대한흉부영상의학회 Weekly Chest Cases

Case No : 1411 Date 2024-11-04

Courtesy of Sangheum Bang, Moon Young Kim, Kwang Nam Jin / SMG-SNU Boramae Medical Center
Age/Sex 38 / F
Chief ComplaintER visits due to abrupt dyspnea and hemoptysis developed after surgical procedure requiring anesthesia

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Diagnosis With Brief Discussion

Diagnosis: Diffuse alveolar hemorrhage induced by inhaled Sevoflurane
Radiologic Findings: Fig. 1 Chest PA shows multiple patchy opacities in both lung fields.
Fig. 2-4 CT scans demonstrates multifocal patchy consolidation and ill defined GGO in both lungs.
Fig. 5 Chest PA shows the disappearance of multiple patchy opacities in both lung fields 2 days later.
Brief Review: Sevoflurane is an inhalational anesthetic agent used to induce and maintain general anesthesia. When metabolized, sevoflurane primarily produces two compounds: Compound A (fluoromethyl-2,2-difluoro-1-(trifluoromethyl) vinyl ether) and Compound B (1,1,1,3,3-Penta fluoro-2-(fluoromethoxy)-3-methoxy-propane). Compound A causes direct renal toxicity, and although the relationship between Compound A and pulmonary toxicity has not been studied, this toxic metabolite may be associated with damage to the alveolar-capillary membrane. Additionally, it is known that other volatile gases can induce pulmonary inflammation and endothelial damage by activating the arachidonic acid cascade. Sevoflurane may have similar mechanisms, potentially increasing alveolar permeability, pulmonary vasoconstriction, and oxidative stress, ultimately triggering an inflammatory response.
The possibility of sevoflurane-induced DAH should be contemplated in patients who manifest hemoptysis, hypoxemia, dyspnea, or radiological evidence of alveolar infiltrates after surgery, following the exclusion of other potential causes. Swift identification of the etiology and initiation of supportive treatment is essential for ensuring the patient's survival.
References: Jordan JH, Pedroza S, Billefals ES, Cruz G. Diffuse alveolar hemorrhage induced by inhaled Sevoflurane. Case report and literature review. Respir Med Case Rep. 2023 Aug 6;45:101906.
Keywords

No. of Applicants : 58

▶ Correct Answer : 6/58, 10.3%

- Shiga University of Medical Science , Japan AKITOSHI INOUE
- , China FANG YING GEN
- , Korea (South) HEONSEOK LEE
- GHICL , France MANUEL TOLEDANO
- , India GOMATHIPONSHANKAR ILAYAPPAN
- , Sweden MOHAMAD TLASS

▶ Correct Answer as Differential Diagnosis : 22/58, 37.9%

- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- Kyoto University , Japan AKIHIKO SAKATA
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- Oita university , Japan AYUMI KAMEI
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Other , Korea (South) SEONGSU KANG
- Secomedic Hospital , Japan FUMINORI MIYOSHI
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Osaka University , Japan AKINORI HATA
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan YOSHIKI ISHII
- Other , Korea (South) CHAEHUN LIM
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- Shiga General Hospital , Japan YUSAKU MORIBATA
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Kyoto University , Japan SHO KOYASU
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Matsunami General Hospital , Japan TARO TAKEDA
- , Japan YUMI MAEHARA

▶ Semi-Correct Answer : 7/58, 12.1%

- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- University of Yamanashi , Japan HIROYUKI MORISAKA
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- University of Yamanashi , Japan KOJIRO ONOHARA
- Jiangsu province hospital , China WANGJIAN ZHA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1411 Date 2024-11-04

Discussion

No. of Applicants : 58