A 52-year-old male with a personal history of smoking 10 cigarettes a day and a bicuspid aortic valve with normal systolic function was diagnosed.
One year before, she underwent surgery for acute diverticula with perforation and peritonitis, and four months after the surgery she developed a right femoralpopliteal deep vein thrombosis (DVT) that had been treated since then.
The study performed 3 months after the episode to rule out hypercoagulability syndrome showed a prothrombin time (PT) of 12.67 sec (VN 9-12 sec) IgG anticardiolipin type 12723 000 IgG antibodies, IgM-16 ml IgG type
Serum levels of antithrombin III, protein S and protein C were normal.
She presented with asthenia and intermittent fever of 38oC since a month before, and that in the 4 days prior to admission she had started with hemoptoic expectoration, dyspnea with moderate persistent efforts and fever.
Physical examination revealed a good general condition, with only a temperature of 38°C and no other relevant alterations except mental retardation.
Analytical analysis showed a hemoglobin level of 14.5 g/dl; 4,650 000/mm3; mean corpuscular volume 89.7 μmc; white blood cell count 8170/dl; and white blood cell count was normal.
The ESR was 50 mm in the first hour.
INR was 2.5, adjusted to acenocoumarol.
Biochemical tests and transaminase levels were normal.
Urinary sediment showed no abnormalities.
Rheumatoid factor, cryoglobulins, antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), normal antiSM-globulinSS basal and glomerular, antiperoxide, antihistone, anti-Ro.
Arterial FiO2 0.21: pH 7.53, pO2 65 mmHg, pCO2 39 mmHg.
The electrocardiogram was normal and the echocardiogram confirmed a bicuspid aortic valve without other alterations.
The chest X-ray showed bilateral alveolar infiltrates with normal cardiac silhouette.
Blood culture and sputum culture for bacteria and positive cultures were negative.
Ventilation/perfusion scintigraphy and computed angiotomography did not show data of pulmonary thromboembolism, so anticoagulant treatment was suspended and treatment with amoxicillin/clavulanic acid persisted with clinical improvement and disappearance of fever.
Bronchoscopy showed no endoscopic abnormalities.
The culture of the bronchoaspirate showed growth for non-positive bacteria and no malignant cells were observed in the cytology.
Pulmonary volumes and diffusion were normal.
After hospital discharge, the patient continues to have hemoptoic sputum.
A new computed axial tomography with high resolution slices (HRCT) reflects the presence of bilateral pulmonary infiltrates and ground glass.
A new bronchoscopy showed no intrabronchial alterations and bronchoalveolar lavage (BAL) showed 512 cells/ml: polymorphonuclear neutrophils 1%, polymorphonuclear eosinophils 1% and histiocytes 98%.
The dyeing with blue dyeing showed 80% of erythrocytes.
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In peripheral blood, the levels of anticardiolipin antibodies and lupus anticoagulant remained high.
With the described findings the patient was diagnosed with primary antiphospholipid syndrome and secondary pulmonary hemorrhage, restarting treatment with acenocoumarol and acetylsalicylic acid.
Occasional hemoptoic sputum samples were presented during one year of follow-up, but chest X-ray and pulmonary function (some areas of diffusion and arterial gases) remained normal, and only HRCT showed evidence of glass.
