Diffuse alveolar hemorrhage

Last revised by Dr Daniel J Bell on 13 Jul 2021

Diffuse alveolar hemorrhage (DAH) is a subset of diffuse pulmonary hemorrhage when bleeding is diffuse and directly into the alveolar spaces. It can occur in a vast number of clinical situations and can be life-threatening.

Blood tends to fill alveolar spaces at multiple sites.

Causes include:

The clinical context is crucial in image interpretation. The exact pattern may differ depending on the underlying cause. In general, the typical feature on plain film during an acute diffuse alveolar hemorrhage is a diffuse infiltrative opacification pattern 5. At times there may a slight predilection towards the mid zones 5 with some apical sparing 8.

The HRCT pattern can vary with time of onset of the hemorrhage and the clinical context is crucial in image interpretation:

  • acute phase
    • can range from lobular or lobar areas of ground-glass opacities to predominant consolidation 
    • ground-glass opacity is generated by subtotal alveolar filling with blood and is accompanied by the apparent prominence of segmental and subsegmental bronchi, which has been referred to as the “dark bronchus sign"
  • 2–3 days
  • between chronic recurrent bleeding events
    • ill-defined centrilobular nodules  
      • reflecting an intra-alveolar accumulation of pulmonary macrophages 
      • usually uniform in size (1-3 mm) 
      • diffusely distributed
      • no zonal predominance
  • with severe repeated hemorrhage: may progress with features of interstitial fibrosis

Repeated episodes can lead to organizing pneumonia, collagen deposition in small airways and ultimately pulmonary fibrosis 7,8.

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Cases and figures

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