A patient with Diffuse Alveolar Hemorrhage: A diagnostic dil
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Diffuse alveolar hemorrhage (DAH) is a usual presentation of pulmonary vasculitis. A 73-year-old man with DAH whose diagnosis only became conclusive near the end of his life. The objective is to discuss the important differential diagnosis in a patient presenting with diffuse alveolar hemorrhage. There are very few case reports on pulmonary angiosarcoma and all of them discussed the rarity of the diagnosis, presentation, and treatment.

A 73-year-old man, former smoker, with a history of repaired abdominal aortic aneurysm (AAA), presented with a 2-week duration of bleeding per rectum. A computed tomography (CT) scan of the abdomen showed sigmoid diverticulosis and associated pericolic hypervascularity. His hemoglobin dropped from 13.5 g/dL to 12.5 g/dL. The esophagogastroduodenoscopy and sigmoidoscopy did not reveal internal bleeding sources. Absence of ongoing blood loss allowed for the patient to discharge with a presumed diagnosis of diverticular bleed.

One month later the patient returned for admission with fatigue, cough, hemoptysis, and shortness of breath. He was pale and had bilateral pedal edema. His hemoglobin decreased to 7 g/dL. Chest X-ray showed bilateral pulmonary infiltrates reported as pulmonary edema. A CT of the thorax with contrast ruled out pulmonary embolism, but there was alveolar edema with large bilateral pleural effusions.Bilateral thoracenteses revealed hemothoraces, which necessitated bilateral pleural drain placement. Bronchoscopy revealed diffuse alveolar hemorrhage.

Intravenous steroids, plasma exchange (PLEX) therapy was then started but therere was no improvement. Despite several weeks of hospitalization with multiple empiric therapies, the patient continued to decline clinically. He cumulatively required 22 units of blood, 3 units of platelets, 1 unit of cryoprecipitate, and multiple units of Fresh Frozen Plasma (FFP) with PLEX. A lung biopsy was deemed too high a risk. A High-Resolution CT scan of the chest revealed bilateral pulmonary nodules, not seen on previous CTs. A CT guided biopsy of these nodules showed areas of malignant-appearing epithelioid-endothelial cells with adjacent red blood cells.

The patient declined chemotherapy. Three days after the definitive diagnosis of metastatic angiosarcoma was made the patient developed sigmoid colonic perforation and died.

source: https://reader.elsevier.com/reader/sd/pii/S2213007120304184?token=E95141DE696F2AAB1201C58EC3E71AD63CE1C381D14128C607A210837348D452464A940BA47691A195A673A942F5E520
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