Life-Threatening Diffuse Alveolar Hemorrhage as an Initial Presentation of Microscopic Polyangiitis: COVID-19 as a Likely Culprit

Abstract

Microscopic polyangiitis (MPA) is a systemic small vessel vasculitis but it is rare to see life-threatening diffuse alveolar hemorrhage (DAH) in MPA as an initial presentation. MPA more commonly presents with renal involvement and develops pulmonary manifestations later in the disease course. Our patient is a 77year-old female with a recent history of recovered COVID-19 infection who presented with sudden onset fever, dyspnea, and hemoptysis for three days. She was diagnosed with MPA because of the new-onset DAH, a strongly positive myeloperoxidase (MPO) antibody, and the low likelihood of another etiology. The patient was treated with pulse-dose steroids and plasmapheresis while being on mechanical ventilation. This case highlights the importance of the prompt recognition of DAH as an initial presentation of MPA and illustrates the possible role of COVID-19 in inciting autoimmune conditions.

New Onset of Autoimmune Diseases Following COVID-19 Diagnosis

“…However, if a patient with COVID-19 and kidney injury presents with abnormalities in the urinalysis suggestive of glomerular injuries such as red blood cell casts or dysmorphic erythrocytes, or if kidney injury presents after resolution of the infection, AAV should be considered in the differential diagnosis and a kidney biopsy should be performed [ 53 ]. In the same vein, COVID-19 may rarely present with diffuse alveolar hemorrhage and in such cases, AAV or anti-GMB disease should be ruled out [ 141 , 142 ].…”

A Case of Diffuse Alveolar Hemorrhage With COVID-19 Vaccination

“…It directs toward a strong indication of cross-reaction between SARS-CoV-2 proteins and a variety of tissue antigens beyond just pulmonary tissue, which could lead to autoimmunity against connective tissue and the cardiovascular, gastrointestinal, and nervous systems [13]. This molecular mimicry could be associated with the development of autoimmune disease in the long term in COVID-19 infected patients or could occur after the vaccination too [14][15].…”

Vasculitis flare after COVID-19: report of two cases in patients with preexistent controlled IgA vasculitis and review of the literature

“…We identified 16 reports describing 18 cases (12 women/6 men) of new-onset ANCA-associated vasculitis in COVID-19 patients and presumably related to this disease [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. The main characteristics of these cases are presented in Table 1.…”

“…All patients received steroids and most cases were treated with immunosuppressive combined therapy: nine with rituximab, nine with plasmapheresis, six with cyclophosphamide (CYC), two with intravenous immunoglobulins (IVIG), one with mycophenolate mofetil (MMF) and the other one with azathioprine. In the follow-up, most patients responded well to glucocorticoids and immunosuppressive agents but two patients died as a result of the disease (both with diffuse alveolar hemorrhage) [10,20]. Another patient died as a consequence of multiple infections [23].…”