Alveolar Hemorrhage Following Positron Emission Tomography/Computed Tomography in 2 Separate Episodes 5 Months Apart

Patient: Female, 57-year-old Final Diagnosis: Diffuse alveolar hemorrhage Symptoms: Hemoptysis Clinical Procedure: Positron emission tomography/computed tomography (PET/CT) Specialty: Pulmonology OBJECTIVE: Unknown etiology BACKGROUND: Positron emission tomography/computed tomography (PET/CT) has become one of the most prominent modalities worldwide for the diagnosis and surveillance of malignancies. Current clinical imaging guidelines report adverse reactions following PET/CT, especially due to contrast-induced toxicities, such as contrast-induced nephropathy and other rare reactions attributed to a hypersensitivity immune response, such as bronchospasm. Other rare lung toxicities were reported in a few case reports. Herein, we report repeated episodes of alveolar hemorrhage, a novel adverse response to PET/CT, occurring on 2 separate occasions 5 months apart. CASE REPORT: A 57 year-old female patient with breast carcinoma managed by mastectomy, adjuvant chemotherapy, irradiation, and hormonal therapy presented with massive alveolar hemorrhage following PET/CT performed for surveillance 13 years after completion of chemotherapy and irradiation. An additional episode of massive alveolar hemorrhage occurred 5 months later following PET/CT, with respiratory failure requiring mechanical ventilation. Fluorine-18 fluorodeoxyglucose ([(18)F] FDG) and iohexol were used for imaging on both occasions. Common causes of alveolar hemorrhage, including malignancy, were excluded. CONCLUSIONS: The repeated episodes immediately following PET/CT and the earlier and more intense respiratory failure following the second event raise the possibility of an immune-mediated alveolar hemorrhage in response to either the administration of iodinated radiocontrast agent or to [(18)F] FDG.