Intra-alveolar haemorrhage in temporal arteritis

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Abstract
A woman born in 1926 presented in 1999 with persistent dry cough and raised erythrocyte sedimentation rate at 60 mm at the first hour. C reactive protein was 14 mg/l. She had a history of pulmonary tuberculosis treated in 1951 with streptomycin and p-aminosalicylic acid. She complained of headache without fever, jaw claudication, scalp tenderness, and visual or musculoskeletal manifestations. She denied any other upper airways symptoms. Physical examination was normal. Arterial pressure was 140/70 mm Hg. Leucocyte count was 6.8×109/l with 4.2×109/l polynuclear neutrophils and 0.2×109/l eosinophils, haemoglobin 130 g/l, and platelets 310×109/l. A dipstick urinary test showed no proteinuria and no haematuria. Chest radiography disclosed calcified nodular density in the upper right lobe, which was confirmed by computed tomography. An electrocardiogram and echocardiogram were normal. Fibre optic bronchoscopy was normal. Bronchoalveolar lavage fluid examination showed 120×109 cells/l, comprising macrophages 56% with siderophages 30%, lymphocytes 39%, polynuclear neutrophils 1%, and polynuclear eosinophils 4%. Bronchoalveolar lavage was sterile on cultures for bacterial infection, Mycobacterium tuberculosis, cytomegalovirus, parasites, and fungi. A search for antinuclear antibodies and cryoglobulin was negative. Histological study of the temporal artery disclosed a granulomatous inflammation of the vessel wall containing mononuclear cells and histiocytes without giant cells, leading to fragmentation of the elastic lamina.