Nakashima Kazuki, Nishimura Naoya, Yanagihara Toyoshi, Egashira Ayaka, Ogo Naruhiko, Asoh Tatsuma, Yoshizawa Seiji, Maeyama Takashige
Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan.
Department of Rheumatology, Hamanomachi Hospital, Fukuoka, 810-8539, Japan.
Respir Med Case Rep. 2021 Feb 17;32:101363. doi: 10.1016/j.rmcr.2021.101363. eCollection 2021.
We describe a fatal case of diffuse alveolar hemorrhage (DAH) complicated by rheumatoid arthritis (RA). A female patient was diagnosed with RA two months earlier and was treated with prednisolone and tacrolimus due to abnormalities in chest images. The patient was admitted to Hamanomachi Hospital for exertional dyspnea and was treated for exacerbation of chronic heart failure. Even after treatment for heart failure, exertional dyspnea remained. Chest CT imaging revealed contractile, patchy consolidations and ground-glass opacities (GGO) with a peribronchial distribution, suggesting an organizing pneumonia (OP) pattern. She was then treated with an additional 25 mg/day of prednisolone following a clinical diagnosis of OP. When the prednisolone dose was tapered, chest imaging showed worsening infiltration. A bronchoscopy was conducted, and bronchoalveolar lavage fluid was sanguineous, indicating DAH. Given that additional workup for the other etiology of DAH was negative, DAH was thought to be related to RA. Intensive treatment, including pulse dose methylprednisolone, failed to halt progression of respiratory failure, leading to a fatal outcome. The clinical presentation proved challenging due to its rarity. DAH might be a differential diagnosis in RA patients with consolidations and GGO in chest CT images. We review past cases of RA-associated DAH and assess potential treatment choices for future cases.
我们描述了一例并发类风湿关节炎（RA）的弥漫性肺泡出血（DAH）致死病例。一名女性患者两个月前被诊断为RA，因胸部影像异常接受泼尼松龙和他克莫司治疗。患者因劳力性呼吸困难入住滨名町医院，接受慢性心力衰竭加重的治疗。即使在心力衰竭治疗后，劳力性呼吸困难仍持续存在。胸部CT成像显示有收缩性、斑片状实变及沿支气管周围分布的磨玻璃影（GGO），提示机化性肺炎（OP）模式。在临床诊断为OP后，她随后接受了额外每日25mg泼尼松龙的治疗。当泼尼松龙剂量逐渐减小时，胸部影像显示浸润加重。进行了支气管镜检查，支气管肺泡灌洗 fluid呈血性，提示DAH。鉴于对DAH其他病因的进一步检查为阴性，DAH被认为与RA有关。包括大剂量甲泼尼龙冲击治疗在内的强化治疗未能阻止呼吸衰竭的进展，导致了致命的结局。由于其罕见性，临床表现颇具挑战性。DAH可能是胸部CT影像中有实变和GGO的RA患者的鉴别诊断之一。我们回顾了既往RA相关DAH的病例，并评估了未来病例的潜在治疗选择。
