Diffuse alveolar haemorrhage mimicking fluid overload in a patient with immune thrombocytopenia and chronic kidney disease

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Abstract
Diffuse alveolar haemorrhage is an uncommon but life-threatening cause of acute hypoxaemic respiratory failure and may closely mimic pulmonary oedema in patients with advanced chronic kidney disease. A man in his 50s with stage 5 chronic kidney disease receiving maintenance haemodialysis and immune thrombocytopenia treated with a tapering dose of oral prednisolone (30 mg/day) presented with minor haemoptysis followed by rapidly progressive breathlessness. He was severely hypoxaemic on arrival. Laboratory evaluation revealed thrombocytopenia and a progressive decline in haemoglobin levels. The absence of elevated jugular venous pressure and peripheral oedema, together with preserved left ventricular systolic function on transthoracic echocardiography, argued against cardiogenic pulmonary oedema. High-resolution CT of the chest showed bilateral ground-glass opacities with patchy consolidation. In the absence of clinical evidence of infection and with negative autoimmune screening, a clinicoradiological diagnosis of diffuse alveolar haemorrhage secondary to bleeding diathesis was made. The patient improved with non-invasive ventilation, platelet transfusion and nebulised tranexamic acid without invasive procedures. This case highlights an important emergency diagnostic pitfall: bilateral infiltrates in chronic kidney disease are not always caused by fluid overload.

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