2017 Resarch Forum

IM: C-3

Applicant: Aarushi Parekh MD Principal Investigator: Ralph Garcia-Pacheco MD

Diffuse alveolar hemorrhage and rituximab Aarushi Parekh MD, Ralph Garcia-Pacheco MD

INTRODUCTION

Diffuse alveolar hemorrhage (DAH) can be life-threatening. Early treatment with immunosuppressant can be necessary and Rituximab, even one dose, can be life-saving. PURPOSE Patient is a 32 year old obese Hispanic male with suspected obstructive sleep apnea/obesity hypoventilation syndrome but no diagnosed past medical history. Initially had dyspnea, cough, and hemoptysis in 2013 with CT chest showing bilateral extensive ground glass, and was treated with antibiotics, Solumedrol, and Plaquaneil with improvement of symptoms and lost to follow up. In 2015 patient had hemoptysis and dramatic hypoxia with CT chest findings suspicious for interstitial process. Rhemuatology panel returned positive for ANA. He did not improve on antibiotics; he was started on high dose steroids however he did not improve and, ultimately, received one dose of rituximab. CT chest positive for ground glass opacities and traction bronchiectasis. Due to significant hypoxia, bronchoscopy was not performed prior to starting steroids and rituximab. Patient was transferred to tertiary care center and bronchoscopy with bronchoalveolar lavage (BAL) was positive for hemosiderin laden macrophages. BAL flow cytometry was positive for moderate CD45. BAL culture was positive for Mycobacterium Mucogenicum. Patient had dramatic clinical improvement with 1 dose of rituximab. He was started on tapering dose of steroids and titrated off oxygen. At tertiary care center, all rheumatology work up was negative. DISCUSSION Most common reason for DAH can be secondary to autoimmune process mediating capillaritis. Isolated pauciimune pulmonary capillaritis (IPPC) is a rare cause of DAH. A prospective study of patients with DAH having BAL should undergo flow cytometry and for evaluation of response with Rituximab in patients positive with CD45. CONCLUSION Patients with IPPC seem to present sub-acutely with DAH and one has to approach DAH with a broad perspective. Steroids play a role in DAH with either APS or with IPCC. Immunosuppression is necessary with either of these diseases and if one cannot eliminate IPPC as a differential, rituximab can be utilized.