Diffuse alveolar haemorrhage

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Diffuse alveolar haemorrhage (DAH) is a subset of diffuse pulmonary haemorrhage 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.

Pathology

Blood tends to fill alveolar spaces asat multiple sites.

Aetiology

Causes include:

pulmonary vasculitides (particularly small vessel vasculitides): a pulmonary capillaritis is considered the most common underlying lesion associated with diffuse alveolar haemorrhage
- ANCA associated pulmonary vasculitides
- non-ANCA associated pulmonary vasculitides: Goodpasture syndrome
certain connective tissue disorders
- systemic lupus erythematosus ^2-3: considered commonest associated connective tissue disorder to result in diffuse alveolar haemorrhage
- mixed connective tissue disease ⁸
coagulative disorders
medications: excessive antiplatelet therapy ⁹
inhaled toxins
conditions causing back pressure
- mitral valve disease
  - mitral stenosis
  - mitral regurgitation
- pulmonary veno-occlusive disease
pulmonary haemorrhage complicating multifocal infection
pulmonary haemorrhage complicating diffuse alveolar damage
pulmonary haemorrhage complicating widespread pulmonary malignancy
post bone marrow transplantation ¹
pulmonary haemosiderosis
antiphospholipid syndrome ⁶

Radiographic features

Plain radiograph

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

CT

The HRCT pattern can vary with time of onset of the haemorrhage 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 apparent prominence of segmental and subsegmental bronchi, which has been referred to as the “dark bronchus sign"
2–3 days
- intralobular lines and smooth interlobular septal thickening superimpose on areas of ground-glass opacity
- may sometimes give rise to a crazy-paving pattern ¹⁰
- these can often resolve
between chronic recurrent bleeding events
- ill-defined centrilobular nodules
  - reflecting intra-alveolar accumulation of pulmonary macrophages
  - usually uniform in size (1-3 mm)
  - diffusely distributed
  - no zonal predominance
with severe repeated haemorrhage: may progress with features of interstitial fibrosis

Complications

Repeated episodes can lead to an organising pneumonia, collagen deposition in small airways and ultimately pulmonary fibrosis ^7-8.

-<p><strong>Diffuse alveolar haemorrhage (DAH) </strong>is a subset of <a href="/articles/diffuse-pulmonary-haemorrhage">diffuse pulmonary haemorrhage</a> 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.</p><h4>Pathology</h4><p>Blood tends to fill alveolar spaces as multiple sites.</p><h5>Aetiology </h5><p>Causes include:</p><ul>
+<p><strong>Diffuse alveolar haemorrhage (DAH) </strong>is a subset of <a href="/articles/diffuse-pulmonary-haemorrhage">diffuse pulmonary haemorrhage</a> 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.</p><h4>Pathology</h4><p>Blood tends to fill alveolar spaces at multiple sites.</p><h5>Aetiology </h5><p>Causes include:</p><ul>
-<a href="/articles/pulmonary-vasculitis">pulmonary vasculitides</a> (particularly <a href="/articles/small-vessel-vasculitides">small vessel vasculitides</a>): a pulmonary capillaritis is considered the most common underlying lesion associated with diffuse alveolar haemorrhage<ul>
+<a href="/articles/pulmonary-vasculitis">pulmonary vasculitides</a> (particularly small vessel vasculitides): a pulmonary capillaritis is considered the most common underlying lesion associated with diffuse alveolar haemorrhage<ul>
~~-<li><a href="/articles/mitral-stenosis">mitral stenosis </a></li>~~
+<li><a href="/articles/mitral-valve-stenosis-1">mitral stenosis </a></li>
-</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>The clinical context is crucial in image interpretation. The exact pattern may differ dependent on the underlying cause. In general, the typical feature on plain film during an acute diffuse alveolar haemorrhage is a diffuse infiltrative opacification pattern <sup>5</sup>. At times there may a slight predilection towards the mid zones <sup>5 </sup>with some apical sparing <sup>8</sup>.</p><h5>CT</h5><p>The <a title="HRCT lung" href="/articles/high-resolution-ct">HRCT</a> pattern can vary with time of onset of the haemorrhage and the clinical context is crucial in image interpretation:</p><ul>
+</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>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 haemorrhage is a diffuse infiltrative opacification pattern <sup>5</sup>. At times there may a slight predilection towards the mid zones <sup>5 </sup>with some apical sparing <sup>8</sup>.</p><h5>CT</h5><p>The <a href="/articles/high-resolution-ct">HRCT</a> pattern can vary with time of onset of the haemorrhage and the clinical context is crucial in image interpretation:</p><ul>
-<li>can range from lobular or lobar areas of <a href="/articles/ground-glass-opacification">ground-glass opacities</a> to predominant <a title="Lung consolidation" href="/articles/air-space-opacification-1">consolidation</a> </li>
+<li>can range from lobular or lobar areas of <a href="/articles/ground-glass-opacification-1">ground-glass opacities</a> to predominant <a href="/articles/air-space-opacification-1">consolidation</a> </li>

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