Diffuse pulmonary hemorrhage

Changed by Henry Knipe, 28 May 2015

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Diffuse pulmonary haemorrhage (DPH) is a subtype of pulmonary haemorrhage where bleeding into the lung is diffuse. If the bleeding is into the alveolar spaces this can be further subclassified as diffuse alveolar haemorrhage (DAH).

Clinical presentation

While the exact presentation can vary is has been classically associated with dyspnoea in the setting of haemoptysis +/- an iron deficiency anaemia ⁷.

Pathology

Associations

small vessel vasculitides: alveolar haemorrhage secondary to extensive parenchymal small-vessel vasculitis is typically more diffuse and initially causes more widespread lobular ground-glass opacification with gravity-dependent density gradients through to air-space consolidation, often with interspersed areas of ground-glass opacity; these include
- Wegener granulomatosis ²
- other connective tissue disorders
  - systemic lupus erythematosus (SLE) ^4,6
post bone marrow transplantation ³
all-trans-retinoic acid (ATRA) syndrome¹¹
Goodpasture syndrome ¹⁰
pulmonary haemosiderosis: idiopathic pulmonary haemosiderosis ⁷
coagulative disorders: often require another precipitating source such as an infection to cause DPH ⁷
widespread metastatic lung disease: has been described as a very rare cause of DPH ⁵

Radiographic features

Plain film

While plain film appearances are ~~non specific~~nonspecific there may be evidence of bilateral air-space consolidation with relative apical sparing ⁷.

CT chest/HRCT

May show areas of widespread ground glass opacification +/- crazy paving pattern ⁸ +/- areas of consolidation. In the subacute phase HRCT may show fine diffuse nodular densities ^9-10. In later stage there may also be evidence of interlobular septal thickening due to intralymphatic accumulation of haemosiderin.

More content required

Differential diagnosis

For radiographic (plain film and CT) in the acute phase of DPH appearances consider:

~~mulitple~~multiple localised pulmonary haemorrhages from diffuse aspiration of blood ⁷
pulmonary oedema ¹
diffuse pulmonary infection/diffuse pneumonia ¹

For HRCT appearances in the subacute phase consider (i.e. fine nodules)

hypersensitivity pneumonitis ⁹

~~-<a href="/articles/granulomatosis-with-polyangitis">Wegener granulomatosis </a><sup>2</sup>~~
+<a href="/articles/granulomatosis-with-polyangiitis">Wegener granulomatosis </a><sup>2</sup>
-</ul><h4>Radiographic features</h4><h5>Plain film</h5><p>While plain film appearances are non specific there may be evidence of bilateral air-space consolidation with relative apical sparing <sup>7</sup>.</p><h5>CT chest/HRCT</h5><p>May show areas of widespread <a href="/articles/ground-glass-opacification">ground glass</a> opacification +/- <a href="/articles/crazy-paving">crazy paving pattern</a> <sup>8</sup> +/- areas of <a href="/articles/air-space-opacification-1">consolidation</a>. In the subacute phase HRCT may show fine diffuse nodular densities <sup>9-10</sup>. In later stage there may also be evidence of interlobular septal thickening due to intralymphatic accumulation of haemosiderin.</p><p><em>More content required</em></p><h4>Differential diagnosis</h4><p>For radiographic (plain film and CT) in the acute phase of DPH appearances consider:</p><ul>
~~-<li>mulitple <a href="/articles/localised-pulmonary-haemorrhage">localised pulmonary haemorrhages</a> from diffuse aspiration of blood <sup>7</sup>~~
+</ul><h4>Radiographic features</h4><h5>Plain film</h5><p>While plain film appearances are nonspecific there may be evidence of bilateral air-space consolidation with relative apical sparing <sup>7</sup>.</p><h5>CT chest/HRCT</h5><p>May show areas of widespread <a href="/articles/ground-glass-opacification">ground glass</a> opacification +/- <a href="/articles/crazy-paving">crazy paving pattern</a> <sup>8</sup> +/- areas of <a href="/articles/air-space-opacification-1">consolidation</a>. In the subacute phase HRCT may show fine diffuse nodular densities <sup>9-10</sup>. In later stage there may also be evidence of interlobular septal thickening due to intralymphatic accumulation of haemosiderin.</p><p><em>More content required</em></p><h4>Differential diagnosis</h4><p>For radiographic (plain film and CT) in the acute phase of DPH appearances consider:</p><ul>
+<li>multiple <a href="/articles/localised-pulmonary-haemorrhage">localised pulmonary haemorrhages</a> from diffuse aspiration of blood <sup>7</sup>
~~-<li>diffuse pulmonary infection/<a href="/articles/diffuse-pneumonia">diffuse pneumonia</a> <sup>1</sup>~~
+<li>diffuse pulmonary infection / <a href="/articles/diffuse-pneumonia">diffuse pneumonia</a> <sup>1</sup>

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Case 52

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