PMC7303994_01
Computed tomography (CT) of the chest imaging of the upper and lower chest at baseline (A-B) shows subtle emphysematous changes (circle). Five days after cycle 1 of nivolumab (C-D), bilateral, predominantly subpleural ground glass opacities are seen, and no pulmonary embolism was detected. Symptoms and degree of hypoxia appeared disproportionate to the relatively subtle CT findings at day 5 post-nivolumab therapy. At cycle 2, day 11 post-nivolumab, the ground glass opacities are more prominent (E-F). A portable chest radiograph following intubation shows diffuse bilateral airspace disease (G).
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Computed tomography (CT) of the chest revealed new subtle bilateral ground glass opacities (Fig. 1A-D). CT chest showed interval progression of ground glass infiltrates and consolidation (Fig. 1E and F). Despite high dose corticosteroids, empiric antibiotics and infliximab, the patient required intubation for progressive hypoxemia respiratory failure (Fig. 1G).
Autopsy studies confirmed extensive alveolar hemorrhage (A, thin arrows reveal red blood cells filling alveoli) with minimal inflammatory reaction within the lung parenchyma (A, thick arrows demonstrate relatively unaffected lung parenchyma). Blood extended into the airways (B, higher power view of red blood cells filling alveolar spaces) and lung, forming bilateral central airway clots and markedly consolidated and hemorrhagic lung parenchyma. No endobronchial sources for bleeding and no pulmonary emboli were found. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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Autopsy studies (Fig. 2) confirmed florid bland DAH without other lung pathology.