A 42-year-old male patient with no significant medical history, ASA I, was scheduled for endoscopic decompression of the left carpal tunnel. Anesthetics used for the procedure included 1% propofol at a dose of 2 mg/kg, remifentanil using target-controlled infusion at a concentration of 3 ng/ml, fentanyl at 1 mcg/kg, and 2% sevoflurane with a gas flow rate of 1 L/min and a 50% oxygen-air mixture for maintenance, without any invasive airway devices. There were no signs of airway obstruction during the procedure, with assisted ventilation at a tidal volume of 6-8 ml/kg. Airway pressures were maintained between 18 and 22 cmH2O, and the respiratory rate was 12-16 cycles per minute.
The surgical procedure was successfully completed within a total duration of 20 minutes. In the recovery room, the patient experienced an episode of hemoptysis (approximately 100 ml of fresh blood) accompanied by mild desaturation (89%) and dyspnea. On physical examination, the only positive finding was a bilateral inspiratory crackle detected upon chest auscultation. The patient denied any recent close contact with individuals exhibiting respiratory symptoms or any pertinent medical history. As an initial measure, a complete blood count (CBC) and a chest X-ray were requested, and oxygen therapy was initiated via nasal cannula (2 L/minute) to achieve oxygen saturation above 90%.
The CBC revealed severe lymphopenia (Table 1), and the chest X-ray showed bilateral perihilar alveolar infiltrates (Fig. 1). A chest CT angiogram was requested, revealing nodular opacities with a "ground-glass" density, suggestive of alveolar hemorrhage. There was no evidence of pulmonary thromboembolism or bronchial artery malformations.
A transthoracic echocardiogram was performed, which showed normal results, ruling out mitral valve pathology. Considering the presence of lymphopenia, HIV testing, and autoimmune diagnostic tests were conducted, all of which yielded negative results (Table 1). Subsequently, the patient was scheduled for a fiberoptic bronchoscopy, which identified findings consistent with acute endobronchitis and evidence of fresh blood within the airway. A bronchoalveolar lavage (BAL) was performed in the anterior basal segment of the lower lobe, resulting in the retrieval of 50 ml of hemorrhagic fluid. The BAL sample was sent for bacterial, mycobacterial, and fungal cultures, PCR for M. tuberculosis, cytology, and iron staining, all of which delivered negative results.
The patient was hospitalized under the care of the pneumology service and showed spontaneous improvement with the resolution of lymphopenia. There were no further episodes of hemoptysis, and the patient no longer required supplementary oxygen. Consequently, he was discharged with a follow-up appointment scheduled in one month.