Rare cause of diffuse alveolar haemorrhage and subconjunctival haemorrhage rescued by extracorporeal membrane oxygenation and rituximab

Abstract

A previously healthy man in his 20s presented with acute respiratory distress syndrome and subconjunctival haemorrhage. Imaging was indicative of pervasive pulmonary haemorrhage. There was no evidence of renal involvement. The patient rapidly deteriorated with aggravating respiratory failure regardless of invasive mechanical ventilation and required extracorporeal membrane oxygenation (ECMO). This maintained the patient adequate time to allow aggressive therapy. Skin biopsy indicated leucocytoclastic vasculitis. Given that the patient was C-antinuclear cytoplasmic autoantibody (ANCA) positive, pulse dose steroids and rituximab were initiated for the suspicion of ANCA-associated vasculitis (AAV) which resulted in improvement of airspace disease and subconjunctival haemorrhage. Only a few cases reported successful use of ECMO in severe diffuse alveolar haemorrhage (DAH) due to AAV, but no case was in DAH combined with subconjunctival haemorrhage. The need for systemic anticoagulation with pre-existing haemorrhage is still a challenging dilemma.