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Weekly Chest CasesArchive of Old Cases

Case No : 1279 Date 2022-04-25

  • Courtesy of Ju Gang Nam / Seoul National University Hospital
  • Age/Sex 45 / F
  • Chief ComplaintDyspnea, blood-tinged sputum (onset, 5 days ago) Underlying systemic lupus erythematosus
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Diffuse alveolar hemorrhage
Radiologic Findings
Fig 1. Chest radiograph showed bilateral multifocal consolidation and ground-glass opacities.
Fig 2-4. Chest CT angiography revealed multifocal central consolidation and ground-glass opacities at both lungs. There was no pulmonary thromboembolism.
Brief Review
Bronchoscopy revealed diffuse hemorrhage without endobronchial lesions. Bronchoalveolar Lavage was done at RUL anterior segmental bronchus, and the color of the fluid became more sanguineous during the three sequential lavages. The patient was diagnosed to have diffuse alveolar hemorrhage.

Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening syndrome causing respiratory failure. Suspicion of DAH could be difficult, as symptoms and radiologic findings are nonspecific. Hemoptysis is absent for up to one-third of the patients. Once the diagnosis is established, the underlying cause must be established in order to initiate treatment.
Radiologic findings are similar to the other disease with acute alveolar filling processes. The exact pattern may vary depending on the underlying causes. In the acute phase, lobular or lobar ground-glass opacities to predominant consolidation could be demonstrated due to subtotal alveolar filling with blood. In 2-3 days, intralobular lines and smooth interlobular septal thickening may appear, sometimes giving rise to a crazy-paving pattern. Interstitial fibrosis can appear due to severe repeated hemorrhage.
Flexible bronchoscopy with bronchoalveolar lavage (BAL) should be performed to establish the clinical diagnosis of DAH and to exclude infections. Progressively hemorrhagic BAL in serial samples is diagnostic of DAH but not the underlying cause. Surgical lung biopsy could be required to find out the cause of the disease if serologic testing or clinical history is uncertain. Pulmonary capillaritis is the most typical histologic finding of DAH, whose appearance consists of an interstitial neutrophilic predominant infiltration, fibrinoid necrosis, and leukocytosis. Pulmonary capillaritis can be developed in association with various underlying diseases including vasculitis, systemic lupus erythematosus, connective tissue disease, or Henoch-Schönlein purpura.

References
1. Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010;137(5):1164-1171.
2. Cortese G, Nicali R, Placido R, Gariazzo G, Anrò P. Radiological aspects of diffuse alveolar hemorrhage. Clinical Imaging. 2008;32(4):331.
3. Kim D, Choi J, Cho S-K, et al. Clinical characteristics and outcomes of diffuse alveolar hemorrhage in patients with systemic lupus erythematosus. Seminars in arthritis and rheumatism: Elsevier, 2017; p. 782-787.
4. Johkoh T, Itoh H, Müller NL, et al. Crazy-paving appearance at thin-section CT: spectrum of disease and pathologic findings. Radiology. 1999;211(1):155-160.
5. Schwarz M, Mortenson R, Colby T, et al. Pulmonary capillaritis. The association with progressive irreversible airflow limitation and hyperinflation Am Rev Resp Dis. 1993;148:507-511.
Please refer to
Case 1112 Case 518
Keywords

No. of Applicants : 131

▶ Correct Answer : 105/131,  80.2%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - , Korea (South) JOHN BAEK
  • - Wakayama Red Cross Hospital , Japan TOMOAKI OTANI
  • - Jichi Medical University Hospital , Japan JUN KANZAWA
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - , France ANNE-LAURE LEJEUNE
  • - Dhq hospital faisalabad , Pakistan AMMAR AHMED
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Seoul Medical Center , Korea (South) WOONYOUNG BAEK
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
  • - Inje University Haeundae Paik Hospital , Korea (South) HYUNGIN PARK
  • - , Italy PAOLO BALDASSARI
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - , Japan CHIAKI SATO
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - Chonnam National University Hwasun Hospital , Korea (South) HONG SEOK CHOI
  • - , Korea (South) CHANGSU KIM
  • - Other , Korea (South) HWANGHEE JO
  • - Asan Medical Center , Korea (South) EUNJI CHOI
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - Scans world , India PHILSON JOSEPH MUKKADA
  • - Manipal HealthMap , India SHASHANK SOOD
  • - , Korea (South) JIN YOUNG LEE
  • - Asan Medical Center , Korea (South) YUJEONG EO
  • - , China FANG YING GEN
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Kyeongpook National University Hospital , Korea (South) HYUNMIN KIM
  • - Seoul Medical Center , Korea (South) HYUK GI HONG
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Kyemyung University Dongsan Hospital , Korea (South) HYO JU SHIN
  • - Osaka University , Japan AKINORI HATA
  • - Kaneda hospital , Japan HIROFUMI MIFUNE
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - , Korea (South) MINJI KIM
  • - Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
  • - Other , Korea (South) HYEON IL CHOI
  • - , Korea (South) HYEWON CHOI
  • - Japanese Red Cross Medical Center , Japan YASUSHI AOYAGI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - HHS , Canada S LEE
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Kyeongpook National University Hospital , Korea (South) HYEONJUN JANG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - McGill , Canada MUTAZ ADNAN KHAIRO
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Ajou University Hospital , Korea (South) YOU NA KIM
  • - Soonchunhyang University Hospital Bucheon , Korea (South) YE RIN KIM
  • - , Korea (South) CHAEHUN LIM
  • - , Korea (South) YEONG UK HWANG
  • - Presbyterian Medical Center , Korea (South) HANLIM SONG
  • - Other , Korea (South) MARI A
  • - Korea University Ansan Hospital , Korea (South) MOIN HA
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - , Japan MIDORI UENO
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - , Albania AN G
  • - none , Mongolia MUNKHGEREL DAVAA
  • - Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
  • - , United Arab Emirates NEHAR RANJAN CHAKRABORTY
  • - AIMS , India NITHYA HARIDAS MALIYAM
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - University of Illinois at Chicago , United States GYE YOUNG PARK
  • - Other , Korea (South) SEONG WON JANG
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Chonnam National University Hwasun Hospital , Korea (South) JEONG YEOP LEE
  • - Asan Medical Center , Korea (South) BYUNGSOO IM
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Hospital of Aosta , Italy ROBERTO CASTELLANA
  • - Other , Korea (South) KYU-CHONG LEE
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - , Pakistan MUHAMMAD AHSAN ASGHAR
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - , Korea (South) SEUNG HOON OH
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Seoul National University Bundang Hospital , Korea (South) YOONAH DO
  • - , Japan SOTA MASUOKA
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - Pusan National University Yangsan Hospital , Korea (South) JI HWAN KIM
  • - Chungbuk National University Hospital , Korea (South) HYE SOO CHO
  • - Hanyang University Hospital , Korea (South) SUNJIN RYU
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - TAKANA HAYASHI
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - , Japan KAZUMA TERAUCHI
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
  • - Sotiria Hospital, Athens , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - Govt. Kilpauk Medical College, Chennai , India VIGNESH K
  • - , India VINOTH KUMAR
  • - , Japan YUKI HAYASHI
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - , Korea (South) WONJU HONG
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 13/131,  9.9%
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
  • - Chonbuk National University Hospital , Korea (South) YONG HWAN JO
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Chungnam National University Hospital , Korea (South) HYUN JAE LIM
  • - Chonnam National University Hwasun Hospital , Korea (South) MYUNG WON SONG
  • - , United States HIROAKI TAKAHASHI
  • - Other , Korea (South) MINSU KIM
  • - Inje University Ilsan Paik Hospital , Korea (South) SOYEUN PARK
  • - Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Seoul National University Bundang Hospital , Korea (South) SUNYOUNG PARK
  • - Chonbuk National University Hospital , Korea (South) HYEONG RYUN CHO
▶ Semi-Correct Answer : 4/131,  3.1%
  • - Hanyang University College of Medicine , Korea (South) JIWON KO
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - , Japan SOSUKE HATANO
  • - , Korea (South) HM PARK
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