J Rheum Dis.  2011 Jun;18(2):125-128.

A Case of a Patient with Dermatomyositis Who Developed a Diffuse Alveolar Hemorrhage

• Kim SH
• Kim KH
• Kim TS
• Han SS
• Moon KW

Abstract

Dermatomyositis is a inflammatory myopathy associated with interstitial lung disease in 5~10% of cases. The occurrence of diffuse alveolar hemorrhage (DAH) is considered exceptional in the course of dermatomyositis. We experienced a case of DAH in a 58-year-old female with dermatomyositis. DAH was diagnosed by anemia, infiltration on chest X-ray and computed tomography, and a bloody aspirate on bronchoscopy. Combined Pneumocystis jiroveci (PJP) pneumonia was suspected, as the polymerase chain reaction for PJP was positive. After intravenous the administration of immunoglobulin and treatment for the PJP, she markedly improved but subsequently developed nosocomial pneumonia and died.

Keyword

Dermatomyositis; Diffuse alveolar hemorrhage; Intravenous immunoglobulin

MeSH Terms

Anemia
Bronchoscopy
Dermatomyositis
Female
Hemorrhage
Humans
Immunoglobulins
Lung Diseases, Interstitial
Middle Aged
Myositis
Pneumocystis jirovecii
Pneumonia
Polymerase Chain Reaction
Thorax
Immunoglobulins

Figure

• 

  Figure 1. On admission, a chest radiograph showed bilateral diffuse reticular haziness in panel (A). On hospital day 2, a chest radiograph showed increased haziness, especially in the left lower lung field, in panel (B), after an intravenous immunoglobulin infusion, a chest radiograph showed much improved bilateral diffuse haziness in panel (C).

• 

  Figure 2. On hospital day 2, a high-resolution chest computed tomography scan showed bilateral diffuse ground glass opacity with interlobular septal wall thickening.

• 

  Figure 3. Sequential Bronchoalveolar lavage showed lavage aliquots were more progressively hemorrhagic.

Reference

References

1. Dickey BF, Myers AR. Pulmonary disease in polymyositis/dermatomyositis. Semin Arthritis Rheum. 1984; 14:60–76.

2. Collard HR, Schwarz MI. Diffuse alveolar hemorrhage. Clin Chest Med. 2004; 25:583–92.

3. Schwarz MI, Sutarik JM, Nick JA, Leff JA, Emlen JW, Tuder RM. Pulmonary capillaritis and diffuse alveolar hemorrhage. A primary manifestation of polymyositis. Am J Respir Crit Care Med. 1995; 151:2037–40.

4. Shoda T, Kotani T, Takeuchi T, Makino S, Hanafusa T. A fulminant case of systemic sclerosis/dermatomyositis complicating thrombotic microangiopathy and diffuse alveolar hemorrhage. Nihon Kokyuki Gakkai Zasshi. 2009; 47:227–31.

5. Omori CH, Jesus AA, Sallum AM, Adde FV, Rodrigues JC, Silva CA. Association between pulmonary hemosi-derosis and juvenile dermatomyositis. Acta Reumatol Port. 2009; 34:271–5.

6. Do-Pham G, Pagès C, Picard C, Galicier L, Lémann M, Dubertret L, et al. A first case report of a patient with paraneoplastic dermatomyositis developing diffuse alveolar haemorrhage. Br J Dermatol. 2010; 163:227–8.

7. Kim NY, Kim SG, Song YW, Han SK, Han JS, Lee JS, et al. Massive pulmonary hemorrhage in a patient with systemic lupus erythematosus. Seoul J Med. 1989; 30:195–201.

8. Hwang KW, Ahn YS, Moon JY, Kim IY, Park YE, Kim GT, et al. Experience of rituximab treatment in two patients with severe systemic lupus erythematosus. J Korean Rheum Assoc. 2006; 13:230–5.

9. Koh JH, Song SY, Lee CK, Seo GH, Ahn HJ, Cha HS, et al. A case of diffuse alveolar hemorrhage in systemic lupus erythematosus: treatment with plasmapheresis. J Korean Rheum Assoc. 1999; 6:185–91.

10. Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008; 75:258–80.

11. Franks TJ, Koss MN. Pulmonary capillaritis. Curr Opin Pulm Med. 2000; 6:430–5.

12. Tanawuttiwat T, Harindhanavudhi T, Hanif S, Sahloul MZ. Amiodarone-induced alveolar haemorrhage: a rare complication of a common medication. Heart Lung Circ. 2010; 19:435–7.

13. Sheares KK, Mahadeva R. Recombinant factor VIIa and intravenous immunoglobulin therapy for diffuse alveolar haemorrhage: a cautionary tale? Respiratory Medicine Extra. 2005; 1:120–3.

14. Uchiyama M, Hattori A, Tanaka T, Miyaji T, Matsuki Y, Fujii T, et al. Acute idiopathic thrombocytopenic purpura complicated with diffuse alveolar hemorrhage in an elderly patient. Intern Med. 2009; 48:1449–52.

15. Deane KD, West SG. Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review. Semin Arthritis Rheum. 2005; 35:154–65.