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Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition associated with many disorders. Here, we report a case of 59-year-old female who had diffuse alveolar hemorrhage associated with methimazole. She had been treated with methimazole for two weeks due to the recurrence of Grave's disease, before visiting the emergency room. She had to be intubated on the 3rd day of hospitalization because of unabated massive hemoptysis and rapid progression of diffuse alveolar infiltration on chest radiographs. Since her clinical condition improved substantially after cessation of methimazole and steroid pulse therapy, she was extubated on the 9th day of hospitalization and then discharged. After discharge, DAH did not recur with cessation of steroid and she had radioactive iodine therapy for her Grave's disease. This was a rare and interesting case of life-threatening DAH associated with cytoplasmic-antineutrophil cytoplasmic antibody and methimazole.
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Figure 1.
Diffuse consolidation and ground glass opacity are observed on both lungs of initial chest X-ray (A). Initial chest computed tomography shows bilateral involvement of diffuse ground glass opacity, interlobular septal thickening, and multifocal consolidations (B).
Figure 2.
Chest X-rays at intensive care unit showed gradual improvement. On hospital day 3 mechanical ventilator care and steroid pulse therapy were started (A). On hospital day 5, both lung consolidations were improved (B). On hospital day 9, extubation was done (C). On hospital day 13, the patient was discharged from the hospital (D).
Figure 3.
Bronchoscopy (A: main carina, B: left, second car-ina, C: right upper lobe branch) performed on hospital day 5 showed no endobronchial lesion.
Table 1.
Summary of cases of diffuse alveolar hemorrhage with MPO-ANCA associated with anti-thyroid drugs
| Drug | Race | Gender/ Age (yr) | Other feature | Anti-MPO | Anti-PR3 | Tx | Outcome | Reference |
|---|---|---|---|---|---|---|---|---|
| MMI | Korean | F/59 | - | + | S | Improved | Present case | |
| PTU | Caucasian | F/27 | Athralgia, | + | SP | Improved | Ortiz-Diaz et al.∗ | |
| renal failure | ||||||||
| PTU | Japanese | F/69 | - | + | S | Improved | Wakabayashi et al.∗ | |
| PTU/MMI | Chineses | F/44 | Hematuria | + | S | Improved | Lau et al. [6] | |
| PTU | Korean | Pregnant F/25 | GN | + | S | Improved | Kang et al.∗ | |
| CMZ | Spanish | F/52 | GN | + | SC | Improved | Calañas-Continente et al.∗ | |
| PTU | NA | F/12 | - | + | S | Improved | Pirot et al.∗ | |
| PTU | Japanese | F/54 | Hematuria | + | S | Improved | Nakamori et al.∗ | |
| PTU | Japanese | F/59 | - | + | + | - | Improved | Yamauchi et al.∗ |
| PTU | Japanese | F/66 | Hematuria | + | S | Improved | Katayama et al. [11] | |
| PTU | Caucasian | F/33 | - | + | SC | Died | Seligman et al.∗ | |
| MMI | Chinese | F/18 | Skin, nerve | + | SP | Improved | Tsai et al. [10] | |
| PTU | NA | Pregnant F/23 | GN | + | SP | Improved | Dhillon et al.∗ | |
| PTU | Japanese | F/44 | Hematuria | + | - | Improved | Ohtsuka et al.∗ | |
| PTU | NA | F/39 | Arthritis | + | - | Improved | Romas et al.∗ |
MPO: myeloperoxidase, ANCA: anti-neutrophil cytoplasmic antibody, PR3: proteinase 3, Tx: treatment, MMI: methimazole, PTU: propylthiouracil, CMZ: carbimizole, F: female, GN: glomerulonephritis, S: steroid, P: plasmapheresis, C: cyclophosphamide, NA: not available.
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