Diffuse Alveolar Hemorrhage in Allogeneic Bone Marrow Transplantation: A Postmortem Study

Abstract

To define better the syndrome of diffuse alveolar hemorrhage (DAH), we conducted a postmortem study in 77 patients who died of pulmonary complications, distributed into three groups. Group A included 47 patients with hematologic diseases treated with allogeneic bone marrow transplant (BMT); Group B, 20 patients with hematologic diseases treated with conventional chemotherapy; and Group C, 10 patients without hematologic diseases. The diagnosis of DAH was established when there was blood in at least 30% of the lung tissue evaluated without evidence of infection or any other pathologic change that could account for its presence. The presence of an associated pulmonary complication was considered only when there was normal lung parenchyma between both blood and the specific lesions. Diffuse alveolar hemorrhage was shown in 11 patients in Group A (23%) compared with 1 patient in Group B (5%) (p < 0.05). Of the 11 patients with DAH in Group A, 10 had some associated pulmonary complication: 7 presented with diffuse alveolar damage (DAD), 2 with associated bacterial pneumonia and 1 with invasive aspergillosis, 2 others had an associated cytomegalovirus (CMV) pneumonitis, and the remaining patients had an associated herpes pneumonia. There were no clinical differences between patients with and without DAH. Of 8 patients with confirmed DAH in Group A, who had been submitted to a bronchoscopic examination within 1 wk of death, 4 had normal BAL fluid; by contrast, 7 of 13 patients without DAH had hemorrhagic BAL fluid.(ABSTRACT TRUNCATED AT 250 WORDS)

Alveolar hemorrhage following allogeneic hematopoietic cell transplantation using reduced-intensity conditioning

“…However, pulmonary infections are frequent in the post transplant period, are often underdiagnosed, and can contribute to the pathogenesis of alveolar hemorrhage. 10,11 Furthermore, it is difficult to distinguish microbial colonization from infection in the immunocompromised HCT recipient and we have previously reported that post transplant IAH and DAH are similar high-risk syndromes. 2 We have defined IAH and DAH using very strict clinical criteria and have analyzed patients with both syndromes in this study.…”

Diffuse Alveolar Hemorrhage Caused by Lung Metastasis of Ovarian Angiosarcoma.

“…Although diffuse alveolar hemorrhage is knownto occur in various immune, idiopathic disorders (1), disseminated intravascular coagulation (2) and after bone marrowtransplantation (3), it rarely occurs in association with malignant lung diseases (4)(5)(6). Further, the mechanismof diffuse alveolar hemorrhage is not well known, although a case of alveolar hemorrhage associated with metastatic angiosarcoma has been reported to be caused by an immunological response because of its successful treatment with glucocorticoid (4).…”

Treatment of diffuse alveolar hemorrhage after allogeneic bone marrow transplant with recombinant factor VIIa

“…Although initially described to occur more commonly after autologous transplant, recent reports have suggested an increasingly frequency (up to 20%) of this complication after allogeneic transplantation; with rates up to 20% being reported. 1,4,5 In a recent review of 42 bronchoscopy specimens performed after BMT, DAH was the most common pulmonary complication (n = 15) diagnosed, with 70% of these cases occurring after allogeneic transplant. 5 The cause of DAH is not fully understood.…”

“…Treatment with high-dose steroids may be beneficial when given early, 9 but overall mortality remains as high as 70-100%. [1][2][3][4]8,9 Steroid treatment is aimed at reducing a possible acute inflammatory response to hemorrhage; with successful treatment typically requiring very high doses (ie 1 g per day) and prolonged treatment duration. Prolonged steroid use, unfortunately, is well known to increase risk or the development of new opportunistic infections from fungal or atypical organisms.…”

“…[1][2][3][4] Although the syndrome was first noted in autologous patients following transplant for solid tumors, 2 recent data have implicated DAH as an increasing cause of morbidity and mortality after all allogeneic transplants. 1,4 At our center, DAH was found to be the most frequently diagnosed non-infectious condition leading to bronchoscopy, occurring in 15/42 (35%) of diagnostic BAL specimens. 5 Diffuse alveolar hemorrhage is second only to pneumonia as the most common cause of respiratory failure requiring intubation and admission to the intensive care unit.…”