Sindhaghatta Venkatram

A 24-Year-Old Pregnant Patient With Diffuse Alveolar Hemorrhage

A 24-year-old pregnant woman was admitted to the hospital at 33 weeks’ gestation for dyspnea of 2-week duration. She had a mild dry cough and denied having chest pain, fever, hemoptysis, or night sweats. She had no arthralgias, rash, anorexia, abdominal pain, nausea, or vomiting. The patient was adherent to regular antenatal care and had been treated for a Staphylococcus aureus urinary tract infection 2 weeks prior to admission. Her gestational history included multiple spontaneous abortions due to cervical incompetence, for which she had prophylactic cerclage during this pregnancy. She denied toxic habits or travel history; her tuberculin test had been negative 6 months earlier.

An interesting case of mycoplasma pneumonia associated multisystem involvement and diffuse alveolar hemorrhage

Severe mycoplasma pneumonia is a rare entity with only 0.5–2% of cases having a fulminant course. We present a 74-year-old woman with hypertension, diabetes mellitus and remote history of marginal zone B-cell lymphoma admitted with abdominal pain and diarrhea of 1–2 days associated with body-aches, dyspnea, dry cough and weight loss for 2–3 weeks. On physical exam, she was febrile, tachypneic, tachycardic and hypoxic on room air. Chest examination revealed diffuse crackles and end-expiratory wheezes. Laboratory tests showed anemia, acute-on-chronic kidney injury and hyaline casts and epithelial cells in the urine analysis. Chest roentgenogram and computed tomograhphy scan showed pulmonary infiltrates. Intravenous ceftriaxone and azithromycin with bronchodilators were initiated. Her clinical course was complicated by hypoxic respiratory failure, hemoptysis, and worsening of infiltrates, requiring intubation and mechanical ventilation. Bronchoscopic bronchoalveolar lavage was consistent with diffuse alveolar hemorrhage (DAH). The patients serum was positive for IgM antibody to Mycoplasma pneumoniae [1134 U/mL] and Anti-I-specific IgM-cold-agglutining [1:40]. A diagnosis of severe mycoplasma infection with DAH was made. The patient was treated with an additional course of doxycycline, pulse dose steroids and plasmapharesis with good clinical response. Surgical lung biopsy showed focal acute lung injury. Bone marrow biopsy and fat pad biopsy were normal. She was liberated from mechanical ventilation and discharged. She returned within 24 hours of discharge with cardiac arrest and new onset right-bundle-branch-block. We hypothesize our patient had severe mycoplasma pneumonia with DAH and multisystem complications of the same including a possible venous thrombo-embolic episode leading to her demise.

Diffuse Alveolar Hemorrhage without Extrapulmonary Manifestations: A Rare Presentation of Lupus

Patient: Female, 31 Final Diagnosis: Lupus DAH Symptoms: Shortness of breath Medication: — Clinical Procedure: — Specialty: Pulmonology Objective: Unusual clinical course Background: Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder resulting in hemorrhage into the lungs due to a variety of reasons. The underlying etiology for DAH is broadly divided into immune and non-immune mediated causes. Rheumatological disorders account for a small number of cases. Although hemoptysis is one of the alarming symptoms of DAH, it is absent in a third of the cases. Diagnosis often requires a conglomerate of history, clinical, and laboratory investigation and radiological studies. Case Report: We describe a case of a 31-year-old female who had an atypical presentation of systemic lupus erythematosus (SLE) with primary lung involvement/DAH and no other organ involvement. Conclusions: This case report illustrates the importance of awareness and early recognition of the complication that can prevent mortality.

An Unusual Triad of Hemophagocytic Syndrome, Lymphoma and Tuberculosis in a Non-HIV Patient

Patient: Female, 58 Final Diagnosis: Hemophagocytic syndrome • lymphoma and tuberculosis in a non-HIV patient Symptoms: Dizziness • fever Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Rare co-existance of disease or patholog Background: Lymphoma complicated with hemophagocytic syndrome and tuberculosis has been rarely reported. The clinical and radiological presentation of these potentially fatal conditions can be easily confused and there is a potential for misdiagnosis. Case Report: We present a 58-year-old Hispanic female who was admitted to the hospital with dizziness and fever. Her initial admission diagnosis was severe sepsis secondary to community acquired pneumonia. She was started on intravenous antibiotics. Due to mediastinal lymphadenopathy, lymphoma was considered as a differential diagnosis for which she underwent bronchoscopy and endobronchial ultrasound-guided sampling of her mediastinal lymph nodes. Lymph node aspirate was suggestive of lymphoma. Initial cultures were negative. Her clinical course was complicated with respiratory failure, cytopenia, and rapidly progressive cervical lymphadenopathy. The patient underwent cervical lymph node excision and bone marrow biopsy. The pathology of the lymph nodes confirmed T cell lymphoma, and bone marrow revealed hemophagocytosis. The patient was started on chemotherapy but she continued to deteriorate and died on day 20 of her hospital admission. Post-mortem results of cultures from a cervical lymph node biopsy and PCR were positive for Mycobacterium tuberculosis. Conclusions: We suggest an aggressive tissue diagnosis with staining for acid-fast bacilli for early diagnosis in patients presenting with hemophagocytic syndrome secondary to lymphoma as coexisting tuberculosis is a consideration. Tuberculosis re-activation should be considered in patients from an endemic region who present with lymphoma and a deteriorating clinical condition.