(1170) A Case of Diffuse Alveolar Hemorrhage Leading to the Diagnosis of Rheumatoid Arthritis

Introduction: Diffuse alveolar hemorrhage (DAH) is a rare, often fatal complication of rheumatoid arthritis (RA), characterized by intra-alveolar bleeding leading to acute respiratory distress syndrome (ARDS). We present a case of a 68-year-old man with dyspnea and hemoptysis, where investigations revealed DAH leading to a diagnosis of RA. Despite prompt treatment, respiratory failure and death ensued, emphasizing the importance of considering autoimmune diseases in ARDS.

Description: A 68-year-old man without prior RA history presented with a week of worsening dyspnea and hemoptysis. He was hypoxemic and in respiratory distress, with diffuse bilateral crackles on lung auscultation. Laboratory tests showed pancytopenia, elevated inflammatory markers, and acute kidney injury, raising suspicion for an underlying autoimmune process. Chest X-ray revealed widespread infiltrates. CT imaging showed patchy ground-glass opacities and consolidations consistent with DAH. RA was diagnosed based on positive rheumatoid factor and anti-CCP antibodies. Despite aggressive treatment with methylprednisolone and cyclophosphamide, he deteriorated, requiring mechanical ventilation, with eventual death in the ICU.

Discussion: DAH is a rare yet severe complication of RA, likely due to immune-mediated injury to the lung microcirculation. Our case illustrates how DAH can be a presenting finding of RA. Timely recognition is crucial due to rapid progression to respiratory failure and high mortality. High-dose corticosteroids are first-line treatment, followed by immunosuppressive drugs for sustained disease control. ICU monitoring is vital to evaluate therapy response and manage complications. Prognosis depends on pulmonary involvement, disease severity, and treatment onset. Long-term management requires a multidisciplinary approach to optimize disease control and minimize relapse risk.

DAH is a rare indicator of underlying autoimmune disease. High-dose corticosteroids and immunosuppressive agents aim to suppress immune-mediated injury and halt disease progression. Further research is necessary to better understand the pathophysiology of DAH in RA and explore novel therapeutic strategies. Increased awareness can enhance early diagnosis and management, ultimately improving patient outcomes.