A 19-year-old female sought medical attention at the primary care clinic for dyspnea on exertion (DOE) and a cough productive of blood-tinged sputum. The patient was diagnosed with pneumonia and was prescribed oral antibiotics as an outpatient. Approximately two weeks later, her hemoptysis progressed to daily episodes of 1-2 teaspoons of fresh blood and her DOE also increased to a point where she was feeling tired while performing her activities of daily living (ADL). She was then admitted to the local emergency department for further workup. Her associated symptoms included weight loss of 30 lbs, subjective low-grade nocturnal fever and drenching night sweats. She also had a past history of menorrhagia and her social history included incarceration for a year approximately 6 months ago. She denied any history of smoking, multiple sexual partners, or drug abuse. Blood workup at the hospital indicated severe anemia with hemoglobin (Hb) of 4.6 g/dL and the chest X-ray showed bilateral infiltrates. With her history of menorrhagia, she was diagnosed with chronic blood loss anemia, transfused packed red blood cells, and advised to follow-up with gynecologist. The chest X-ray was interpreted as bacterial pneumonia and the patient was discharged with oral antibiotics to follow-up in an outpatient clinic. Approximately one week later, her symptoms worsened to severe dyspnea at rest along with substernal chest pain and persistent hemoptysis and she was eventually brought to the emergency department at our hospital. On arrival, her vital signs were significant with temperature of 36.5 C, blood pressure of 126/84 mmHg, pulse 115 beats/minute, respiratory rate of 15 breaths/minute, and oxygen saturations of 90% on room air corrected to 96% with a 2-liter nasal cannula. Upon physical examination; the patient was anxious; coarse crackles were heard in bilateral lung fields; tachycardia with a regular rhythm; and 1+ pitting edema in bilateral lower extremities were noted. Initial laboratory work was notable for hemoglobin (Hbg) 8.5 g/dl, hematocrit (Hct) 28.6%, mean corpuscular volume (MCV) 91 fl, platelets 198 x 103 mul, serum sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 21 mEq/L, serum creatinine 0.66 mg/dl, blood urea nitrogen (BUN) 5 mg/dl, blood glucose 83 mg/dl, prothrombin time (PT) 14.2 second, partial thromboplastin time of 24 seconds, international normalization ratio of 1.1 and a negative respiratory viral panel. Urine analysis was remarkable for hematuria (176 RBCs/HPF) without red blood cell cast, 7 WBCs/HPF, 100 mg/dl proteinuria, and the absence of glucose or ketones. Chest X-ray revealed patchy bilateral infiltrates, as shown in Figure 1.
The patient also underwent computed tomography (CT) of the chest with a contrast pulmonary embolism protocol, which revealed diffuse bilateral pulmonary infiltrates with ground glass and diffuse mediastinal lymphadenopathy (Figures 2(a)-2(d)).
Based on the clinical and radiological findings, the patient was diagnosed with pneumonia and admitted to the medicine floor. She was started on intravenous (IV) azithromycin and ceftriaxone. However, her hypoxemia worsened in the next 12 hours with an increased oxygen requirement to 5-liter nasal cannula. Pulmonology was consulted, and the patient was moved to the intensive care unit (ICU). Given the high index of suspicion for alveolar hemorrhage, her heparin drip was stopped. Patient's oxygen requirements continued to worsen, and she was eventually intubated. Follow-up chest X-ray is shown in Figure 3.
To establish a diagnosis, flexible bronchoscopy was performed, which revealed a gross bloody return with gradual darkening on three subsequent bronchoalveolar lavages (BAL) consistent with diffuse alveolar hemorrhage (DAH). The BAL cell count was remarkable for 743,000 mm3 RBCs and a total WBC count of 3233 mm3 with 78% neutrophils and 20% lymphocytes. BAL cultures were reported negative for bacterial growth. Autoimmune workup revealed positive antinuclear antibody (ANA), high antidouble stranded DNA titer of 48 IU/ml, high antismith antibodies titers of 4.3 AU/ml, normal rheumatoid factor titers (<20 mu/ml), negative antibasement membrane antibody (anti-GBM), negative cytoplasmic antinuclear antibody (cANCA) and negative perinuclear antinuclear antibody (pANCA). A diagnosis of diffuse alveolar hemorrhage secondary to systemic lupus erythematosus (SLE) was made. Patient was started on pulse dose of Methylprednisolone, 1 gm IV for 5 days oral mycophenolate mofetil (MMF) for maintenance immunosuppression therapy. She also underwent 3 sessions of plasmapheresis. Her condition improved in a week, she was extubated to nasal cannula and subsequently discharged home on stable doses of prednisone and MMF. Six weeks later, the laboratory reported that her BAL cultures grew Mycobacterium tuberculosis (MTB). The patient was informed about the recent finding of tuberculosis and was setup in outpatient TB clinic for antituberculous therapy (ATT). She is currently finishing her 6 months of ATT with reduced dosing of MMF with close monitoring without any further complications in her condition.