Abstract Introduction Diffuse alveolar hemorrhage is defined as widespread extravasation of blood from the pulmonary capillaries into the alveolar space, resulting in destruction of the capillary-alveolar basement membrane. Diffuse alveolar hemorrhage is most commonly a result of immune-mediated vasculitis or connective tissue disease. Other causes include congestive heart failure, infection, coagulopathy, and trauma. Case Presentation Presented is a 79-year-old female who developed progressively worsening dyspnea on exertion two weeks prior to admission associated with chills, unintentional fifteen pound weight loss, and cough. Symptoms developed after she cleared land around a cemetery. CT chest revealed diffuse bilateral mixed interstitial and airspace opacities, reactive mediastinal adenopathy, small bilateral pleural effusions, and a small pericardial effusion. The patient was hospitalized for five days and received empiric antibiotics, steroids, diuresis, and nebulizing treatments. Her symptoms improved, and her oxygen requirement decreased. She was discharged home on doxycycline, prednisone taper, and oxygen supplementation with plans to follow-up with Pulmonology outpatient. Laboratory findings were negative for anti nuclear antibodies and anti neutrophil cytoplasmic antibodies. Fungitell assay was negative and hypersensitivity pneumoniae panel had no antibodies detected. Three weeks after discharge, she presented for worsening dyspnea. She underwent bronchoscopy, and bronchoalveolar lavage of the lateral subsegment of the right middle lobe resulted in three successive aliquots of 30 ccs each which became increasingly bloody with the third aliquot being red and opaque. The airways were inflamed with blood distally although there was no blood pooling. Due to bleeding and hypoxia, no transbronchial biopsies were obtained. Pathology from the bronchoalveolar lavage was suspicious for adenocarcinoma. Transbronchial biopsies later obtained and confirmed adenocarcinoma with final staging revealing stage IV adenocarcinoma of the bilateral lungs. Discussion While this patient presented with progressively worsening dyspnea and unintentional weight loss, imaging findings and initial bronchoscopic findings were consistent with hypersensitivity pneumonitis. Diffuse alveolar hemorrhage is uncommonly caused by malignancy, and the malignancies involved are usually hematologic malignancies and metastatic solid tumors. Primary lung malignancies are a rare cause. Mechanisms include tumor cells directly invading the alveolar-capillary barrier, tumor-associated vascular remodeling, and vascular injury due to tumor which results in disruption of the microvasculature and bleeding into the alveolar spaces. Conclusion Diffuse alveolar hemorrhage is an unusual but possible presentation for lung adenocarcinoma. While uncommon, it is important to consider primary lung malignancies as a cause for diffuse alveolar hemorrhage in addition to the more common etiologies, such as immune-mediated vasculitis. This abstract is funded by: None
Brewer et al. (Fri,) studied this question.