Diffuse alveolar hemorrhage in pediatric hematopoietic cell transplant patients

Objective. Diffuse alveolar hemorrhage (DAH) is defined as a syndrome of hypoxia, dyspnea, infiltrates on chest radiograph, and bloody fluid on successive bronchoalveolar lavages without apparent infection. Minimal experience has been reported with DAH after hematopoietic cell transplant (HCT) in children. We reviewed the incidence, management and outcome of DAH in a pediatric HCT population. Methods. Retrospective review of 138 patients undergoing allogeneic (n = 89) or autologous (n = 49) HCT at a referral children's medical center between January 1996 and April 2000. Results. Seven (5.1%) of 138 patients met criteria for DAH; all were allogeneic recipients. Mean age of DAH patients was 11 years (range: 1.4-15.2). Median onset of DAH following HCT was day 24 (range: 10-50), median day of engraftment day 20 and white blood cell count 0.54 × 10⁹/L (range: <0.1-7.03), with no difference between survivors and nonsurvivors. All patients developed clinical respiratory failure and 6 required intubation, with PaO₂/fraction of inspired oxygen <200. Patients were intubated a median of 12 days (range: 1-75). All patients experienced >1 episode of bleeding and 3 patients required reintubation after successful extubation resulting from recurrent DAH. Bronchoalveolar lavage fluid cultures were negative for viruses, bacteria and fungi. All DAH patients received steroids. Three patients died with progressive pulmonary failure and other organ system involvement. Four of 7 DAH patients (57%) survived to discharge, but 3 died from disease relapse at days 116, 138, and 273 post-HCT. Conclusion. DAH occurred more frequently in allogeneic HCT recipients compared with autologous recipients. Onset of DAH coincided closely with white blood cell engraftment. Although associated with significant respiratory failure and need for mechanical ventilation, HCT patients can survive DAH.