Abstract Introduction Alveolar hemorrhage is a rare complication of thrombotic antiphospholipid syndrome (APS). Capillaritis in patients with nonthrombotic APS is frequently overlooked, as these patients may lack the symptoms typically associated with thrombotic disease. We report a case of APS with alveolar hemorrhage despite no prior thrombotic events. Case Presentation A 47-year-old woman with APS and hypothyroidism presented to the emergency department (ED) with progressive fevers, cough, and hemoptysis. She reported similar symptoms annually that resolved with antibiotic treatment. She received doxycycline ten days prior for similar symptoms without improvement. In the ED, she was febrile and tachycardic with clear lung sounds. CT chest angiography revealed bilateral multilobar peribronchial consolidations and ground-glass opacities with apical predominance. She declined admission and was discharged on azithromycin and amoxicillin-clavulanate. Prior to this, her APS had manifested solely as obstetric complications with multiple miscarriages. She had declined hydroxychloroquine and aspirin, preferring a naturopathic approach. Worsening dyspnea, persistent fevers and blood-tinged frothy sputum prompted direct admission from pulmonary clinic two weeks after initial presentation. Repeat imaging showed interval progression of bilateral nodular and ground-glass opacities. Bronchoscopy with bronchoalveolar lavage revealed progressively darker, pink-tinged fluid, though laboratory evaluation was unremarkable. Mild alveolar hemorrhage from capillaritis in the setting of untreated APS was diagnosed. Prednisone 60mg daily produced significant improvement. She started hydroxychloroquine, aspirin, and mycophenolate mofetil. After a prolonged prednisone taper, she achieved stability off steroids without hemorrhage recurrence. Discussion Nonthrombotic lung injury in APS is hypothesized to be from endothelial dysfunction due to the inflammatory cascade (1, 2). Alveolar hemorrhage is a diagnosis of exclusion and infections can present like autoimmune-mediated disease in patients with APS, further complicating the diagnostic process. Our patient had recurrent pneumonia that delayed diagnosis of alveolar hemorrhage from capilliritis due to untreated APS. Her rapid clinical and radiographic improvement once starting steroids confirmed the diagnosis. Prior literature demonstrates diagnostic delays when typical manifestations of APS are absent (1, 2). In conclusion, clinicians should maintain high suspicion for alveolar hemorrhage in patients with APS with ground-glass opacities or alveolar infiltrates on imaging, with or without hemoptysis. 1.Seth I, Srinivasan SPB, Bulloch G, Yi DS, Frankel A, Hsu K, et al. Diffuse Alveolar Haemorrhage As A Rare Complication Of Antiphospholipid Syndrome. Respirol Case Reports. 2022. 2.Deane KD, West SG. Antiphospholipid Antibodies as a Cause of Pulmonary Capillaritis and Diffuse Alveolar Hemorrhage: A Case Series and Literature Review. Seminars in Arthritis and Rheumatism. 2005. This abstract is funded by: None
Gregoire et al. (Fri,) studied this question.