Diffuse Alveolar Hemorrhage as a Consequence of Microscopic Polyangiitis Due to Covid-19

Abstract

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a small vessel vasculitis of which microscopic polyangiitis (MPA) is a subset. They are known to cause life threatening renal failure and/or pulmonary hemorrhage. Viruses are a known trigger of vasculitis, including MPA. (1) We present a case of MPA caused by COVID-19 presenting as diffuse alveolar hemorrhage (DAH) CASE PRESENTATION: 55 year old female with a past medical history of hemorrhagic stroke, hypertension & asthma who presented with respiratory distress & severe hypoxemia. At the time of intubation, a moderate amount of blood was suctioned from her endotracheal tube. She was profoundly hypoxemic & required 100% FiO2 and PEEP 18 cmH2O. A SARS CoV2 PCR test was positive. Other admission laboratory values were significant for a creatinine of 4.9 mg/dL (baseline: 0.8mg/dL), hemoglobin of 8 g/dL (baseline: 11.8g/dL), ferritin 569 ng/mL, D-dimer 3.18 ug/mL, CRP 62.8 mg/L, ESR 118 mm/hr. Chest X-ray showed dense bilateral airspace opacities. A CT scan showed extensive bilateral consolidations with air bronchograms that were not typical for a COVID-19 pneumonia (Image 1) except in the apices where these dense consolidations had a peripheral pattern. She was admitted to the medical ICU where she continued to have bleeding into her endotracheal tubing. Bronchoscopy showed blood in the airways diffusely with no focality to the bleeding. A bronchoalveolar lavage was performed of two separate lobes, and was notable for progressively bloody aliquots consistent with DAH. Because of concern for a pulmonary-renal syndrome, rheumatologic testing was performed. She was empirically treated with high dose intravenous steroids and plasmapheresis. Unfortunately, profound hypoxia persisted and family elected to withdraw life-sustaining therapies. Two days after her death, serologies revealed a mildly positive ANA and a strongly positive anti-MPO ANCA, suggesting the diagnosis of MPA.

SARS-CoV-2 Infection: A Forerunner or Precursor in Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis With Kidney Injury

“…Among the 25 cases, we found in the literature (median age of 49 years with 13 females) (Table 2), AAV was diagnosed one to six months after COVID-19 in 12 patients [11,[16][17][18][19][20][21][22][23][24][25][26] while COVID-19 and AAV were diagnosed during the same admission in 11 cases [5,[27][28][29][30][31][32][33][34][35][36]. It is noteworthy that severe AAV with life-threatening alveolar haemorrhage can follow a mild COVID-19 infection, exemplified by two patients who had mild COVID-19 (managed with self-quarantine but not requiring hospital admission) but subsequently died following pulmonary haemorrhage [12,21].…”

A Rare Case of SARS-CoV-2-Induced Microscopic Polyangiitis

“…The incidence of COVID-19 in patients with ANCA-associated vasculitis appears to be similar to that of the general population [ 14 ]. There has been another case of a patient with COVID-19-associated microscopic polyangiitis reported as well [ 15 ]. Uppal et al have also reported cases with de novo ANCA vasculitis with glomerulonephritis in patients with COVID-19 [ 16 ].…”

Life-threatening gastrointestinal haemorrhage requiring surgical resection caused by SARS-CoV-2 induced ANCA associated vasculitis: A case report

“…SARS-CoV-2 has also been found to induce and/or exacerbate various other autoimmunological disease processes [2] . Different phenotypes have been reported in the literature, affecting integumentary, renal, and respiratory systems with a variety of clinical manifestations associated with each [5] , [6] , [7] , [18] . However, there have been no reported cases of severe GIH caused by SARS-CoV-2 associated vasculitis.…”

“…A rare manifestation that carries a high mortality is an involvement of the gastrointestinal (GI) tract [4] . GI involvement can lead to severe life-threatening haemorrhage and often requires prompt surgical management [5] , [6] , [7] . Currently, there are no specific standards of care or guidelines to guide decision making for these patients.…”