Pulmonary alveolar hemorrhages caused by myelodysplastic syndrome in a hemodialysis patient

The patient was a 78-year-old female who had been receiving maintenance hemodialysis for 2 years. She was urgently admitted to our hospital for a hemorrhagic duodenal ulcer on September 5, 2005. She initially received proton pump inhibitor (PPI), but the treatment ceased when laboratory findings demonstrated pancytopenia. Pancytopenia worsened even after the cessation of PPI, and the condition was diagnosed as myelodysplastic syndrome (MDS) based on a bone marrow examination. A month later, she suddenly developed a high fever, productive cough, and massive hemoptysis. Pulmonary alveolar hemorrhage was discovered on chest x-ray revealing the presence of air-space consolidation. Steroid pulse therapy was initiated for the treatment of suspected vasculitis. Microscopic polyangitis, Wegener's granulomatosis, and Goodpasture's syndrome were all ruled out, as well as other conditions capable of inducing malignancy, collagen disease, or infection. The patient responded with marked sensitivity to steroid therapy, but relapsed immediately each time steroid pulse therapy was administered. She then underwent a plasma exchange with steroid pulse therapy and received ganciclovir for cytomegalovirus infection. The steroid therapy became ineffective when a propensity toward bleeding appeared systemically. The patient finally died of multiple organ failure on November 23, 2005. Noting that the onset was consistent with MDS-related activities, we suspected pulmonary alveolar hemorrhage associated with MDS, but the pathogenesis remains unclear.