Diffuse alveolar hemorrhage☆
Section snippets
Definition
The term “diffuse alveolar hemorrhage” refers to a distinct form of pulmonary hemorrhage that originates from the pulmonary microcirculation (including alveolar capillaries, arterioles, and venules). Although alveolar hemorrhage can be focal, there are generally multiple areas of involvement, and thus the term DAH is preferred. DAH must be distinguished from other causes of pulmonary hemorrhage that are caused by localized abnormalities in the lung (eg, bronchiectasis, malignancy, infection)
Etiology
DAH can be caused by many conditions, with most etiologies sharing a common pathophysiologic theme: damage to the alveolar microcirculation. Any source of injury to the alveolar microcirculation theoretically can cause alveolar hemorrhage. The cause may be lung specific (eg, diffuse alveolar damage, infection) or more generalized (eg, vasculitis). Most cases of DAH are associated with a neutrophilic infiltration of the alveolar wall centering on capillaries and venules [1]. This “capillaritis”
Clinical presentation
The usual presentation of DAH includes hemoptysis, alveolar infiltrates on chest radiograph, and anemia. Many cases do not have a classic clinical picture, however, and the clinical suspicion for DAH should remain whenever any of the previously mentioned features is present.
Histopathology
Alveolar hemorrhage must be distinguished from other causes of red blood cell accumulation in the alveolar space, most notably surgical trauma at the time of biopsy. True alveolar hemorrhage often demonstrates intra-alveolar fibrin and hemosiderin in the alveolar walls and hemosiderin-laden alveolar macrophages (Fig. 2) [4]. Hemosiderin, a product of hemoglobin degradation, appears at least 48 hours after bleeding and is helpful in distinguishing DAH from surgical trauma. There also may be
Approach to diagnosis
DAH represents a medical emergency. A thoughtful and thorough approach to the diagnosis of DAH is of critical importance to appropriate management. There are two important goals of the clinical evaluation: (1) establishing the diagnosis of DAH and (2) identifying the underlying cause. Although individual cases of DAH may require modifications, the general approach outlined next is recommended.
Specific causes of diffuse alveolar hemorrhage
The management of DAH is discussed in the context of the underlying cause. The following section presents the most common causes of DAH individually and reviews the pathophysiology, diagnosis, and treatment in each case. The most common treatment recommendations for the most common causes of DAH are summarized in Table 1.
Summary
DAH represents a medical emergency, and clinicians must have an expedient approach to the identification of DAH and its underlying cause. There are many causes of DAH, including vasculitides, such as Wegener's granulomatosis and microscopic polyangiitis, Goodpasture's syndrome, collagen vascular disease, and idiopathic conditions. Careful attention to the medical history, physical examination, and targeted laboratory evaluation often suggests the underlying cause. Patients in whom the diagnosis
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2021, American Journal of Emergency MedicineCitation Excerpt :The pathological manifestations of diffuse alveolar hemorrhage are extensive destruction of the capillary basement membrane, and extensively hemorrhage of the terminal bronchi in the distal alveolar space [1,2]. The causes can be divided into infectious and non-infectious factors [3,4]. The patient did not have any pertinent past medical history that required him to take daily medication.
Diffuse alveolar hemorrhage, a rare presentation of polymyositis
2020, Respiratory Medicine Case ReportsCitation Excerpt :This extensive inflammatory response causes leakage of blood through the capillaries which leads to the collection of blood within the alveoli [8]. There are three distinct histopathological patterns for diffuse alveolar hemorrhage [5,10]: Pulmonary capillaritis: This pattern results from pulmonary capillary inflammation and neutrophil infiltration leading to necrosis and leakage of blood into the alveolar space.
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Dr. Collard is supported by an institutional grant from the Pulmonary Fibrosis Foundation.