Medical Image of the Week: DAH

 

Figure 1. Portable CXR (A) and CT (B) showing diffuse infiltrates of unclear etiology.

Figure 2. Progressively bloodier lavage indicative of pulmonary hemorrhage syndrome.

A 59 year old female was admitted to the ICU with hypoxemic respiratory failure and a clinical picture of ARDS (Figure 1), requiring intubation and mechanical ventilation. She underwent bone marrow and renal transplantation several years prior for multiple myeloma and myeloma kidney, respectively. She had been restarted on lenalidomide one month prior to presentation.  She was also taking tacrolimus, mycophenolate, prophylactic antimicrobials, warfarin for deep venous thrombosis, and aspirin for coronary artery disease. Emergent bronchoscopy with bronchoalveolar lavage revealed progressively bloodier specimens (Figure 2) consistent with diffuse alveolar hemorrhage (DAH). Further work-up was negative for vasculitis. Her lenalidomide, anticoagulation, and trimethoprim/sulfamethoxazole was stopped. She was started on high dose steroids and improved over 2 weeks.

Sage P. Whitmore, MD; Candy Wong, MD; James L. Knepler, MD and Carmen Luraschi-Monjagatta, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Whitmore SP, Wong C, Knepler JL, Luraschi-Monjagatta C. Medical image of the week: DAH. Southwest J Pulm Crit Care 2013;6(3):129. PDF