A Case Cracked

CC: "Influenza"

• G.C. is a 45 y.o.male with a PMHx of GSW presenting with chest pain, cough, fevers, and chills that started acutely this morning. Called EMS because was concerned about the flecks of blood in his cough; was given 324 ASA en route.
• Vitals T35°C BP122/81 P110 RR18 96% on RA

what else do you want to know?

• Cough with flecks of blood in yellow phlegm x1 day.
• Fever, chills, diaphoresis x1 day.
• Mid-sternal, non-radiating, pleuritic chest pain x1 day.
• Marijuana user. Denies any other illicit drug use.
• Denies any seizures, LOC, or urinary symptoms

Physical Exam

• Gen: AAOx3, uncomfortable HEENT: PERRL, moist mucus membrane CV: RRR s1s2 no murmur, rubs, gallops Pulm: diffuse b/l rales Abd: soft. nontender, nondistended Skin: diaphoretic, no burns

Differentials?

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• Pneumonia
• URI/Sepsis
• Barotrauma/Mallory - Weiss
• Pulmonary Edema
• Aspiration Pneumonitis
• ARDS
• Acute Eosinophilic Pneumonia
• Malignancy

Labs

• Na 140/ K 4.3/ Cl 101/ HCO3 21/ BUN 17/ Cre 1.24/ Glu 119
• WBC 36.4/ Hg 13.1/ Hct 41/ Plt 277
• Lactate 2.9
• ESR 26
• Utox: + THC, +Cocaine
• UA: 1+ ketone, 2+ blood, Protein 30, WBC 2, 1+ bacteria, 1+ Squamous Epi

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Diffuse Alveolar Hemorrhage

The 3 histologic patterns of DAH

• Pulmonary capillaritis
• Bland pulmonary hemorrhage
• Diffuse alveolar damage

Pulmonary Capillaritis

• Neutrophilic infiltration of the alveolar septa leading to necrosis
• Behçet's syndrome, Cryoglobulinemia, Wegener's, Henoch-Schönlein, Goodpasture's, RA, SLE, Leptospirosis, UC, endocarditis, Acute Lung Injury, MCTD
• Drugs: Hydralazine, PTU, Carbimazole

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Vasculitis?

• Wegner's- upper respiratory tract, lungs, and glomerulonephritis, + C ANCA
• Churg strauss-chronic rhinosinusitis, asthma, and peripheral blood eosinophilia, + P ANCA
• Goodpasture's- Anti-GBM, Lungs and glomerulonephritis
• Henoch-Schönlein- skin, GI, arthritis

Bland Damage

• Hemorrhage into the alveolar spaces without inflammation or destruction of the alveolar structures
• Causes include: Anti GBM, SLE, Anticoagulant therapy, Promyelocytic leukemia, Mitral Stenosis/Regurgitation Thrombocytopenias (ITP, TTP, HUS)

Diffuse Damage

• Edema of the alveolar septa and by formation of hyaline membranes that line the alveolar spaces
• Causes include: infectious/viral ARDS, polymyositis, SLE, Amiodarone, Amphetamine, Crack cocaine, Cytotoxic drugs, Isocyanates, Nitrofurantoin, Penicillamine PTU, Sirolimus, Trimellitic anhydride

Crack Lung

• 25 to 60% of crack users present with respiratory symptoms
• Cocaine blocks the presynaptic reuptake of the neurotransmitters dopamine and NE, leading to severe vasoconstriction.
• Cocaine also causes direct alveolar cell damage

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Toxins/Adulterants

• Butyrfentanyl
• Levamisole, an anti-helminthic, can cause an +ANCA vasculitis
• Other common adulterants (talc, mannitol, tetracaine, lidocaine, procaine) are not associated with DAH

Clinical Presentation

• Cough, hemoptysis, fever, & dyspnea
• CXR is nonspecific patchy/diffuse opacities, abnormal R heart border in Mitral stenosis. Less likely to exhibit Kerley B lines, pleural effusions, and peri-bronchial cuffing as in edema
• CT findings are ground glass opacities that are diffuse and b/l
• Labs are often nonspecific

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DAH

Diagnosis

• DLCO >100% is a sensitive finding if patient can tolerate PFTs. Due to increased hemoglobin in the alveolar space, which removes CO from the exhaled air
• Bronchoalveolar lavage is gold standard
• Antibodies if suspicious of vasculitis
• Biopsy

Treatment

• Cessation of implicated drugs and exposures, treatment of infection, and reversal of excess anticoagulation are key
• O2, methylprednisone (500-2000mg x 5 days IV followed by prednisone 1mg/kg PO), and cyclophosphamide are mainstays

Disposition