Chest
Pulmonary and Critical Care Pearls: ArticlesAcute Dyspnea, Chest Tightness, and Anemia in a 33-Year-Old Man
Section snippets
Physical Examination
Vital signs: temperature, 37.2° C; pulse, 130/min; respirations, 40/min; and BP, 90/50 mm Hg. General: pale, diaphoretic with marked respiratory distress. Skin: no rashes or cyanosis. Lymph nodes: none palpable. Chest: widespread, bilateral coarse crackles. Cardiac: regular tachycardia. Abdomen: normal. Nervous system: normal. Extremities: left-sided below-knee amputation, no clubbing.
Laboratory Findings
Hematocrit, 19%; WBC, 15,100/mm3, with 86% neutrophils, 9% lymphocytes, and 5% monocytes; platelets, 223,000/mm3. Electrolytes, BUN, creatinine, and liver function tests: normal. Chest radiograph: (Fig 1). Arterial blood gases (24% oxygen): PaO2, 40 mm Hg; PaO2, 41 mm Hg; pH, 7.35. Arterial blood gases (60% oxygen by Venturi mask): PaO2, 42 mm Hg; PaCO2, 53 mm Hg. Urine: normal. One stage prothrombin time: 620 s (control, 16 s; international normalized ratio [INR], 61.4). ECG: sinus tachycardia.
What is the likely cause of this man's acute respiratory distress?
Diagnosis: Diffuse alveolar hemorrhage from excessive anticoagulation.
Diffuse alveolar hemorrhage is a relatively uncommon disorder that most often occurs in patients with systemic autoimmune or idiopathic diseases, such as antiglomerular basement membrane disease (Goodpasture's syndrome), systemic vasculitis (especially Wegener's granulomatosis), idiopathic pulmonary hemosiderosis, and rapidly progressive glomerulonephritis. Less common causes include exposure to exogenous agents, such as
Clinical Pearls
- 1.
Although spontaneous bleeding commonly occurs in patients who receive excessive anticoagulation therapy, the lung is a rare site of hemorrhage in patients treated with warfarin.
- 2.
The absence of hemoptysis does not exclude the diagnosis of diffuse alveolar hemorrhage if other typical features of the condition are present.
- 3.
Pulmonary venous hypertension may predispose patients to alveolar hemorrhage from excessive anticoagulation.
- 4.
The presence of blood in the alveoli causes an increase in the TLCO,
Suggested Readings (1)
- et al.
Occult pulmonary hemorrhage in anticoagulated patients
Am Rev Respir Dis
(1975)
Cited by (4)
Pulmonary Bleeding during Right Ventricular Support after Left Ventricular Assist Device Implantation
2016, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :In these patients, no disorders of the coagulation systems were revealed before surgery or were newly diagnosed while the patients were receiving biventricular mechanical circulatory support. Spontaneous pulmonary hemorrhage refers to a clinical syndrome resulting from extensive bleeding in the acinar portion of the lung.15 It often presents with clinical features of hemoptysis, anemia, diffuse radiographic alveolar consolidation, and acute respiratory failure.15
Successful management of warfarin-exacerbated diffuse alveolar hemorrhage using an extracorporeal membrane oxygenation
2013, Multidisciplinary Respiratory MedicineWarfarin induced intra alveolar hemorrhage: A case report
2010, Internet Journal of Internal Medicine