Hhhh

1. DIFFUSE ALVEOLAR HEMORRHAGE:
AN USUAL PRESENTATION OF HEMOPTYSIS
DUE TO MALIGNANT ARTERIAL
HYPERTENSION
Presenting Author: Dr. Arisha javed1
Corresponding Author: Dr. Abhijeet Khandelwal2 Dr. Riyaz A. Asad3,
Dr. Kumar Girendra4 Dr. Sudarshan Gupta5
1- Post Graduate Resident, Department of Pulmonary Medicine & Sleep Diseases Index Medical College & Hospital, Indore, (M.P.), India
2- Professor, Department of Pulmonary Medicine & Sleep Diseases Index Medical College & Hospital, Indore, (M.P.), India
3- Senior Consultant Nephrologist, Shalby Hospital, Indore (MP), India
4- Professor & Head, Department of Pulmonary Medicine & Sleep Diseases Index Medical College & Hospital, Indore, (M.P.), India
5- Assistant Professor, Department of Pulmonary Medicine & Sleep Diseases Index Medical College & Hospital, Indore, (M.P.), India

2. INTRODUCTION:
• DAH is a clinicopathological syndrome that often leads to respiratory failure, with
associated hemoptysis and anemia.
• Chest radiograph presents non-specific findings of diffuse alveolar hemorrhage perihilar
infiltrates, while computed tomography shows ground-glass attenuation or areas of
consolidation with interlobular septal thickening.
• Bronchoalveolar lavage is used to confirm the clinical and radiological suspicion.
• While vasculitis and other causes of pulmonary renal syndrome are the most common
causes of diffuse alveolar hemorrhage, a rare cause, malignant hypertension should be
considered at appropriate clinical settings.

3. CASE REPORT:
• A 48-year-old man with
history of hypertension and
irregular medication
presented with multiple
episodes of massive
hemoptysis for 1 day.
• Vitals:
Temperature- 37 C,
Pulse-116 beats/min,
BP of 230/140 mm Hg.
GCS was 13 (E3V4M6)
RR- 26/min
SpO2- 94%,
• ABG- pH 7.36, PaCO2 of 30
mmHg, PaO2 of 80mm Hg.
• Coarse crackles were heard
over bilateral lung fields.
• WBC- 11300/μL. Hb-10 g/dl. Platelet
count of 110000/μL.
• Serum creatinine- 6.4 mg/dL,
Blood urea- 173 mg/dl.
• Urinalysis shows 25 (RBCs) per high
power field and proteinuria of 4+.
• Chest radiograph revealed bilateral
perihilar opacities.
• HRCT Chest reveals bilateral
centrally distributed patchy ground
glass attenuation.
• Ultrasonographic and doppler scan
of kidneys noted bilateral renal
parenchymal disease of grade 3
with significantly reduced renal
perfusion.

4. CASE REPORT (contd…….)
• HRCT Chest - centrally distributed patchy
ground-glass attenuation bilaterally.
• Bronchoscopy - bronchial hyperemia and
bronchoalveolar lavage (BAL) with
progressively bloody fluid was obtained
with increased numbers of red blood cells,
which indicated diffuse alveolar
hemorrhage.
• 2D Echo - concentric left ventricular
hypertrophy.
• Autoantibodies ANCA, ANA and Anti GBM
all are negative.
• Conclusively, malignant hypertension was
diagnosed as the cause of the concomitant
diffuse alveolar hemorrhage presenting
with hemoptysis and renal failure.
• The patient was treated with oxygen
administration, anti-hypertensive drugs
and hemodialysis.

5. DISCUSSION:
• DAH represents a medical emergency, and clinically it is usually evidenced by the triad of
hemoptysis, anemia and hypoxemic respiratory failure. Histopathology reveals intra-alveolar red
blood cells originating from the alveolar capillaries, fibrin and hemosiderin-laden macrophages.
Once the diagnosis of diffuse alveolar hemorrhage is achieved through BAL, the underlying cause
must be rapidly established so that adequate treatment can be chosen.
• There are several culprits, the most frequent being Wegener granulomatosis (32%), Goodpasture
syndrome (13%), idiopathic pulmonary hemosiderosis (13%), collagen vascular diseases (13%) and
microscopic polyangiitis (9%).
• Malignant hypertension is characterized by elevated blood pressure accompanying
encephalopathy or acute nephropathy as target organ damage and histologically characterized by
fibrinoid necrosis of arterioles and progresses rapidly observed in a variety of organs, however,
pulmonary hemorrhage is rare.
• The possible mechanism of how malignant hypertension causes alveolar hemorrhage can be,
humoral factors, such as renin, aldosterone, vasopressin, catecholamines, and endothelin might
be involved in the alveolar capillary injury, injury to capillaries in systemic circulation, pulmonary
edema and the ensuing alveolar hemorrhage due to left ventricular dysfunction caused by the
arterial hypertension. In conclusion, although it is very rare for malignant hypertension to first
manifest with pulmonary disease, when applicable, this diagnosis should be included in the
differential of acute diffuse alveolar hemorrhage.