Early ECMO and Immunotherapy for Severe Diffuse Alveolar Hemorrhage in ANCA-Associated Vasculitis

Sunday, March 22, 2026

12:15 PM - 1:15 PM Central Time

Location: Connections Central - RST 01

Ye Ji Jung, n/a

KOR

Disclosure(s): No relevant financial relationship(s) to disclose.
SR

Sunjin Ryu, n/a

Dr.
Department of Radiology, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.
YK

Young Kim, n/a

Dr.
Division of Pulmonary and Critical care Medicine, Department of Internal Medicine, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.
KS

Kye Chul Shin, n/a

Dr.
Division of Pulmonary and Critical care Medicine, Department of Internal Medicine, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.
SJ

Seongho Jo, N/A

Dr.
Division of Nephrology, Department of Internal Medicine, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.
SY

Seong Gyu Yoon, n/a

Dr.
Division of Cardiology, Department of Internal Medicine, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.
JK

Jung Tae Kim, n/a

Dr.
Department of Cardiovascular & Thoracic Surgery, Cheonan Chungmu Hospital, Cheonan, Republic of Korea, Republic of Korea

Disclosure information not submitted.

Introduction: Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of ANCA-associated vasculitis (AAV), requiring prompt immunosuppressive therapy. In cases of refractory hypoxemia, extracorporeal membrane oxygenation (ECMO) can serve as critical cardiopulmonary support. We report a case of AAV-related DAH successfully managed with early steroid pulse therapy, ECMO, and cyclophosphamide.

Description: A 62-year-old previously healthy woman presented with hemoptysis and rapidly progressive hypoxemia. Despite high-flow oxygen and mechanical ventilation, hypoxemia worsened, necessitating venovenous ECMO, which maintained oxygen saturation above 90%. Due to ongoing hemoptysis, anticoagulation was minimized using low-dose heparin.
Methylprednisolone pulse therapy (1 g/day for 3 days) was initiated. Chest CT revealed bilateral ground-glass opacities with subpleural sparing, more consistent with pulmonary vasculitis rather than infection. Based on these findings and the patient's critical status, intravenous cyclophosphamide (500 mg) was started. Hemoptysis resolved, and oxygenation improved.
Renal function initially deteriorated (creatinine 5.5 mg/dL, BUN 123 mg/dL) but improved without continuous renal replacement therapy. Urinalysis showed significant proteinuria (P/C ratio 4708 mg/g), suggestive of pauci-immune glomerulonephritis, raising suspicion for microscopic polyangiitis (MPA). Perinuclear ANCA (P-ANCA, MPO-ANCA) was confirmed positive before the second cyclophosphamide dose on day 14.
The patient was weaned off ECMO and mechanical ventilation within 3 weeks, without thrombotic complications. Follow-up imaging and inflammatory markers showed improvement. She is tapering corticosteroids and undergoing rehabilitation, with azathioprine initiated for maintenance therapy.

Discussion: This case underscores the importance of early immunosuppressive therapy in life-threatening DAH due to ANCA-associated vasculitis, even before ANCA confirmation. ECMO provided vital cardiopulmonary support during the acute phase, allowing time for treatment to take effect. Despite bleeding and thrombotic risks, ECMO can be lifesaving when used within a prompt, multidisciplinary strategy. This case reinforces the role of ECMO as a bridge to recovery in severe pulmonary vasculitis.