Rare cause of respiratory failure in a young woman: isolated diffuse alveolar haemorrhage requiring extracorporeal membrane oxygenation.

A previously healthy 21-year-old young woman presented with worsening dyspnoea and haemoptysis. Imaging was suggestive of widespread pulmonary haemorrhage. There was no other organ system involvement in particular no evidence of renal involvement. Raised antimyeloperoxidase titres allowed diagnosis of isolated diffuse alveolar haemorrhage (DAH) secondary to microscopic polyangiitis (MPA). The patient rapidly deteriorated with worsening respiratory failure despite invasive mechanical ventilation and required extracorporeal membrane oxygenation (ECMO). This maintained the patient long enough to allow aggressive therapy in the form of immunosuppression and plasma exchange. She made a remarkable recovery and is asymptomatic 2 years on. Isolated DAH in the absence of renal disease is an atypical presentation of MPA and can lead to diagnostic uncertainty. A literature review reveals increasing reports of successful use of ECMO in severe DAH due to pulmonary vasculitis. Despite this, the need for systemic anticoagulation in the presence of pre-existing haemorrhage remains a challenging dilemma.

The unmasking of a pyopericardium.

Pyopericardium is a rare condition with a high mortality rate in which infection propagates in the pericardial space, leading to a pus filled pericardial effusion and cardiac tamponade, which can cause cardiogenic shock and death. We present a case of a previously healthy woman of 52, who was admitted with a severe lower respiratory tract infection that eventually led to a pyopericardium. The diagnosis of pyopericardium was delayed due to masking of symptoms by her underlying infection, sepsis and an upper gastrointestinal bleed that the patient suffered during the admission, requiring an emergency gastroscopy. The pyopericardium was considered when ST elevation was seen on an ECG and an ECHO discovered a large pericardial effusion causing tamponade. An emergency pericardiocentesis drained frank pus. Treatment with intravenous antibiotics, frequent pericardial drainage and a pericardectomy led to an excellent outcome, and a full recovery.

The importance of "His" story.

A 73-year-old previously healthy man presented with a 3-day history of rigours, abdominal pain, diarrhoea, haemoptysis and myalgia. He had not been abroad recently, but reported being a farmer and having had a recent rat infestation. Laboratory investigations revealed acute kidney failure, deranged liver function tests, raised C reactive protein and a chest CT revealed bilateral ground-glass opacities. This presentation was consistent with icteric leptospirosis which was confirmed by serological testing. Following haemofiltration and the administration of antibiotics the patient made an excellent recovery from his leptospirosis.