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.
- pulmonary vasculitides (particularly small vessel vasculitides): a pulmonary capillaritis is considered the most common underlying lesion associated with diffuse alveolar hemorrhage
- certain connective tissue disorders
- coagulative disorders
- medications: excessive antiplatelet therapy 9
- inhaled toxins
- conditions causing back pressure
- pulmonary hemorrhage complicating multifocal infection
- pulmonary hemorrhage complicating diffuse alveolar damage
- pulmonary hemorrhage complicating widespread pulmonary malignancy
- post bone marrow transplantation 1
- pulmonary hemosiderosis
- antiphospholipid syndrome 6
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:
- 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
- ill-defined centrilobular nodules
- with severe repeated hemorrhage: may progress with features of interstitial fibrosis
Repeated episodes can lead to organising pneumonia, collagen deposition in small airways and ultimately pulmonary fibrosis 7,8.
- 1. Witte RJ, Gurney JW, Robbins RA et-al. Diffuse pulmonary alveolar hemorrhage after bone marrow transplantation: radiographic findings in 39 patients. AJR Am J Roentgenol. 1991;157 (3): 461-4. AJR Am J Roentgenol (citation) - Pubmed citation
- 2. Zamora MR, Warner ML, Tuder R et-al. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome. Medicine (Baltimore). 1997;76 (3): 192-202. Medicine (Baltimore) (link) - Pubmed citation
- 3. Makino Y, Ogawa M, Ueda S et-al. CT appearance of diffuse alveolar hemorrhage in a patient with systemic lupus erythematosus. Acta Radiol. 1993;34 (6): 634-5. - Pubmed citation
- 4. Specks U. Diffuse alveolar hemorrhage syndromes. Curr Opin Rheumatol. 2001;13 (1): 12-7. Curr Opin Rheumatol (link) - Pubmed citation
- 5. Cortese G, Nicali R, Placido R et-al. Radiological aspects of diffuse alveolar haemorrhage. Radiol Med. 2008;113 (1): 16-28. doi:10.1007/s11547-008-0229-x - Pubmed citation
- 6. Deane KD, West SG. Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review. Semin. Arthritis Rheum. 2005;35 (3): 154-65. doi:10.1016/j.semarthrit.2005.05.006 - Pubmed citation
- 7. Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;75 (4): 258, 260, 264-5 passim. Cleve Clin J Med (link) - Pubmed citation
- 8. Marten K, Schnyder P, Schirg E et-al. Pattern-based differential diagnosis in pulmonary vasculitis using volumetric CT. AJR Am J Roentgenol. 2005;184 (3): 720-33. AJR Am J Roentgenol (citation) - Pubmed citation
- 9. Ikeda M, Tanaka H, Sadamatsu K. Diffuse alveolar hemorrhage as a complication of dual antiplatelet therapy for acute coronary syndrome. Cardiovasc Revasc Med. 12 (6): 407-11. doi:10.1016/j.carrev.2011.03.003 - Pubmed citation
- 10. Johkoh T, Itoh H, Müller NL et-al. Crazy-paving appearance at thin-section CT: spectrum of disease and pathologic findings. Radiology. 1999;211 (1): 155-60. Radiology (citation) - Pubmed citation