A fatal case of diffuse alveolar hemorrhage complicated by rheumatoid arthritis

Fig. 1. Chest X-ray images of the patient. Chest X-ray images (A) upon diagnosis of rheumatoid arthritis, (B) on admission, (C) on day 15, (D) on day 26, and (E) on day 37.

Fig. 2. Chest CT images of the patient. (A) Chest CT images at the initial diagnosis of rheumatoid arthritis. Slight subpleural reticular shadows in both lower lobes and subpleural consolidations are manifest. (B) On admission to Hamanomachi Hospital (day 1). Chest CT images showed patchy consolidations and ground-glass opacities (GGO) with peribronchial distribution predominantly in the right lobes, suggesting a radiologic pattern of organizing pneumonia (OP). Right pleural effusion was also noted. (C) On day 26, chest CT images showed worsening GGO and consolidations. Pleural effusion was reduced compared to that on admission.

Fig. 3. Bronchoscopic findings showing diffuse alveolar hemorrhage. (A) Bronchoscopy shows hemoptysis from the right main bronchus to the trachea. (B) Bronchoalveolar lavage fluid from the right B3 bronchus shows significant alveolar hemorrhage.

Fig. 4. A clinical course of the case. The patient was referred to the Department of Respiratory Medicine on admission day 8. Diffuse alveolar hemorrhage was diagnosed by bronchoscopy on day 28. Despite treatment, including pulsed-dose methylprednisolone, respiratory failure progressed, leading to a fatal outcome on day 39.mPSL: methylprednisolone, PSL: prednisolone, IVIG: intravenous immunoglobulin, RBC: red blood cell transfusion, LVFX: levofloxacin, ST: sulfamethoxazole-trimethoprim, CRP: C-reactive protein, LDH: lactate dehydrogenase, BF: bronchoscopy, NHF: nasal high flow, FiO2: fraction of inspiratory oxygen, NPPV: non-invasive positive pressure ventilation. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)