of dyspnea for a few days. Chest computed tomography (CT) findings revealed “crazy-paving” pattern in the right upper lobe implicating DAH and consolidation in the lower lobe. Analysis of the bronchoalveolar lavage (BAL) fluid revealed DAH, with further analyses identifying L. pneumophila SG 1 as the causative agent. The patient was successfully treated with levofloxacin and a red blood cell transfusion and discharged on the 32nd day of hospitalization. A literature review of 6 reported cases (including our case) of Legionella pneumonia-associated DAH revealed that the median age of patients with DAH was 59 years (range, 44–75 years), involving female patients in 4 cases (67%) and the use of immunosuppressive drugs in 2 cases (33%). Three cases were BAL Legionella polymerase chain reaction (PCR)-positive and 4 cases were diagnosed using a urinary Legionella antigen test (one case was simultaneously PCR-positive). These infections were caused by L. pneumophila SG 1 in three cases and SG 3 in one case. Mechanical ventilation was used in 5 cases (83%) and one patient had an unfavorable prognosis. Steroids for DAH were used in 5 cases (83%), and 2 cases responded to this treatment.Conclusions:Our case highlights that clinicians should be aware of Legionella spp. as a cause of DAH in an immunocompe-tent host with “crazy-paving” pattern on chest CT, and perform a urinary antigen test and BAL PCR for diagnosis.

Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years.

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS). This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS. A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients. All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.

A Case of Acute Breathlessness in Section Systemic Lupus Erythematosus: A Devastating Complication

Diffuse Alveolar Haemorrhage (DAH) is a severe respiratory complication of Systemic Lupus Erythematosus (SLE) and is associated with high mortality. A drop in blood haemoglobin, dyspnoea, haemoptysis, diffuse infiltrates on chest imaging indicate this devastating diagnosis. The DAH is rare in SLE, even rarer in the early months in an undiagnosed patient. Defective phagocytosis, immune complexes, depletion of complement, autoantibodies is the etiology. Immune complex induced alveolar capillaritis is the cause of DAH. This report was about a 28-year-old female, who presented with acute worsening dyspnoea on a background history of inflammatory joint pain, digital gangrene, alopecia, oral ulcers, and Raynaud’s phenomenon. She was subsequently diagnosed as SLE with DAH. This case was rare as she presented with DAH in the early months of her disease. Patient was started on high dose steroid, cyclophosphamide, and plasmapheresis, but succumbed on day 14 of admission due to high disease activity and respiratory failure. The DAH carries very high mortality rate even in best centres even when diagnosed early.

Ticagrelor Induced Diffuse Alveolar Hemorrhage - A Case Report

Drug-induced Alveolar Hemorrhage is a rare cause of Diffuse Alveolar Hemorrhage (DAH). It requires to be considered in the differential diagnosis among patients presenting with DAH and prompt management, including the need for mechanical ventilation in severe cases. Here we present a case of severe DAH following percutaneous coronary intervention and Ticagrelor therapy that responded well to discontinuation of Ticagrelor.

Liposteroid Therapy for Idiopathic Pulmonary Hemosiderosis: A Scoping Review of the Literature.

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage (DAH). Glucocorticosteroids (CS) represent the first line therapy for IPH. Although most patients respond to CS, steroid refractoriness is seen in an appreciable minority of patients. This paper reviews and evaluates the efficacy and safety profile of liposomal dexamethasone 21-palmitate (liposteroid) for the treatment of IPH. Medline, Embase and Web of Science biomedical databases were searched between 1980 and 2020 to identify papers describing patients with IPH, who were treated with liposteroid. A total of five articles were identified. Four in the form of case reports and one as a case series. A total of 12 pediatric patients (5 boys, 7 girls) were identified, with a median age of 2.3 years (range 0.5-8.6). Liposteroid therapy in intravenous doses ranging 0.06-0.1 mg/kg body weight appeared to be effective for both remission induction therapy, and maintenance therapy. There was no mortality among patients treated with liposteroid, either in the acute phase or during follow-up. The majority of patients for whom long-term follow-up data were available, were cured or in disease remission. No acute adverse events were reported, and long-term side effects were minimal and tolerable. Liposteroid represents a potential alternative or supplement to conventional CS therapy, as it appears to be more efficacious and associated with fewer side effects. Larger prospective, controlled trials are necessary to be able to define more precisely the therapeutic role of liposteroid in IPH.

DIFFUSE ALVEOLAR HEMORRHAGE RESULTING FROM RIVAROXABAN USE: A RARE COMPLICATION IN A PATIENT WITHOUT PREDISPOSING CONDITIONS

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a rare complication of direct oral anticoagulant (DOAC) use with few reported cases in patients with predisposing conditions or underlying lung disease. DAH results from disruption of the alveolar-capillary interface. Infectious, autoimmune, and drug mediated conditions may lead to DAH. Rivaroxaban is a DOAC used to treat venous thromboembolism (VTE) and non-valvular atrial fibrillation (NVAF). We present a case of a patient who developed DAH one month after starting rivaroxaban. CASE PRESENTATION: A 43-year-old female with a past medical history of hyperlipidemia and tobacco use disorder presented with frank hemoptysis and shortness of breath. She was diagnosed with lower extremity deep vein thrombosis (DVT) and was started on rivaroxaban. Vitals were stable without hypoxia. Hemoglobin dropped from 14 to 7 g/dL (normal 12.3-15.3 g/dL) requiring 2 units of blood. Prothrombin Complex Concentrate was given. Computed tomography angiogram of the chest showed bilateral lung fields with patchy ground-glass opacities with peripheral sparing, without significant intra-lobular septal thickening and no pulmonary embolus. Infectious work up was negative. Rheumatological workup with anti-glomerular basement antibodies, anti-double stranded DNA antibodies, lupus anticoagulant, antinuclear antibody, rheumatoid factor, anti-neutrophilic cytoplasmic antibody, proteinase-3 antibody, myeloperoxidase antibody, C-reactive protein and erythrocyte sedimentation rate was negative. Bronchoscopy confirmed the diagnosis of DAH. Hemoptysis resolved after discontinuing rivaroxaban, repeat lower extremity dopplers were negative for DVT. She was discharged home without anticoagulation. DISCUSSION: DAH occurs from direct injury or inflammation of the pulmonary arterioles, venules, or alveolar septal capillaries causing bleeding into the lung. It presents with non specific symptoms including cough, chest pain, hemoptysis, and dyspnea. It is life threatening with fast clinical deterioration leading to respiratory failure. The underlying vascular injury of DAH is based on histological appearance and is divided into pulmonary capillaritis, bland pulmonary hemorrhage, and diffuse alveolar damage. The diagnosis is usually made clinically and supported with imaging and bronchoscopic findings. There are few cases of rivaroxaban induced DAH in the literature. The majority of the cases report patients with an underlying medical conditions such as autoimmune disease, lung cancer, interstitial lung disease and pulmonary hypertension, predisposing them to DAH. Our patient had no predisposing factors that put her at risk of developing DAH. CONCLUSIONS: Oral anticoagulants are a under-recognized cause of DAH with limited literature on the incidence of DAH with the use of these medications. This case illustrates that patients with no underlying risk factors can develop DAH with the use of rivaroxaban. REFERENCE #1: Collard HR, Schwarz MI. Diffuse alveolar hemorrhage. Clinics in Chest Medicine 2004; 25(3): 583-92. REFERENCE #2: Park MS. Diffuse alveolar hemorrhage. Tuberc Respir Dis (Seoul) 2013; 74(4): 151-62. REFERENCE #3: Chen A, Stecker E, Warden BA. Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges. Journal of the American Heart Association 2020; 9(13): e017559 DISCLOSURES: No relevant relationships by Ahmad Alhajhusain, source=Web Response No relevant relationships by Stephanie Baltaji, source=Web Response No relevant relationships by Helene Rovnan, source=Web Response

Testosterone undecanoate injection, a rare cause of diffuse alveolar hemorrhage: A case report from Almoosa Hospital

Many systemic and few respiratory (cough, pulmonary embolism) adverse effects follow anabolic agent use. Pulmonary hemorrhage is not considered one among them. We present a case of an adult Saudi male who developed diffuse alveolar hemorrhage (DAH) as a results of the utilization of injectable anabolic steroid hormone replacement therapy. The literature reported only three cases of DAH related to anabolic agent abuse. The patient was presented with acute dyspnea and hemoptysis with diffuse alveolar shadow on chest radiograph. The symptoms promptly resolved with cessation of exposure and recurrent after the reuse. Pulmonary hemorrhage as an acute complication of anabolic agent use must be considered when clinical and radiological findings support it. It's important to rule out the autoimmune and infectious-related causes before considering it drug-related.

Hemosiderosis pulmonar idiopática: seguimiento de pacientes durante 25 años (1995-2019)

Idiopathic pulmonary hemosiderosis (IPH) is a cause of diffuse alveolar hemorrhage. Objective: to describe the evolution of children with IPH in our institution. Retrospective monitoring with a follow-up protocol was carried out. 13 patients, seven males, were recruited. From an agricultural area (6/13). Not all of patients had the complete diagnostic triad: cotton infiltrates (9/13), anemia (11/13), hemop- tysis (9/13). Hemosiderin-laden macrophages counting in the bronchoalveolar lavage fluid was over 30% in all the patients. Computed chest tomography was informed as normal (5/13), interstitial pattern (5/13), ground glass (2/13) and fibrosis (1/13). Spirometry: normal (7/13), restrictive (4/13), obstructive (1/13) and not performed (1/13). Treatment during the acute phase: bolus of methylprednisolone (7/13) or prednisone (6/13) or hydrocortisone (1/13). In the maintenance phase: prednisone (13/13) plus an immunosuppressant, azathioprine (12/13), hydroxychloroquine (1/13), mycophenolate (1/13), plus bu- desonide MDI (13/13). Eight patients stopped the bleeding episodes. Two patients died and there were five physiological pregnancies in 3 adolescents. It was observed:(a) different modes of IPH presentation that delayed its diagnosis; (b) large exposure to pesticides; (c) prognosis improved if diagnosis and treatment were early, also in adolescent girls; (d) most of the patients stopped the bleeding episodes.

Risk factors and outcomes of immune and non-immune causes of diffuse alveolar hemorrhage: a tertiary-care academic single-center experience.

Diffuse alveolar hemorrhage (DAH) is a rare but potentially life-threatening emergency that has both immune and non-immune etiologies. The objective of this investigation was to compare the risk factors and outcomes of immune and non-immune causes of DAH at a tertiary-care academic center. This was a retrospective observational study conducted at a University center. We reviewed all chest radiographs spanning 12years (2007-2019) at our institute with the words "diffuse alveolar hemorrhage" in the body of their report, and ascertained cases of DAH through a detailed chart review. We used Chi-squared test to determine the differences in risk factors and outcomes between immune versus non-immune causes of DAH. We performed logistic regressions to assess whether baseline demographics and clinical features influence four critical outcomes: death, shock, renal failure, and severe anemia requiring transfusions. Over the 12-year period, there were 88 patients with DAH, 55 with non-immune and 33 with immune etiologies. Among immune causes of DAH, granulomatosis with polyangiitis (GPA) (10.2%), microscopic polyangiitis (MPA) (9%) and systemic lupus erythematosus (SLE) (9%) were most common. Among non-immune causes of DAH, coagulopathy (6.8%), decompensated heart failure (4.5%) and infection (3.4%) were most common. Patients with non-immune causes of DAH were 45.8% more likely to die and 20.7% less likely to experience sustained remission (p = 0.001). Patient with immune causes of DAH were 21% more likely to have extra-pulmonary findings and 23.7% more likely to have received hemodialysis (HD). The presence of extra-pulmonary findings was statistically significantly correlated with the number of blood products received, the need for HD and non-statistically significantly correlated with likelihood of death. Patients with immune causes of DAH were 71.5% more likely to receive multimodal therapy including corticosteroids. Immune-mediated DAH is associated with a better prognosis than non-immune DAH, despite its greater association with extra-pulmonary findings and requirement for hemodialysis.

Diffuse Alveolar Hemorrhage in Cardiac Diseases.

Diffuse alveolar hemorrhage (DAH) is a rare condition with reported mortality ranging between 20 and 100%. There are many etiologies of DAH. Cardiac diseases are likely underreported causes of DAH. Heart failure and mitral valve diseases are the most common cardiac causes of DAH. The DAH results from pulmonary venous hypertension leading to stress failure of the pulmonary capillaries. There is also a contribution of the bronchial circulation. The Alveolar-capillary membrane or blood-gas barrier is an extremely thin structure that allows rapid and passive diffusion of oxygen from the inhaled air to the pulmonary capillaries while preventing pulmonary edema and DAH with chronic elevation of the transmural hydrostatic pressure. The purpose of this manuscript is to inform the clinician about this rare cause of DAH, which may be overlooked unless specifically sought after. We also discuss the pathophysiologic aspects of DAH and the safety mechanisms in place to prevent such occurrences.

A CASE OF HEMORRHAGE RESCUED BY EXTRACORPOREAL MEMBRANE OXYGENATION

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a well-known complication of many disease processes including vasculitides. DAH secondary to vasculitis, however rare, is one of the most devastating presentations of vasculidities carrying a substantial mortality. A significant percentage of patients with DAH progress to acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been described to improve oxygenation in ARDS while underlying etiologies are addressed. The role of VV ECMO in DAH secondary to vasculitis is unclear. CASE PRESENTATION: A 37-year-old woman presented with severe ARDS. In the preceding two weeks, she experienced polyarthralgias and a lower extremity rash. She presented to the emergency department after developing hemoptysis which necessitated intubation. On presentation to the intensive care unit, she was afebrile and had an oxygen saturation of 95% on an FiO2 of 1. Of note, the patient had non-blanching, palpable, hemorrhagic bullae. Lab-work was notable for a white blood cell count of 13,600, a hemoglobin of 8.4 g/dL, a PaO2/FiO2 (P/F) ratio of 92, and urinalysis with protein and dysmorphic red blood cells. Computed tomography of the chest demonstrated diffuse infiltrates sparing the periphery. She was paralyzed and placed in a prone position for severe ARDS. She was started on pulse-dose steroids and on plasma exchange for suspected DAH. On day three, her P/F ratio was 61 and she was placed on VV ECMO. Bronchoscopy was performed with sequentially bloodier returns on alveolar lavage. Further workup revealed negative bacterial cultures, a positive ANA titer of 1:320, a C-ANCA titer of 1:40, and an elevated PR3 antibody. The patient was diagnosed with granulomatosis with polyangiitis and was started on cyclophosphamide. She was decannulated from ECMO after four days, extubated two days thereafter, and was discharged from the hospital in her premorbid state. DISCUSSION: The causes of DAH are varied but are commonly due to autoimmune phenomena. The current evidence for use of ECMO in DAH is limited to case reports and case series. Before the more widespread deployment of extracorporeal support, the treatment of respiratory failure from DAH was limited to aggressive ventilator management and immunomodulating medications. Despite progress in immunosuppressive therapy, the mortality for DAH remains unacceptably high. The deployment of ECMO may provide enough time with sufficient oxygenation for the causes of DAH to be addressed. CONCLUSIONS: Though there is a dearth of high-quality evidence justifying the use of ECMO in DAH, our case demonstrates that VV ECMO can be used successfully to temporize the hypoxemia in DAH. This measure could provide the time necessary for immunosuppression to take effect and reduce overall mortality from the most devastating consequence of vasculitis. Reference #1: Park M. S. (2013). Diffuse alveolar hemorrhage. Tuberculosis and respiratory diseases, 74(4), 51-62. Reference #2: Guo, Z., Li, X., Jiang, L. Y., & Xu, L. F. (2009). Extracorporeal membrane oxygenation for the management of respiratory failure caused by diffuse alveolar hemorrhage. The journal of extra-corporeal technology, 41(1), 37-40. Reference #3: West S, Arulkumaran N, Ind PW, Pusey CD. (2013). Diffuse Alveolar Haemorrhage in ANCA-associated Vasculitis. Internal Medicine, 52(1):5-13. DISCLOSURES: No relevant relationships by Lisa Daniels, source=Web Response No relevant relationships by Joshua Detelich, source=Web Response No relevant relationships by Maxwell Hockstein, source=Web Response

DIFFUSE ALVEOLAR HEMORRHAGE FOLLOWING DUAL CHECKPOINT INHIBITOR THERAPY

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Immune checkpoint inhibitors (ICIs) have emerged as new therapeutic agents with survival benefit for various cancers, but are associated with various complications (1,2). ICI related pulmonary toxicity usually manifests in the form of pneumonitis, but diffuse alveolar hemorrhage (DAH) caused by ICIs has not been previously described (3). CASE PRESENTATION: A 72-year-old man with history of Diabetes Mellitus, Asthma, Acute Myeloid Leukemia who failed three lines of chemotherapy and bone marrow transplant, was started on ICI therapy with ipilimumab and nivolumab. He was admitted to hospital for worsening night sweats, fatigue and recurrent falls. On day 2, he developed fever, dyspnea, minor hemoptysis (<5mL) and hypoxemia requiring supplemental oxygen (3L via nasal cannula). CT chest revealed bilateral ground-glass infiltrates. He was treated with diuresis and antimicrobials including meropenem and posaconazole. His course was complicated by increasing oxygen requirements (non-invasive ventilation). Extensive infectious workup was negative including blood, urine cultures, respiratory viral panel and fungal serologies. Bronchoalveolar lavage (BAL) performed on day 3 revealed grossly hemorrhagic fluid with no change on 3 sequential lavages. Hemosiderin laden macrophages were reported on the cytologic exam. Of note, he had thrombocytopenia from leukemia, and his platelet count was 13000/cu.mm on the day of bronchoscopy. Following BAL, he was started on IV methylprednisolone 1 mg/kg/day for suspected pneumonitis related to ICI therapy. Within 24 hours, he showed significant improvement in work of breathing and oxygen was weaned to 2L via nasal cannula. BAL culture grew Pseudomonas aeruginosa and vancomycin resistant Enterococcus faecium. He was transitioned to oral steroids was discharged in a stable condition on room air. DISCUSSION: Association of ICIs with pulmonary toxicity in the form of pneumonitis is well recognized. However, DAH has not been described in association with this therapy. We report a case of DAH that appeared after 3 months of ipilimumab and nivolumab treatment. DAH was confirmed through grossly hemorrhagic sequential lavages with the presence of hemosiderin-laden macrophages. Though BAL cultures in this patient showed growth, infection as a cause of DAH is extremely unlikely given progression of disease despite antibiotics and dramatic response to steroids. Further research is needed to elucidate the mechanism and association of DAH in setting of ICI therapy and prognostic and therapeutic implications of such presentation. CONCLUSIONS: Use of immunotherapy for cancer is rapidly expanding, and complications related to such therapy are being increasingly recognized. We describe a case of DAH manifesting with hemoptysis and hypoxic respiratory failure in a patient who was receiving ipilimumab and nivolumab. To our knowledge, this is the first description of such an association. Reference #1: Valadolid J, Amin A. Immune checkpoint inhibitors in clinical practice: update on management of immune-related toxicities. Trans Lung Cancer Res. 2015;4(5):560-75 Reference #2: Suresh, Karthik et al. Pneumonitis in Non–Small Cell Lung Cancer Patients Receiving Immune Checkpoint Immunotherapy: Incidence and Risk Factors Journal of Thoracic Oncology , Volume 13 , Issue 12 , 1930 – 1939 Reference #3: Naidoo J, Wang X, Woo KM, et al. Pneumonitis in Patients Treated With Anti-Programmed Death-1/Programmed Death Ligand 1 Therapy. J Clin Oncol. 2016;35(7):709-717. DISCLOSURES: No relevant relationships by Herbert Berger, source=Web Response No relevant relationships by Vikas Koppurapu, source=Web Response No relevant relationships by Roger Struble, source=Web Response

Idiopathic Pulmonary Hemosiderosis in a Young Adult Patient: A Rare Case

Idiopathic pulmonary hemosiderosis (IPH) is often an ignored and rare cause of diffuse alveolar hemorrhage (DAH). It is characterized by triad of hemoptysis, anemia, and alveolar opacity on radiology. It is a diagnosis of exclusion, established after ruling out other causes of DAH such as Goodpasture’s syndrome, large vessel vasculitis, small vessel vasculitis associated with anti-neutrophil cytoplasmic antibody (ANCA) (Wegener’s granulomatosis, Churg–Strauss syndrome, microscopic polyangiitis), immune complex-related vasculitis (collagen vascular diseases, Henoch–Schonlein purpura, mixed cryoglobulinemia) drug reactions, anticoagulation and thrombocytopenia. Though it is a disease primarily affecting children, we hereby report a case of IPH in an adult patient who responded dramatically to oral corticosteroid.