Nabi Chaudhri-Martínez, MD
Internal Medicine Resident
Mercy Hospital St. Louis, United States
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Title: Uremic Pneumonitis: A Forgotten Etiology Of DAH
Introduction: Diffuse Alveolar Hemorrhage (DAH) is a life threatening syndrome that is characterized by hemoptysis, anemia, diffuse radiographic pulmonary infiltrates and hypoxemia. It is commonly due to vasculitis and other autoimmune disorders. However, we present a rare case of DAH from uremic pneumonitis (UP), where the history was further complicated by newly diagnosed acquired immunodeficiency syndrome (AIDS) and travel history from Ethiopia.
Description: A 71-year-old Ethiopian male with PMH of chronic kidney disease and hypertension, presented with several days of hemoptysis and weight loss. Physical exam revealed axillary and supraclavicular lymphadenopathy. Computed tomography chest imaging displayed bilateral airspace opacities and labs were significant for Hb 11.1g/dL, BUN/Cr 62/8.59 mg/dL, CRP 57 mg/L, and sedimentation rate 119 mm/hr. Due to the travel history, HIV and TB tests were attained, and revealed HIV+ (28K viral load) with CD4+ count of 183 cells/mcL. BAL was consistent with DAH, but corticosteroids were held due to concern for opportunistic infections. Empiric treatment for Pneumocystis pneumonia (PCP) was initiated, but workup for autoimmune, vasculitis, Good Pastures was negative. Patient was treated with pulse dose steroids without resolution of hemoptysis, however subsequent initiation of dialysis led to resolution of hemoptysis.
Discussion: DAH is a clinicopathologic syndrome with numerous etiologies and can be life threatening. It is often due to vasculitis, infections, autoimmune disorders, drugs, inhaled toxins, congestive heart failure, and coagulation disorders. Our patient was a 71-year-old male who presented with hemoptysis, bilateral lung infiltrate, and newly diagnosed AIDS syndrome. Immediate suspicion arose for opportunistic infections such as PCP, which instigated empiric treatment. However, as the workup for autoimmune disorders and infections resulted in negative, all other etiologies were entertained. As the uremia was treated with dialysis, the patient's respiratory failure and hemoptysis resolved. With dialysis widely available, UP is rarely seen. Thus, it is important for clinicians to keep UP as an important differential diagnosis for DAH, particularly in populations with limited healthcare resources