Key Points
- Confirm diagnosis early with highest‑yield tests (and do not let testing delay time‑critical therapy).
- Use explicit hemodynamic, respiratory, and neurologic targets to guide escalation.
- Document disposition criteria, follow‑up, and patient education before discharge.
Algorithm
- Stabilize oxygenation; consider early intubation with lung‑protective ventilation.
- Obtain STAT CBC, coags, renal panel; type and cross.
- Bronchoscopy with BAL to confirm DAH and exclude infection.
- Send ANCA (PR3/MPO) and anti‑GBM serologies; obtain urinalysis for RPGN.
- Start pulse methylprednisolone (1 g IV daily ×3) → high‑dose taper.
- ANCA vasculitis: add cyclophosphamide or rituximab.
- Anti‑GBM disease: add plasma exchange and cyclophosphamide.
- Prophylaxis: PJP, VTE; monitor for complications and relapse.
- Transition to maintenance immunosuppression after induction.
Clinical Synopsis & Reasoning
Hemoptysis (often absent), hypoxemia, and new diffuse alveolar infiltrates with falling hemoglobin; bronchoscopy with sequentially bloodier BAL confirms hemorrhage. Pulse‑dose IV steroids are first‑line; add cyclophosphamide or rituximab for ANCA vasculitis, and add plasma exchange for anti‑GBM disease or severe overlap; manage respiratory failure with lung‑protective ventilation.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions when predefined failure criteria are met. Define ICU, step‑down, and ward disposition triggers explicitly, and arrange specialty consultation early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitating factors
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Anemia/leukocytosis | Context‑specific | Trend response |
| BMP | Electrolytes/renal | Derangements common | Renal dosing/monitoring |
| Condition‑specific imaging | Per topic | Diagnostic hallmark | Do not delay with red flags |
| Bronchoscopy with BAL | Confirm DAH | Sequentially bloodier aliquots | Send cytology/serologies |
| ANCA and anti‑GBM serology | Etiology | PR3/MPO or anti‑GBM positive | Guides immunotherapy |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Methylprednisolone 1 g IV daily ×3 | Glucocorticoid | Hours | Induction of remission | Hyperglycemia, infection |
| Cyclophosphamide or Rituximab | Immunosuppression | Days–weeks | Treat ANCA vasculitis | Myelosuppression, infusion reactions |
| Plasma exchange (selected) | Immunotherapy | Immediate | Anti‑GBM disease/severe overlap | Access/bleeding risks |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy
Patient Education / Counseling
- Explain red flags, adherence, and the follow‑up plan; provide written instructions.
References
- See bibliography — Link