Diffuse Alveolar Hemorrhage in the Setting of Cytarabine Therapy in a Critically Ill Patient

Abstract

Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening pulmonary condition characterized by hypoxemia with progression to respiratory failure, rapid onset of dyspnea, and blood loss anemia. While hemoptysis may be present and corroborates the diagnosis, it is absent in about half of the cases, resulting in a diagnostic challenge with variable presenting symptoms. Imaging findings on chest x-ray or computed tomography (CT) scans are also non-specific, often showing diffuse bilateral alveolar opacities. Because DAH is an under-recognized diagnosis, physicians should maintain a degree of clinical suspicion for DAH in patients with unexplained airspace opacities and no signs of an infectious etiology. This is especially important in higher-risk populations such as patients with hematological malignancies, who have a propensity for thrombocytopenia and coagulopathy compounded by the use of anticoagulants. Patients with hematological malignancies, namely acute myeloid leukemia (AML), are also at risk for drug-induced DAH due to the use of cytotoxic medications like cytarabine. Here, we present the case of a 48-year-old male with a past medical history of AML and myeloid sarcoma who developed shortness of breath after receiving cytarabine chemotherapy. Chest radiography revealed diffuse bilateral infiltrates. He was intubated and underwent flexible bronchoscopy, which resulted in a bloody effluent consistent with DAH. After ruling out infectious etiologies, we reached a final diagnosis of DAH and started the patient on corticosteroid therapy.

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“…The mass appeared isointense with gray matter on T1w imaging, which also more clearly illustrated the surrounding edema 55 . In the respiratory system, cytarabine-associated diffuse alveolar hemorrhage may present with diffuse bilateral infiltrates on radiographs and chest CT 56 …”

“…The mass appeared isointense with gray matter on T1w imaging, which also more clearly illustrated the surrounding edema. 55 In the respiratory system, cytarabine-associated diffuse alveolar hemorrhage may present with diffuse bilateral infiltrates on radiographs and chest CT. 56 Single-photon emission computed tomography can also be effective at detecting cytarabine-induced neurotoxicity. In a 1999 study, Vera et al 57 followed 12 pediatric patients receiving high-dose cytarabine therapy.…”