Normal chest radiograph and ground glass opacities on a thoracic computed tomographic scan in a patient with diffuse alveolar haemorrhage due to dual antiplatelet therapy prescribed after patent foramen ovale percutaneous device closure

A 40-year-old woman was re-admitted due to haemoptysis 6 days after her patent foramen ovale (PFO) was successfully closed with the Amplatzer® PFO Occluder. Initially, a combination of aspirin (75 mg per day) and clopidogrel (75 mg per day) was given to protect against thrombus formation on the device. She complained of a cough but without dyspnoea. She presented normotensive and her pulse rate was not elevated. Oxygen saturations and her temperature were normal. Discontinuous soft crepitations were heard at the right lung base. White blood cell count, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein level were all within normal limits. There was a drop in haemoglobin concentration (13.4 g/dL before PFO closure → 11.9 g/dL at the moment) and falling haematocrit level (40.1 → 34.6%, respectively). Laboratory signs of neither renal impairment nor thrombocytopenia were present. Chest X-ray appeared entirely normal [Panel 1—posteroanterior (PA) projection, Panel 2—a magnified PA view of the right lung base and its lateral aspect—Panel 3]. Thoracic computed tomographic scan demonstrated unilateral ground glass opacities in a posterior (Panel A—‘P’), lateral (Panel A—‘L’), and medial (Panel A—‘M’) basal segments of the right lung. These were attributed to bleeding into the alveolar spaces, affecting ∼20% of the right lung (Panel B). Correct occluder position was verified (arrows on Panels 3 and A). Diffuse alveolar haemorrhage (DAH) was diagnosed, with bleeding through alveolar-capillary membrane without its inflammation or destruction. Its pathogenesis was attributed to a coagulation disorder related to potent dual antiplatelet therapy. Clopidogrel was withdrawn and haemoptysis stopped. Aspirin alone was given (150 mg per day) and 6-month follow-up was uneventful. Various transcatheter closure device protocols are in routine use worldwide. The combination of aspirin and clopidogrel is regularly scheduled after percutaneous device closure procedures and we should be aware of the DAH syndrome as its potential life-threatening complication.