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Answers on p e16
A 16 year old man presented with a 10 month history of recurrent haemoptysis, five to six episodes a day with 10–20 ml of clotted blood being coughed out mostly in the early morning hours. Subsequently, he developed generalised weakness, easy fatigability, and breathlessness on exertion with palpitations. He had received antitubercular treatment for four months before admission with no improvement. There was no history of chest pain, fever, audible wheeze, cardiovascular disease, bleeding tendencies, arthritis/arthralgia, or haematemesis. However, malena was present, coinciding with the bouts of haemoptysis. There was no history of allergy to milk or cereals.
Family history and medical history were non-contributory.
Investigations showed haemoglobin count of 30 g/l (a reading taken one month previously was 90 g/l), with normal leucocyte and platelet count. A peripheral blood smear showed dimorphism with predominantly hypochromic appearance. Bleeding time and clotting time were normal. Liver and renal function tests were normal and erythrocyte sedimentation rate was also within normal limits. Electrocardiography and echocardiography showed normal cardiac function. Antinuclear cytoplasmic antibodies (perinuclear and cytoplasmic ANCA), antinuclear factor, and anti-GBM antibodies were not present. Bone marrow showed mixed cellularity with decreased iron stores (fig 1A, 1B). No abnormality was seen on the chest radiography (fig 2). However, computed tomography showed bilateral interstitial pneumonia and ground glass haze (fig 3). Fibreoptic bronchoscopy showed normal, patent airways with no mass lesion and transbronchial lung biopsy showed normal lung tissue with no evidence of vasculitis. Bronchoalveolar lavage showed haemosiderin laden macrophages.
What is the probable diagnosis?
What are the differential diagnoses of recurrent haemoptysis?
What are the differential diagnoses of diffuse alveolar haemorrhage?