26683938 Visualization

A 69 Age - year Age - old Age woman Sex with a history of hypertension Disease_disorder presented Clinical_event with a generalized Detailed_description petechial Detailed_description rash Sign_symptom and shortness Sign_symptom of Sign_symptom breath Sign_symptom of 3 Duration days Duration duration Duration .
The rash Coreference was nonpruritic Detailed_description , painless Detailed_description , and started at the thighs Biological_structure , but rapidly disseminated to the rest Biological_structure of Biological_structure the Biological_structure body Biological_structure .
She had progressive Detailed_description dyspnea Sign_symptom on exertion Detailed_description , with a significant decrease Lab_value in exercise Diagnostic_procedure tolerance Diagnostic_procedure .
She denied fever Sign_symptom , headache Sign_symptom , dizziness Sign_symptom , hemoptysis Sign_symptom , or bleeding Sign_symptom from anywhere Biological_structure .
There was no History history History of History new History drug History use, History unusual Activity food Activity intake Activity , contact History with History any History sick History persons, History or History recent History travel Activity .
Her only medication was enalapril Medication , which she had been taking for several Duration years Duration .
The patient denied History any History use History of History recreational Activity drugs Activity , tobacco Activity , or History alcohol Activity .
On admission, she was afebrile Sign_symptom , normotensive Sign_symptom with mild Severity tachypnea Sign_symptom ( respiratory Diagnostic_procedure rate Diagnostic_procedure of 22 Lab_value breaths Lab_value per Lab_value minute Lab_value ).
Physical Diagnostic_procedure examination Diagnostic_procedure revealed scattered petechial Detailed_description rash Sign_symptom , more prominent in lower Biological_structure extremities Biological_structure , nonpalpable Detailed_description and nonblanching Detailed_description .
Chest Diagnostic_procedure auscultation Diagnostic_procedure revealed coarse Detailed_description crackles Sign_symptom bilaterally Detailed_description .
Cardiovascular Biological_structure , abdominal Biological_structure , and neurological Detailed_description examinations Diagnostic_procedure were normal Lab_value .
There was no palpable lymphadenopathy Sign_symptom or visceromegaly Sign_symptom .
Laboratory Diagnostic_procedure examination Diagnostic_procedure revealed thrombocytopenia Sign_symptom ( platelets Diagnostic_procedure 7000/μL Lab_value ), anemia Sign_symptom ( hemoglobin Diagnostic_procedure 10.8 Lab_value   mg/dL Lab_value and hematocrit Diagnostic_procedure 34% Lab_value ), and leukocytosis Sign_symptom ( white Diagnostic_procedure blood Diagnostic_procedure cells Diagnostic_procedure [ WBCs Diagnostic_procedure ] 11,600/μL Lab_value ).
The coagulation Diagnostic_procedure profile Diagnostic_procedure was normal Lab_value , which excluded disseminated Disease_disorder intravascular Disease_disorder coagulation Disease_disorder .
Arterial Diagnostic_procedure blood Diagnostic_procedure gas Diagnostic_procedure on ambient Detailed_description air Detailed_description revealed a partial Diagnostic_procedure pressure Diagnostic_procedure of Diagnostic_procedure oxygen Diagnostic_procedure ( PaO2 Diagnostic_procedure ) of 64 Lab_value Torr Lab_value , a partial Diagnostic_procedure pressure Diagnostic_procedure of Diagnostic_procedure carbon Diagnostic_procedure dioxide Diagnostic_procedure ( PaCO2 Diagnostic_procedure ) of 37 Lab_value Torr Lab_value ( pH Diagnostic_procedure 7.45 Lab_value ), and an increased Lab_value alveolar Diagnostic_procedure - arterial Diagnostic_procedure gradient Diagnostic_procedure ( 44 Lab_value Torr Lab_value ).
Diffuse Detailed_description airspace Sign_symptom consolidation Sign_symptom was found on chest Biological_structure roentgenogram Diagnostic_procedure (Fig.1A).
Computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) of the chest Biological_structure showed diffuse Detailed_description ground Texture glass Texture alveolar Biological_structure opacities Sign_symptom and patchy Detailed_description infiltrates Sign_symptom (Fig.1B, C).
She was started on broad Detailed_description - spectrum Detailed_description antibiotics Medication and received intravenous Administration steroids Medication .
Peripheral Diagnostic_procedure smear Diagnostic_procedure showed giant Sign_symptom platelets Sign_symptom and occasional Detailed_description small Detailed_description platelet Sign_symptom clumps Sign_symptom , with no schistocytes Sign_symptom .
A flexible Diagnostic_procedure fiber Diagnostic_procedure - optic Diagnostic_procedure bronchoscopy Diagnostic_procedure ( FFB Diagnostic_procedure ) showed normal Lab_value mucosa Diagnostic_procedure with no endobronchial Biological_structure lesions Sign_symptom (Fig.2A).
Serial aliquots of BAL Diagnostic_procedure fluid Diagnostic_procedure ( BALF Diagnostic_procedure ) turned more hemorrhagic Sign_symptom , confirming the bronchoscopic diagnosis of DAH Disease_disorder (Fig.2B).
Cytology Diagnostic_procedure of BALF Coreference showed a substantial amount of hemosiderin Detailed_description - laden Detailed_description macrophages Sign_symptom , further supporting the diagnosis.
All BALF Coreference cultures Diagnostic_procedure and gram Diagnostic_procedure stains Diagnostic_procedure were negative Lab_value .
The patient remained with severe Severity thrombocytopenia Sign_symptom and hypoxia Sign_symptom despite steroids Medication and platelets Medication transfusion Medication .
High Dosage doses Dosage of pulse steroids Medication and intravenous Administration immunoglobulins Medication (IVIGs) were added with clinico Detailed_description - radiological Detailed_description improvement Sign_symptom .
A bone Diagnostic_procedure marrow Diagnostic_procedure aspirate Diagnostic_procedure was morphologically Lab_value normal Lab_value .
Additional laboratory Diagnostic_procedure studies Diagnostic_procedure failed Lab_value to Lab_value reveal Lab_value an Lab_value etiology Lab_value for secondary thrombocytopenia Sign_symptom (Table ​1), supporting the diagnosis of ITP Disease_disorder .
Steroids Medication were gradually tapered.
Repeat chest Biological_structure radiograph Diagnostic_procedure showed almost complete resolution of bilateral Detailed_description infiltrates Sign_symptom (Fig.3).
Platelet Diagnostic_procedure count Diagnostic_procedure returned to normal Lab_value by week Date 10 Date after admission without any additional Therapeutic_procedure therapies Therapeutic_procedure (Fig.4).