Diffuse Alveolar Hemorrhage with Predominantly Right-sided Infiltration Resulting from Cardiac Comorbidities

Abstract

Objective Radiographic findings in patients with diffuse alveolar hemorrhage (DAH) are usually diffuse and bilateral, although they may occasionally be unilateral. The clinical aspects of predominantly unilateral DAH are not well known. Therefore, our objective was to describe the clinical characteristics of predominantly right-sided DAH. Methods We retrospectively reviewed data for 460 bronchoalveolar lavage fluid (BALF) samples collected between January 2009 and July 2013. Patients who presented with increasingly hemorrhagic BALF were diagnosed with DAH, and unilateral predominance was determined based on the degree of infiltration on chest radiographs. Results The records of 54 patients with DAH were evaluated. The leading etiology was pulmonary congestion due to heart failure (n=15). The radiographs showed right-sided infiltration in 18 patients (33%), leftsided infiltration in six patients (11%) and bilateral infiltration in 30 patients (56%). Predominantly rightsided DAH was often caused by pulmonary congestion resulting from heart failure (10 of 18 patients). A multivariate logistic regression analysis revealed a previous history of cardiovascular disease to be the only significant predictor of right-sided DAH (OR 13.1, 95% CI 2.9-95.4). Conclusion Predominantly right-sided DAH is frequently caused by pulmonary congestion resulting from heart failure and is significantly related to comorbidities with cardiovascular disease.

Acute mitral valve regurgitation causing severe alveolar hemorrhage

“…Unilateral DAH is rare and is occasionally accompanied by heart failure, clotting disorder, and pneumonia. In a previous report, right‐sided DAH was frequently caused by pulmonary congestion resulting from heart failure 9 …”

Unilateral Diffuse Alveolar Hemorrhage Due to Selective Directionality of Mitral Regurgitant Jet in a Patient With Severe Aortic Stenosis

“…Approximately 90% of these patients had right-sided infiltrate [11]. As data regarding the occurrence of UDAH are scarce (mostly in the form of case reports), a diagnosis is often delayed or even missed, as was the case for our patient [12]. The following mechanisms have been proposed as the possible explanation for the preferential occurrence of right-sided DAH: (i) Directionality of the regurgitant flow: Severe mitral regurgitation is often present in this patient population.…”

“…This can occur in patients with an accessory RML pulmonary vein that drains to the left atrium in a venous confluence with RUL pulmonary vein. Unilateral infiltrate involving the left upper lobe has also been reported [12]. (ii) Inadequate lymphatic drainage of the right lung: the lymphatic drainage of the right and left lungs is accomplished by the right broncho-mediastinal trunk and thoracic duct, respectively.…”

“…The increased blood flow to the right side can cause vascular congestion and increase the propensity for UDAH [16]. (iv) Variation in pulmonary venous drainage: impaired venous return from the right lung may also be responsible for UDAH [12].…”

Diffuse Alveolar Hemorrhage Associated with Dilated Cardiomyopathy and Sleep Apnea Syndrome

“…Chronic heart failure increases pulmonary venous pressure, which might induce micro-vessel rupture, resulting in DAH ( 13 , 14 ). Interestingly, a recent study showed that cardiovascular diseases increased long-term mortality in patients with DAH ( 15 ), which is indicative of a close pathophysiologic relationship between them.…”