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Study objectives To demonstrate that pulmonary capillaritis and diffuse alveolar hemorrhage (DAH) occur and are isolated to the lung and therefore not part of systemic vasculitis at the time of the DAH episode in rheumatoid arthritis (RA) and mixed connective tissue disease (MCTD). Design Lung biopsy specimens from patients with DAH were reviewed and those with the histologic features of pulmonary capillaritis were identified. Setting The patients were selected from seven Denver-area general hospitals. Patients Fifty-eight patients with biopsy specimen proved pulmonary capillaritis (1991 to 1997) were identified and classified according to disease. Three patients met the American Rheumatism Association criteria for RA and one patient fulfilled clinical and serologic criteria for MCTD. Interventions All clinical, laboratory, and radiographic data on initial presentation and at follow-up periods were extracted from the charts of the four study patients. Histologic slides were reviewed and immunofluorescent studies of lung tissue were performed. Measurements and results All four patients had a connective tissue disease diagnosis prior to the DAH episode. Symptoms referable to pulmonary capillaritis were of short duration (2 to 14 days) and there was no clinical or serologic evidence for an accompanying systemic vasculitis, in particular glomeronephritis. Three patients, two with RA and one with MCTD, demonstrated pulmonary immune complex deposition. Three resolved their illness following IV methylprednisilone and cyclophosphamide therapy. One RA patient died following a myocardial infarction. In the three survivors, no further episodes of DAH have occurred after a mean of 24 months (range, 10 to 48 months). Conclusions To our knowledge, these are the first cases of DAH due to pulmonary capillaritis documented to complicate RA and MCTD. The capillaritis was not part of a systemic vasculitis at the time of the DAH episode, but rather represented an isolated small-vessel vasculitis of the lungs in this group of patients. Immune complex deposition may be involved in the pathogenesis.

short ofbreath with stridor while on a commercial airline. Upon arrival attheairport terminal, hesustained a cardiopulmonary arrest. Endotracheal intubation was complicated bythepresence ofanapparent massinhis upperairway. Subsequent history revealed that hehad symptoms ofasinusproblem afewdays earlier andhad taken over-the-counter sinusmedications. Thepatient smoked apack ofcigarettes aday. There was nohistory of alcohol abuse, allergies, orforeign body aspiration. Hedid nottake anyprescription medications. Physical Examination Onarrival intheICU, histemperature was 37.2°C; pulse, 144beats/min; BP,150/95 mm Hg; respirations, 14 breaths/min on mechanical ventilation. Hewas ahealthy appearing man whowasintubated endotracheally. There was norash orlymphadenopathy; physical examination of thehead, neck, chest, abdomen, andextremities was normal. Neurological exam was notable forprofound coma with no response tonoxious stimuli, intermittent generalized myoclonic jerks, diminished deep tendon reflexes, and anextensor plantar response bilaterally.