Abstract Introduction Diffuse alveolar hemorrhage (DAH) is a complex pulmonary syndrome that can be caused by a multitude of different pathologies and may be difficult to diagnose and treat. Here, we present a case of DAH due to choriocarcinoma syndrome (CS) in a young patient with extragonadal choriocarcinoma. Case Presentation A 26-year-old male with alcohol use disorder, newly diagnosed stage IV extragonadal choriocarcinoma, presented with fevers, abdominal pain, and dyspnea for 1 month. He had been undergoing chemotherapy; the last dose was 6 weeks prior to admission. On admission, he was febrile, tachycardic, and tachypneic but did not require supplemental oxygen. Initial CT scans demonstrated diffuse, bilateral metastatic pulmonary lesions, retroperitoneal and pelvic lymphadenopathy, as well as periaortic and hepatic metastases. Relevant data included a serum beta-hCG 439 mIU/mL. While admitted, he developed mild hemoptysis and required up to HFNC 40L at 60% FiO2. Repeat CT on day 6 showed development of confluent consolidative opacities along the bronchovascular bundles. Bronchoscopy was offered but the patient declined due to concerns of requiring intubation. In addition to continuing antibiotics, he was empirically started on IV methylprednisolone 250mg every 6 hours to treat pulmonary capillaritis. With this, patient was weaned to 4L NC. He eventually agreed to bronchoscopy on day 12, which demonstrated serially bloodier aliquots from the right middle lobe, concerning for DAH. His hospitalization was further complicated by persistent anemia requiring frequent blood transfusions, recurrent hemorrhagic ascites requiring paracenteses, and repeat CT imaging with new and enlarging abdominal metastases. He underwent chemotherapy on day 17 but continued to clinically decline, eventually developing multi-organ failure. Given his worsening clinical status, he transitioned to comfort-focused care, where he succumbed to his disease. Discussion DAH is typically associated with symptoms of cough, hemoptysis, fever, and dyspnea, and may be seen as diffuse, bilateral central ground glass or consolidative opacities on CXR/CT chest. Given the presumed pulmonary metastasis and negative infectious workup, this patient’s DAH was suspected to be due to bleeding from metastases. Choriocarcinoma is a vascular tumor and tends to bleed. CS is classified by extensive tumor hemorrhage from metastases. As in this patient with rapidly worsening metastasis, choriocarcinoma can present as acute pulmonary hemorrhage. It can occur immediately following chemotherapy or spontaneously in aggressive disease. Although there are no consensus guidelines on treatment of CS, early recognition and management of organ-specific hemorrhage are essential to reduce morbidity and mortality. This abstract is funded by: None
Nguyen et al. (Fri,) studied this question.