Alveolar Hemorrhage Syndromes

SCHNEIDER: A 71-year-old, previously healthy, retired truck mechanic presented with severe respiratory distress, fever, and hemoptysis.His symptoms had begun 4 weeks earlier and consisted of a nonproductive cough and malaise.Six days before admission, he had visited his private physician because of worsening cough and blood-tinged sputum.He wasstarted on clarithromvcin, 500 mg orally twice daily, but was only able to take 4 doses because of nausea and vomiting.The day of admission, the patient was transported by ambulance from his home to an outside hospital because of severe dyspnea and hemoptysis.His arterial Oz saturation was 65% on room air; his chest x-ray revealed bilateral, diffuse alveolar infiltrates, with areas of nodularity in the right mid-lung field and left lingular region.He was started on 100% Oz and transferred via helicopter to Baylor University Medical Center.While en route, he required intubation.On arrival, a nasogastric tube was placed, and 300 ern! of marooncolored blood was recovered.The patient's wife and family reported that the patient had had a nonproductive cough for 3 months and a to-pound weight loss over the past few months, with decreased appetite and fatigue.The patient had an appendectomy at age 5 I.He was on no medication and had no known drug allergies.He had never smoked, drunk alcohol, or received a blood transfusion or tattoos.His family history was negative for pulmonary disease, heart disease, and cancer.On examination, the patient was overweight and unresponsive, the latter secondary to paralytic therapy on the ventilator.He had bloody secretions in his endotracheal tube and marooncolored blood in his nasogastric tube.His blood pressure was 220/ 110 mm Hg; heart rate, 119 beats/minute and regular; and respiratory rate, 16 breaths/minute on a ventilator setting of 16 breaths/minute.His temperature was 39.14°C (l01.9°F).His pupils were equal and reactive to light, and the sclera were anicteric.His nares were patent with blood-tinged mucus.His mucous membranes were moist with bloody secretions; no lesions, exudates, petechiae, or erythema were noted.His neck was supple without adenopathy or thyromegaly, and his jugular veins were not distended.His chest showed symmetrical expansion and equal breath sounds, with diffuse rhonchi and coarse breath sounds bilaterally.S 1 and S2 were normal, and there were no precordial murmurs, gallops, or rubs.His abdomen was rotund,•