3. High dose corticosteroids

The patient has an acute diffuse process involving both lungs, is requiring oxygen to maintain her PaO2, and the tempo of her disease is one of rapid worsening. Therfore, admission to the intensive care unit is appropriate. Computerized CT of the chest can more acurately define the extent of the process and may suggest an etiology. Coccidioidomycosis serology is appropriate in areas where Valley Fever is endemic such as Arizona. Bronchoscopy will be necessary to establish a diagnosis. Corticosteroids might be appropriate but not until a steroid responsive disease process is identified.

A chest CT was performed (Figure 2).

Figure 2. Computed Tomography with contrast of the chest

Bronchoscopy showed multiple areas of capillary hemorrhage throughout the glottis and tracheobronchial tree. Bronchoalveolar lavage of the right middle lobe showed progressively bloodier returns (Figure 3). 

Figure 3. Aliquots from the returns obtained by bronchoalveolar lavage from another patient. The initial return is relatively clear (far left) but the returns became progressively bloodier.

Which of the following have been associated with similar progressively bloodier bronchoalveolar returns?

  1. Systemic lupus erythematosis
  2. Mitral stenosis
  3. Excess anticoagulation
  4. Crack cocaine inhalation
  5. All of the above

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