diffuse alveolar hemorrhage | The Journal of Critical Care Medicine

Bronchoscopic Intrapulmonary Recombinant Factor VIIa for Diffuse Alveolar Hemorrhage- induced Acute Respiratory Failure in MPO-ANCA Vasculitis: A Case Report

Illaa Smesseim¹, Titia Schaepman-Ruys¹, Jan Willem Duitman^1,2, Yosta Vegting³, Jorinde Raasveld⁴, Marc Hilhorst³, Alexander Vlaar⁴, Josien van Es¹, Peter Bonta¹

1 Department of Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam and Free University Amsterdam, The Netherlands
2 Department of Experimental Immunology (EXIM), Amsterdam University Medical Center, University of Amsterdam, The Netherlands
3 Department of Internal Medicine, Section of Nephrology, Location Meibergdreef Amsterdam UMC, University of Amsterdam, The Netherlands
4 Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands

DOI: 10.2478/jccm-2022-0004

Introduction: Diffuse alveolar haemorrhage (DAH) is a potentially life-threatening disease, characterized by diffuse accumulation of red blood cells within the alveoli. It can be caused by a variety of disorders. In case DAH results in severe respiratory failure, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be required. Since VV-ECMO coincides with the need for anticoagulation therapy, this results in a major clinical challenge in DAH patients with hemoptysis.
Case presentation: We report a patient case with severe DAH-induced acute respiratory failure and hemoptysis in need for VV-ECMO complicated by life-threatening membrane oxygenator thrombosis. The DAH-induced hemoptysis was successfully treated with local bronchoscopic recombinant factor VIIa (rFVIIa), allowing systemic anticoagulation to prevent further membrane oxygenator thrombosis. Neither systemic clinical side effects nor differences in the serum coagulation markers occured after applying recombinant factor VIIa (rFVIIa) treatment endobronchially.
Conclusion: This is, to our knowledge, the first case that reports the use of rFVIIa in a patient with DAH due to vasculitis and in need for VV-ECMO complicated by membrane oxygenator thrombosis.

Introduction: Silicone (polydimethylsiloxane) injections are used for cosmetic augmentation. Their use is associated with life-threatening complications such as acute pneumonitis, alveolar hemorrhage, and acute respiratory distress among others [1,2]. We report a case of a Hispanic woman who developed severe respiratory distress syndrome after gluteal silicone injections.
Case Presentation: A 44-year-old Hispanic female presented to the Emergency Department complaining of progressive dyspnea on exertion for two weeks. Chest imaging revealed patchy bibasilar airspace opacities of peripheral distribution. Labs were significant for leukocytosis, elevated PT, D-dimer, lactate dehydrogenase, and fibrinogen, concerning for COVID-19, however SARS-CoV-2 testing was negative multiple times. The patient later became encephalopathic, hypoxemic, and eventually required intubation. Further history uncovered that the patient had received illicit gluteal silicone injections a few days prior to her onset of symptoms. The patient was diagnosed with silicone embolism syndrome (SES) and initiated on high dose intravenous methylprednisolone [1].
Case Discussion: Patients from lower socioeconomic backgrounds utilize illicit services to receive silicone injections at minimal costs. This leads to dangerous outcomes. The serology and imaging findings observed in our case have similarities to the typical presentation of COVID-19 pneumonia making the initial diagnosis difficult. This case serves as a cautionary tale of the importance of thorough history taking in patients with concern for COVID-19.