Clinical characteristics of patients with diffuse alveolar hemorrhage diagnosed by cytological examination of 1000 bronchoalveolar lavage samples.

Results

The distribution of cases according to aetiology is summarized in Fig. 2 and Table 1.

Patient demographics: The mean age of the patients was 39.4 ± 17.2 years (range 13–73 years). Of these, 61.7% (n = 29) were male. A total of 8.5% (n = 4) had a smoking history, and 8.5% (n = 4) were immunocompromised. The causes of the immunocompromised state were renal transplantation (n = 1) and immunosuppressive therapy (n = 3). Symptoms at presentation included cough in 44.7% (n = 21), hemoptysis in 61.7% (n = 29), dyspnea in 55.3% (n = 26) and fever in 40.4% (n = 19) of cases. Female sex was significantly correlated with immune DAH (p value 0.033).

Laboratory parameters: All patients had peripheral blood analysed for complete blood cell counts during the BAL procedure. There was a significant drop in hemoglobin from admission to diagnosis (1.5 (1.1, 2.6), p < 0.05), but this drop was similar in both groups. The mean hemoglobin level in the immune DAH group was lower than that in the nonimmune DAH group (p value 0.018).

Chest radiography and computed tomography High-resolution computed tomography (HRCT) of the chest were available for all patients and revealed bilateral ground glass opacities in 70.2% (n = 33) of the cases (Fig. 3A) and multifocal consolidation in 23.4% (n = 11). Uncommon findings were pleural effusion in 6.4% (n = 3) (Fig. 3B), cavitatory lesions in 2.1% (n = 1) (Fig. 3A), fibronodular opacities in 4.3% (n = 2) and bronchiectasis in 2.1% (n = 1).

Bronchoalveolar lavage fluid analysis: The mean proportion of HLMs in BALF was 56.4 ± 29.1% (range 0–96%). On differential cell count, alveolar macrophages were the predominant cell type, with a mean percentage of 77.8 ± 12.1. Lymphocytes, neutrophils, and epithelial cells accounted for 8.9 ± 3.0, 5.8 ± 10.6, and 7.5 ± 8.8%, respectively.

Etiologies: The causes of DAH (n = 47) were immune and nonimmune. The immune DAH group included antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis [AAV] in 27.6% (n = 13): p-ANCA in 8, c-ANCA in 5 cases, anti-glomerular basement membrane [anti-GBM] disease in 6.4% (n = 3), systemic lupus erythematosus [SLE] vasculitis in 6.4% (n = 3) and antiphospholipid antibody syndrome [APLA] syndrome in 4.3% (n = 2). The nonimmune DAH group included infections in 21.3 (10%), pulmonary arterial hypertension [PAH] in 4.3% (n = 2), idiopathic pulmonary hemosiderosis in 6.4% (n = 3) and anticoagulant therapy in 6.4% (n = 3). A total of 10.6% (n = 5) of cases were classified as miscellaneous and included those without a definite cause, despite extensive clinical and laboratory workup, which was not firmly established. (Fig. 2)

Lung biopsy was available in six cases (12.7%), of which three were diagnosed as pulmonary hemosiderosis and one as organizing pneumonia, granulomatous lesion favoring vasculitis, and aspergillosis. Renal biopsy was available in fourteen (29.8%) cases, of which eleven were diagnosed as crescentic glomerulonephritis (nine ANCA-associated glomerulonephrites and two anti-GBM disease), one as advanced diabetic nephropathy even though the patient had AAV, one case had a membranoproliferative glomerulonephritis pattern, and one was a graft biopsy, which revealed chronic active antibody-mediated rejection with focal segmental glomerulosclerosis.

Treatment: Immunosuppressive therapy was given to 55.3% (n = 26) of DAH cases, which included steroids (55.3%, n = 26) with or without cyclophosphamide (22.2%, n = 12%), rituximab (9.3%, n = 5), intravenous immunoglobulins (9.3%, n = 5), or plasmapheresis (13.0%, n = 7). The remaining 44% (n = 21) of DAH cases did not receive immunosuppressive therapy, as their disease severity was relatively low, and the adverse risk associated with immunotherapy outweighed the benefit.

Mortality: Overall mortality was 8.5% in the immune group and 14.28 vs 3.85% in the nonimmune group. However, this difference was not statistically significant.

Univariate and multivariate analysis: Female sex, lower hemoglobin at admission, higher TLC, higher platelets, a high ESR, were found to significantly associated with immune DAH. However, on multivariate analysis female sex, a high ESR and a higher platelet count were found to be significant. (Fig. 5)

Discussion

Diffuse alveolar hemorrhage (DAH) is a life-threatening condition characterized by hemoptysis, anemia, and diffuse alveolar infiltrates. The diagnosis of DAH is generally established by BAL along with radiology and serology in the appropriate clinical setting. Renal biopsy and lung biopsy may be required if vasculitis or anti-GBM disease is being considered to guide the therapy and prognosticate the disease. The majority of cases of DAH are caused by vasculitis, which may be primary idiopathic small vessel vasculitis, primary immune-complex mediated, or secondary. Coagulation disorders, drugs, inhaled toxins, or transplantation are other known causative factors. In our series, the most common cause of DAH was vasculitis. DAH has traditionally been linked to systemic vasculitides.¹² Quadrelli et al. characterized 39 patients with DAH of proven immunological etiology, the most frequent being ANCA-related vasculitides (74%), mainly granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). In their series, these two diseases accounted for a similar number of cases (14 GPA vs. 13 MPA). Alexandre et al. found that ANCA-related vasculitides were the most common cause of immune-related DAH (~ 73%).¹³ AAV was the most common cause in our study, followed by anti-GBM disease, SLE vasculitis, and one case of unclassifiable vasculitis.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are a group of systemic diseases marked by inflammation and necrosis of small and medium-sized arteries, and one of the most common symptoms is pulmonary involvement. The damage to the alveolar basement membrane resulting from the widespread injury of the pulmonary capillaries promotes the extravasation of red blood cells into the pulmonary alveolar spaces. DAH affects approximately 7–45% of GPA and 10–30% of MPA patients but is uncommon in EGPA patients. The severity of the disease varies from life-threatening to milder types, with associated renal impairment occurring in up to 97% of cases.¹⁴ The frequency of DAH was 8–36%, and 57% of the patients showed anti-proteinase-3 (PR3) antibodies, according to a systematic analysis by West et al., which comprised nine studies with a total of 207 patients.¹⁵ ANCA antibodies were found to be positive in 13 cases in our study. DAH is the most common and the most severe form of pulmonary manifestation of anti-GBM disease. The molecular and nephritogenic properties of anti-GBM antibodies that bind to renal glomeruli and alveolar-capillary basement membranes are responsible for causing glomerulonephritis and DAH, respectively.¹⁶ The exact pathogenesis of DAH in SLE is not fully understood. Diffuse alveolar bleeding, interstitial inflammation, and alveolar hemorrhage without vasculitis are the histopathology findings mentioned. Other reports, on the other hand, have revealed pulmonary vasculitis, with evidence pointing to pulmonary capillaritis and microangiitis as the source of DAH in SLE patients.¹⁷

The nonimmune causes include infections, APLA syndrome, PAH, idiopathic pulmonary hemosiderosis, and miscellaneous. The main infections that induce DAH in immunocompromised people include cytomegalovirus, adenovirus, invasive aspergillosis, Mycoplasma, Legionella, and Strongyloides. Influenza A (H1N1), dengue fever, leptospirosis, malaria, and Staphylococcus aureus infection are the most common infectious diseases that cause DAH in immunocompetent patients.¹⁸ Infection was implicated as the aetiology in ten of our cases, with two cases of Klebsiella pneumonia and one each of cytomegalovirus, Escherichia coli, tuberculosis, Candida, Aspergillus, mucormycosis, and Acinetobacter baumannii. All these cases were confirmed by microbiological studies. In one case, the causative agent could not be elucidated. One mortality seen in this group was due to mucormycosis.

Hemoptysis is a leading sign of DAH and may develop over days to weeks; however, it may be initially absent in up to one-third of DAH cases.⁶ The prevalence of hemoptysis is highly variable in different series, from 59.0–96.3%. Therefore, the absence of hemoptysis should not exclude this diagnosis.¹⁹ The symptoms of DAH, other than hemoptysis, are nonspecific and include fever, chest pain, cough, dyspnea, and respiratory failure. Non-pulmonary signs and symptoms accompany the underlying systemic disease.⁶ In the present study, hemoptysis was present in only 61.7% (n = 29) of cases of DAH.

Typical pulmonary lesions of DAH on chest X-rays include bilateral, reticular, or nodular opacities. Chest computed tomography is indispensable in characterizing the pattern and extent of pulmonary disease.²⁰ Ground-glass opacities and consolidation were the most common CT findings in our cases. Although MR has been used to confirm lung hemorrhage, it is probably of limited use in most clinical settings.^{9, 21}

Our study had three cases of idiopathic pulmonary hemosiderosis (IPH) confirmed by lung biopsy. Idiopathic pulmonary hemosiderosis is a diagnosis of exclusion and is an uncommon disease of childhood manifesting with the triad of recurrent hemoptysis, diffuse parenchymal infiltrates on chest radiographs, and iron deficiency anemia.²² The age of presentation is bimodal, with frequency peaks in children less than five years of age and adolescents 11 years or older.²² The diagnosis of IPH is based on the clinical picture, radiological findings on the chest X-ray and CT scan, demonstration of HLM in BALF, and exclusion of other diseases by appropriate serological, microbiological, and radiological tests.²³ One case was of a 35-year-old female with Lane-Hamilton syndrome who presented with hemoptysis and, upon evaluation, was found to have chronic diarrhea with raised serum anti-tissue transglutaminase antibody levels. The duodenal biopsy revealed villous atrophy, BALF showed numerous HLMs, and a subsequent lung biopsy confirmed the findings of hemosiderosis (Fig. 4). Only 16 cases of Lane-Hamilton syndrome affecting adults have been reported in the literature thus far.²⁴ Deposition of immunocomplexes (including food allergens) in the alveolar-capillary basement membrane and cross-reaction between antireticulin antibodies and alveolar basal membrane antigens are implicated in the pathogenesis.^{25, 26}

In patients with evidence of DAH and renal involvement, a kidney biopsy may be considered to identify the etiology and guide the therapy.²⁷ In a study by Fatma et al. on 15 cases of DAH associated with renal diseases, 13 underwent a kidney biopsy, of which ten showed crescentic pauci-immune glomerulonephritis.²⁸ In our study, 11 out of 14 cases were diagnosed as crescentic glomerulonephritis, highlighting the utility of renal biopsy as an adjunctive tool in such cases.

Treatment of the cases was based on the underlying etiology. Patients with immune DAH were managed aggressively by immunosuppressive therapy, including steroids, cyclophosphamide, rituximab, intravenous immunoglobulins, and plasmapheresis. Established standard treatment regimens include corticosteroids and immunosuppressive therapy, but these can be detrimental when DAH is due to infection. Plasma exchange improves renal function in patients with ANCA-associated vasculitis. Rituximab can be used as an alternative or in addition to cyclophosphamide to treat AAV and SLE-associated DAH.¹² In contrast, patients with nonimmune DAH were managed conservatively such as antibiotics and antifungals for infections. Hence, the prognosis for diffuse alveolar hemorrhage depends primarily on the classification proposed by us.

The main limitation of the study is that it is a retrospective study. Because the disease is rare, the sample size for proper calculation of risk factors is small, so the multivariate analysis may fail to give proper odds ratio in such a setting. A multicenter prospective study may throw more light on this disease.

Conclusion

DAH appears to be a heterogeneous syndrome because of varying etiologies. In our series, patients with immune DAH required more aggressive management. Female sex, erythrocyte sedimentation rate, and higher platelet count were significantly associated with immune-DAH. Finally, BALF cytology is an essential adjuvant investigation that can confirm a diagnosis of DAH in an appropriate clinical setting. Early recognition of DAH is crucial because prompt diagnosis and treatment are necessary for survival.

Declarations

Data availability statement

All data are available and can be obtained by request from the corresponding author.

Author Contributions: CRediT author statement

1. Pallavi Prasad: Writing - Original Draft, Investigation, Supervision, Resources, 
2. Aviral Gupta: Investigation, Supervision, Resources, 
3. Alok Nath: Project administration, Supervision, 
4. Zia Hashim: Conceptualization, Methodology, Software, Writing - Review & Editing, Format analysis, Supervision, Resources,
5. Ajmal Khan: Investigation, Resources, Validation, 
6. Narendra Krishnani: Project administration, Supervision

Acknowledgements: None

Conflict of Interest: The authors have no conflict of interest to declare

Data Availability Statement: (Respirology expects authors to share the data and other artefacts supporting the results in the paper and to provide a data availability statement.  Review Wiley’s Data Sharing policy where you will be able to see and select the data availability statement that is right for your submission. If the dataset is archived in an appropriate public repository before publication, the link to the repository should be included)

Human/Animal Ethics Approval Declaration:  

The study was approved by the Institutional Ethics Committee (IEC)

(IEC Reference Code # 2022-19-IMP-EXP-45).

References

1. Travis WD, Colby TV, Lombard C, Carpenter HA. A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Surg Pathol. 1990; 14: 1112–25.
2. Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008; 75: 258, 60, 64 – 5 passim.
3. Marten K, Schnyder P, Schirg E, Prokop M, Rummeny EJ, Engelke C. Pattern-based differential diagnosis in pulmonary vasculitis using volumetric CT. AJR Am J Roentgenol. 2005; 184: 720–33.
4. Ficker JH, Bruckl WM, Suc J, Geise A. [Haemoptysis: Intensive care management of pulmonary hemorrhage]. Internist (Berl). 2017; 58: 218–25.
5. Finley TN, Aronow A, Cosentino AM, Golde DW. Occult pulmonary hemorrhage in anticoagulated patients. Am Rev Respir Dis. 1975; 112: 23–9.
6. Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010; 137: 1164–71.
7. Drew WL, Finley TN, Golde DW. Diagnostic lavage and occult pulmonary hemorrhage in thrombocytopenic immunocompromised patients. Am Rev Respir Dis. 1977; 116: 215–21.
8. De Lassence A, Fleury-Feith J, Escudier E, Beaune J, Bernaudin JF, Cordonnier C. Alveolar hemorrhage. Diagnostic criteria and results in 194 immunocompromised hosts. Am J Respir Crit Care Med. 1995; 151: 157–63.
9. Golde DW, Drew WL, Klein HZ, Finley TN, Cline MJ. Occult pulmonary haemorrhage in leukaemia. Br Med J. 1975; 2: 166–8.
10. Maldonado F, Parambil JG, Yi ES, Decker PA, Ryu JH. Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage. Eur Respir J. 2009; 33: 1361–6.
11. Chamberlain DW, Braude AC, Rebuck AS. A critical evaluation of bronchoalveolar lavage. Criteria for identifying unsatisfactory specimens. Acta Cytol. 1987; 31: 599–605.
12. Quadrelli S, Dubinsky D, Solis M, Yucra D, Hernandez M, Karlen H, et al. Immune diffuse alveolar hemorrhage: Clinical presentation and outcome. Respir Med. 2017; 129: 59–62.
13. Alexandre AT, Vale A, Gomes T. Diffuse alveolar hemorrhage: how relevant is etiology? Sarcoidosis Vasc Diffuse Lung Dis. 2019; 36: 47–52.
14. Quartuccio L, Bond M, Isola M, Monti S, Felicetti M, Furini F, et al. Alveolar haemorrhage in ANCA-associated vasculitis: Long-term outcome and mortality predictors. J Autoimmun. 2020; 108: 102397.
15. West S, Arulkumaran N, Ind PW, Pusey CD. Diffuse alveolar haemorrhage in ANCA-associated vasculitis. Intern Med. 2013; 52: 5–13.
16. Nasser M, Cottin V. Alveolar Hemorrhage in Vasculitis (Primary and Secondary). Semin Respir Crit Care Med. 2018; 39: 482–93.
17. Quintana JH, Aragon CC, Santos VA, de Las Salas A, Tafur RA, Aguirre-Valencia D, et al. Diffuse Alveolar Hemorrhage: A Cohort of Patients With Systemic Lupus Erythematosus. J Clin Rheumatol. 2020; 26: S153-S7.
18. von Ranke FM, Zanetti G, Hochhegger B, Marchiori E. Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients: a state-of-the-art review. Lung. 2013; 191: 9–18.
19. Kostianovsky A, Hauser T, Pagnoux C, Cohen P, Daugas E, Mouthon L, et al. Alveolar haemorrhage in ANCA-associated vasculitides: 80 patients' features and prognostic factors. Clin Exp Rheumatol. 2012; 30: S77-82.
20. Lohrmann C, Uhl M, Kotter E, Burger D, Ghanem N, Langer M. Pulmonary manifestations of wegener granulomatosis: CT findings in 57 patients and a review of the literature. Eur J Radiol. 2005; 53: 471–7.
21. Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci. 2021; 22.
22. Bakalli I, Kota L, Sala D, Celaj E, Kola E, Lluka R, et al. Idiopathic pulmonary hemosiderosis - a diagnostic challenge. Ital J Pediatr. 2014; 40: 35.
23. Sethi GR, Singhal KK, Puri AS, Mantan M. Benefit of gluten-free diet in idiopathic pulmonary hemosiderosis in association with celiac disease. Pediatr Pulmonol. 2011; 46: 302–5.
24. Berger N, Nichols J, Datta D. Idiopathic pulmonary haemosiderosis with celiac disease (Lane-Hamilton syndrome) in an adult - a case report. Clin Respir J. 2016; 10: 661–5.
25. Hoca NT, Dayioglu D, Ogretensoy M. Pulmonary hemosiderosis in association with celiac disease. Lung. 2006; 184: 297–300.
26. Khemiri M, Ouederni M, Khaldi F, Barsaoui S. Screening for celiac disease in idiopathic pulmonary hemosiderosis. Gastroenterol Clin Biol. 2008; 32: 745–8.
27. Guillevin L, Pagnoux C. Indication for plasma exchange for systemic necrotizing vasculidities. Transfus Apher Sci. 2007; 36: 179–85.
28. Fatma LB, El Ati Z, Lamia R, Aich DB, Madiha K, Wided S, et al. Alveolar hemorrhage and kidney disease: characteristics and therapy. Saudi J Kidney Dis Transpl. 2013; 24: 743–50.