Coexistence of Diffuse Alveolar Hemorrhage and Pulmonary Thromboembolism.

A 56-year-old man suffering from intractable pneumonia was referred to our hospital. Chest computed tomography and bronchoalveolar lavage fluid revealed diffuse alveolar hemorrhage (DAH) (Picture), and the anti-nuclear antibody and myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) positivity. Microscopic hematuria and the serum creatinine level (1.5 mg/dL; normal value, <1.1 mg/dL) indicated a decline in the renal function. Thus, the patient was diagnosed with microscopic polyangiitis (MPA). Three days after treatment with intravenous cyclophosphamide and corticosteroids, he suddenly complained of breathing difficulties. Urgent enhanced chest CT revealed left-sided acute pulmonary thromboembolism (Picture). This was suspected to have occurred secondarily to deep vein thrombosis and was confirmed by D-dimer and color Doppler ultrasonography of the lower limbs. We performed inferior vena cava filter placement. Because DAH appeared to be quiescent, we started systemic heparinization for the treatment of pulmonary thromboembolism (PTE) and he was subjected to plasmapheresis; however, he died from hemorrhagic shock.

Picture.

DAH and PTE represent complex situations that are extraordinarily crucial because it is difficult to select whether anticoagulation or hemostasis is appropriate (1). In a pediatric case series from the United States elective anticoagulation therapy was selected for two patients with granulomatosis with polyangiitis with concurrent DAH and PTE (2). Nonetheless, it is difficult to say anticoagulation or hemostasis is appropriate for this complicated situation.

There are several explanations regarding thrombosis in MPA. First, an impaired endothelial function and hypercoagulability could explain the risk of thrombosis. Second, circulating antineutrophil cytoplasmic antibodies may cause vascular damage on the endothelial surface (3). Physicians should be aware that the simultaneous onset of DAH and PTE can occur in MPA.

The author states that he has no Conflict of Interest (COI).