Pulmonary Hemorrhage: Discussion
Despite aggressive diuretic management, subsequent chest radiographs demonstrated progressive diffuse pulmonary air-space disease (Fig 3). Empiric therapy with vancomycin, metronidazole, ceftriaxone, gentamicin, and dihydroxypropoxymethylqua-nine (DHPG) were initiated. Laboratory determinations disclosed the following values: PT, 19.3 s; PTT, 51 s; and platelet count, 128,000/mm; and arterial blood gas determination demonstrated a pH of 7.42, Pcc>2 of 29, and P02 of 122 while breathing 40% FI02 via an endotrachial tube.
On the 14th hospital day, diagnostic fiberoptic bronchoscopy demonstrated return of persistently bloody fluid, bilaterally. There were no endobronchial abnormalities. Specimens for special stains and cultures of routine microbiology and P carinii were negative. Hemosiderin-laden macrophages were demonstrated on cytologic examination (Fig 4).
In the absence of identification of new pulmonary pathogens, amphotericin В therapy was continued, while other empiric antimicrobials were discontinued. The patient received a total of 11 U of packed RBCs, 6 U of fresh frozen plasma, vitamin K, and continued supportive care. Sequential radiographs demonstrated gradual resolution of the pulmonary infiltrates, and the patient was successfully extubated. so
Pulmonary infiltrates in HIV-infected individuals represent a common clinical problem, and the differential diagnosis includes infection, pulmonary edema, immune-mediated processes, neoplasia, and drug or radiation-induced disease. Diagnostic bronchoscopy with BAL has been established as effective in diagnosing many of these processes. As empiric treatment can introduce potentially toxic or immunosuppressive agents or medications with a high adverse effect profile, early use of BAL can be helpful in confirming clinical suspicions and in guiding the selection or modification of treatment. In contrast, the inability to establish an etiology for new pulmonary infiltrates in patients with AIDS often results in the administration of empiric drugs for prolonged periods.
Figure 3. Chest radiograph at the time of fiberoptic bronchoscopy demonstrating diffuse bilateral infiltrates.
Figure 4. High-power (original magnification X600; Paponi-colou stain) light photomicrograph of a cytology smear from a BAL specimen demonstrating a cluster of hemosiderin-laden macrophages (arrow).
Category: Respiratory Symptoms
Tags: AIDS, alveolar hemorrhage, pulmonary infiltrates