Correct!
1. Bronchoscopy with sequential bronchoalveolar lavage
Bronchoalveolar inspection and sequential bronchoalveolar lavage (BAL) is the test of choice. Bronchoscopy with BAL will be useful to rule out infections, inflammatory processes, and diffuse alveolar hemorrhage (DAH). Although indicated, lupus serology would most likely only confirm the diagnosis. Cultures would be unlikely to change her clinical course. Needle biopsy and VATS lung biopsy are overly aggressive and not indicated at this time.
The bronchoscopy was done at bedside following the American Thoracic Society guidelines (2). It showed a bloody fluid throughout the airways. After wedging the bronchoscope in the right middle lobe, a lavage with normal saline was performed with return of bloody secretions. Subsequent aliquots of lavage fluid returned with progressively bloody characteristics which was diagnostic of DAH (2). Additionally, a neutrophil predominance was found in the cellular component and is common in cases of DAH (2). For patients who can complete pulmonary function testing, another sensitive marker for DAH is a sequential increase in diffusing capacity for carbon monoxide (DLCO).
It is important to distinguish DAH from other pulmonary manifestations of SLE such as lupus pneumonitis, lupus pleuritis, pulmonary embolism secondary to circulating lupus anticoagulant, pulmonary hypertension. To rule out the above mentioned causes and evaluate the presence of other collagen vascular disease, several lab tests were ordered which are below:
Positive:
- ANA titer 1:2560, speckled pattern
- Anti-ribonucleoprotein >8
- Anti-Smith >8
- Anti-SSA 32.
- Complement C3-26 mg/dL,
- Complement C4-5.8 mg/dL
Negative:
- Anti-glomerulo-basement-membrane
- Anti-neutrophil cytoplasmic antibody
- Anti-double-stranded DNA
- Blood cultures
- Respiratory cultures
- Acid fast bacilli culture
- ß-D glucan assay
- HIV
- CT angiogram of chest: negative for PE
- Echocardiogram: Negative for pulmonary hypertension with normal EF
Is diffuse alveolar hemorrhage a frequent pathology in SLE? (Click on the correct answer to proceed to the fourth of five panels)