Virginia Research Day 2025

Medical Resident Research Case Reports

22 Diffuse Alveolar Hemorrhage in Patient with Interstitial Lung Disease Without Microscopic Polyangiitis Diagnosis

Nistha Acharya, MD; Diana Duong, DO; Kimberly Bird, MD; Sulaiman Tijani, MD Corresponding author: nistha.acharya@lpnt.net

Sovah Danville Internal Medicine Residency

on serial aliquots (Figure A). Autoimmune panel was ordered and positive for complement C3. CT (Figure B) demonstrated diffuse bilateral interstitial and ground-glass infiltrates which had increased since prior study likely concerning for pulmonary edema. Mild increased right paratracheal and right retroclavicular adenopathy was present as well as stable mediastinal and right hilar adenopathy. Superimposed pneumonic infiltrates could not be excluded and patient was started on antimicrobial coverage for community-acquired pneumonia. The patient was initially treated with prednisone 80 mg IV daily with plans for steroid taper, decreasing by 10 mg every week. However, patient remained tachycardic and hypoxic with oxygen requirements up to 10 L in relation to her baseline oxygen 4 L at rest and 8 L on ambulation. Due to persistent hypoxia, she received pulse dose steroid therapy of

methylprednisolone 500mg IV for 3 days followed by a steroid taper. The patient was also recommended to initiate atovaquone 1.5 g for Pneumocystis pneumonia prophylaxis. Discussion: DAH is defined by the clinical triad of hemoptysis, anemia and progressive hypoxemia, all of which our patient exhibited. Usually, ILD and DAH are the two key pulmonary manifestations that increase morbidity and death rate of patients with microscopic polyangiitis (MPA). In clinical practice, the diagnosis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is based on clinical manifestations, ANCA testing, pathology of tissue biopsies, and imaging data. However, this case is unique in that the autoimmune panel returned ANCA negative making MPA less likely. Regardless, treatment remains the same with pulse dose steroids

Introduction: Diffuse alveolar hemorrhage (DAH) is a syndrome that results from pulmonary microcirculation injury, including alveolar capillaries, arterioles, and venules. Patients typically present with hemoptysis, diffuse lung infiltrates, anemia, and compromised respiratory function. This syndrome is a rare manifestation and has poor prognosis with inpatient mortality ranging from 20% to greater than 50%. Case Description: The patient is a 57-year old female with chronic hypoxic respiratory failure secondary to interstitial lung disease (ILD), presumed to be related to hypersensitivity pneumonitis on Mycophenolate mofetil and Prednisone who presented for second episode of submassive hemoptysis with concern for DAH. The patient underwent bronchoscopy and serial bronchoalveolar lavage (BAL) which demonstrated persistent bleeding

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