Alveolar hemorrhage in a case of fat embolism syndrome: A case report with short systemic review
A 25-year-old man was referred to us three days post road traffic accident. He was found to have open fracture shaft of left femur and fracture condyle of left humerus. There was no associated history of loss of consciousness, vomiting, convulsions or any bleed. Intra medullary nailing was done for fracture femur under general anesthesia in a peripheral hospital. Intra-operative and immediate post-operative period were uneventful. Within next 18 hours he developed altered sensorium and became restless. He was hypotensive and shortly became breathless and hypoxic. He was intubated and mechanically ventilated. Endotracheal bleed was detected post intubation. He was transferred to our center for further management. On evaluation in emergency department, he was found to be drowsy, restless, hypotensive, and there were signs of pulmonary hemorrhage in the form of blood stained endotracheal secretion with hypoxia. There were no obvious petechial rashes apart from small hemorrhagic spots in bilateral conjunctiva. Initial resuscitation was done and he was started on noradrenalin infusion in view of hypotension. Fiberoptic bronchoscopy showed blood in trachea and bilateral tracheobronchial tree. Bronchoalveolar lavage fluid was hemorrhagic suggestive of alveolar hemorrhage. Initial laboratory parameters showed: Hemoglobin 8.4 gm/dl, total leucocyte count 11300/cc, platelet count 80000/cc. Renal functions were deranged with serum urea 38 mg/dl and serum creatinine 1.2 mg/dl. His liver function tests showed serum billirubin 2.1 mg/dl (direct 1.0 mg/dl), SGOT/SGPT 235 and 114 IU/L. His serum lactate level was 2.6 mmol/dl. Initial arterial blood gas analysis showed, pH 7.37, PaCO2 63.5 mm Hg, PaO2 70.8, SaO2 93% with FiO2 of 1. X-ray chest was consistent with bilateral diffuse alveolar opacities consistent with ARDS. Other investigations include Serum d-Dimer 4.3 (Normal 0.063–0.245 mg/dl), Anti-CCP antibodies 0.43 (Normal < 5 RU/ml), ANA (Immunofluroscence) negative at 1:100 dilutions, PR-3ANCA (ELISA) 1.5 IU/ml (Normal < 6 u/ml). Bronchoalveolar lavage fluid showed numerous debris laden alveolar macrophages and Pearl′s stain was suggestive of intracellular positivity. Urine examination for fat globules was negative. His serum creatinine phosphokinase was 691IU/L. EEG showed delta-theta coma pattern suggestive of modest encephalopathy.\nOn presentation there was evidence of subcutaneous emphysema with X-ray chest showing signs of pneumomediastenum. Initial high resolution computed tomography (HRCT) chest scan showed confluencing air space opacity with ground glass densities and interlobar septal thickening involving bilateral lung fields suggestive of acute respiratory distress syndrome (ARDS) []. He was electively ventilated for next three days, intercostal drain was placed in view of pneumomediastenum. Subcutaneous emphysema gradually subsided and elective tracheostomy was done on 7th day of admission. Repeat HRCT chest on day 6 revealed patchy ill defined air space opacity in bilateral lower lobes with ground glassing in bilateral upper and middle lobes. Right pneumothorax, pneumo mediastenum, excessive subcutnaneous emphysema. ARDS changes in bilateral lung fields were significantly reduced []. His neurological status gradually improved over next 5 days and was put on T piece on 12th day, which he tolerated well. He underwent fixation of fracture humerus condyle, which was uneventful. He was decannulated on 15th day of admission and discharged on 18th day.