Medical Image of the Week: DAH

 

Figure 1. Portable CXR (A) and CT (B) showing diffuse infiltrates of unclear etiology.

Figure 2. Progressively bloodier lavage indicative of pulmonary hemorrhage syndrome.

A 59 year old female was admitted to the ICU with hypoxemic respiratory failure and a clinical picture of ARDS (Figure 1), requiring intubation and mechanical ventilation. She underwent bone marrow and renal transplantation several years prior for multiple myeloma and myeloma kidney, respectively. She had been restarted on lenalidomide one month prior to presentation.  She was also taking tacrolimus, mycophenolate, prophylactic antimicrobials, warfarin for deep venous thrombosis, and aspirin for coronary artery disease. Emergent bronchoscopy with bronchoalveolar lavage revealed progressively bloodier specimens (Figure 2) consistent with diffuse alveolar hemorrhage (DAH). Further work-up was negative for vasculitis. Her lenalidomide, anticoagulation, and trimethoprim/sulfamethoxazole was stopped. She was started on high dose steroids and improved over 2 weeks.

Sage P. Whitmore, MD; Candy Wong, MD; James L. Knepler, MD and Carmen Luraschi-Monjagatta, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Whitmore SP, Wong C, Knepler JL, Luraschi-Monjagatta C. Medical image of the week: DAH. Southwest J Pulm Crit Care 2013;6(3):129. PDF

Medical Image of the Week: Trousseau’s Sign

Figure 1. Metacarpophalangeal joint flexion, extension of the distal interphalangeal and proximal interphalangeal joints and finger adduction (Trousseau’s sign) during blood pressure measurement.

A 22 year old woman was admitted for numbness and tingling of her hands, feet and face 72 hours after total thyroidectomy for a nonfunctional goiter. Initial ionized calcium was 3.2 mg/dL and magnesium 1.2 mg/dL. The patient received 1 ampule of calcium gluconate (90 mg calcium) and 2 mg MgSO4 intravenously.  The next day a rapid response was called.  The patient was lethargic, and said she felt very ill, although she could not be more specific.  Her ionized calcium was 4.3 mg/dL. She demonstrated Trousseau's sign when her blood pressure was measured with an arm cuff (Figure 1). She also had a positive Chvostek's sign.  She did not have stridor or papilledema. She received another ampule of calcium gluconate and 2 mg MgSO4 intravenously and was transferred to the ICU, where she had a 60 sec duration generalized seizure.  A calcium gluconate infusion was started, that delivered 990 mg calcium as calcium gluconate over 20 hours.  Oral calcium and vitamin D supplements were started.  PTH levels confirmed hypoparathyroidism, likely secondary to a surgical mishap at the time of thyroidectomy. 

Emad Wissa MD and Robert A. Raschke MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

Reference as: Wissa E, Raschke RA. Medical image of the week: Trousseau's sign. Southwest J Pulm Crit Care. 2013;6(3):128. PDF