Pulmonary Hemorrhage: Recommendation
However, in contrast to aspergillosis infection, hemorrhage due to H capsulatum infection is not usual. A pulmonary-renal syndrome could be postulated in either case, but this is unlikely in view of the clinical recovery in the absence of specific therapy. Kaposi’s sarcoma could account for pulmonary hemorrhage, especially in case 1, although the absence of characteristic endobronchial lesions makes this less likely. Although a specific infectious etiology could be postulated, no new infection was identified in either case. Importantly in both cases, the pulmonary infiltrates resolved despite discontinuing empirically initiated treatment with antimicrobial medications.
The diagnosis of pulmonary hemorrhage requires a high index of suspicion, as clinical clues such as hemoptysis are not usual. Consideration of this entity will prompt an awareness for the characteristic features of lavage fluid to support this diagnosis. This includes documentation of persistently bloody return following sequential instillation of saline solution aliquots, demonstration of bilateral return of hemorrhagic BAL fluid in the case of diffuse radiographic abnormalities, and the demonstration of hemosiderin staining of macrophages. These characteristics differentiate pulmonary hemorrhage from trauma induced by bronchoscopy. antimicrobialmed.com
Some investigators have advocated performing semi-quantitative analysis of the amount of hemorrhage in BAL specimens by determination of a macrophage hemosiderin score. This scoring system reportedly corrolates highly with the degree of hemorrhage observed on autopsy lung specimens. However, Grebski and colleagues recently reported a limited utility of the hemosiderin score. Although scoring of hemosiderin-laden macrophages supports the diagnosis of pulmonary hemorrhage, the score is not able to distinguish among different specific etiologies that predispose to pulmonary hemorrhage.
The purpose of this report is to add the entity of pulmonary hemorrhage to the differential diagnosis of new pulmonary infiltrates in the hospitalized HIV-infected patient. The importance of properly identifying pulmonary hemorrhage is to facilitate subsequent evaluation. Consequently, in the absence of evidence for a new infection or vasculitis, correct identification of pulmonary hemorrhage may support the decision to discontinue treatment with empiric medications, preclude alterations in medical management, and obviate further invasive investigation. The treatment of pulmonary hemorrhage in patients with AIDS may simply require continued supportive measures while known underlying conditions predisposing to hemorrhage are corrected.
Category: Respiratory Symptoms
Tags: AIDS, alveolar hemorrhage, pulmonary infiltrates