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• W4379800019 abstract "We appreciate the insightful comments from Drs Mahendran and Guptam regarding our case report of idiopathic pulmonary hemosiderosis and four issues about the causative disease of diffuse alveolar hemorrhage (DAH) that were raised. We believe that our responses to these comments will contribute to a better understanding of the differential diagnosis, including underlying diseases that cause DAH. Regarding the first issue about the necessity of biopsy to look for pulmonary vasculitis, we agree. Actually, surgical biopsy is necessary for accurate diagnosis of pulmonary vasculitis considering sample volume,1Frankel S.K. Schwarz M.I. The pulmonary vasculitides.Am J Respir Crit Care Med. 2012; 186: 216-224Crossref PubMed Scopus (40) Google Scholar but it induces excessive physical load and might have been difficult to perform aggressively at the time of initial diagnosis of the present case. Currently, we are planning lung biopsy if DAH relapses after corticosteroid tapering if the patient’s consent can be obtained, because other immunosuppressants might be needed for hidden pulmonary vasculitis.2Monti S. Brandolino F. Milanesi A. Xoxi B. Delvino P. Montecucco C. Novel therapies for ANCA-associated vasculitis.Curr Rheumatol Rep. 2021; 23: 38Crossref PubMed Scopus (7) Google Scholar Regarding the second issue in the present case, the existence of autoimmune diseases was not ruled out completely, even though we checked autoantibodies and markers of the complement system such as C3, C4, and CH50 multiple times. Indeed, the possible existence of antibody-negative autoimmune disease should be considered; the antibodies including anti-neutrophil cytoplasmic antibody might become positive later in the course of disease.3Ando M. Miyazaki E. Ishii T. et al.Incidence of myeloperoxidase anti-neutrophil cytoplasmic antibody positivity and microscopic polyangitis in the course of idiopathic pulmonary fibrosis.Respir Med. 2013; 107: 608-615Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Therefore, we are observing the patient carefully, focusing on the development of vasculitis-related organ disorders, positive conversion of the antibodies, and relapse of DAH with the need for lung biopsy, as mentioned earlier. Regarding the third issue about pulmonary venous congestion caused by valvular heart diseases, her echocardiogram showed no valvular heart diseases and a normal ejection fraction. Her N-terminal pro-brain natriuretic peptide level in blood was also within the normal range (38.8 pg/mL). Although pulmonary venous congestion is one of the causative diseases of DAH,4Lara A.R. Schwarz M.I. Diffuse alveolar hemorrhage.Chest. 2010; 137: 1164-1171Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar it was not involved in the present case considering the recovery of DAH when treated by corticosteroid. Regarding the existence of Lane Hamilton syndrome with celiac disease, the fourth issue, her mean corpuscular volume was 77.1 fL, and mean corpuscular hemoglobin concentration was 29.7%, which indicated microcytic hypochromic anemia. These data and the serum levels of iron, ferritin, total iron-binding capacity, and unsaturated iron binding capacity that are shown in our case report were consistent with iron deficiency anemia caused by DAH. We are grateful that these important issues were raised, and we hope that our responses will result in further developments in the exploration of the differential diagnosis that causes DAH, including idiopathic pulmonary hemosiderosis. See earlier cited article for author conflicts of interest. A Closer Look Into a Bleeding Lung…CHESTVol. 163Issue 6PreviewThe CHEST Pearl published in CHEST (January 2023) was discussed in the academic forum with great interest.1 We think it is worthwhile to share the salient points of discussion for the benefit of medical community. Full-Text PDF A 45-Year-Old Woman With Unexplained Iron Deficiency Anemia and No Respiratory SymptomsCHESTVol. 163Issue 1PreviewA 45-year-old Japanese woman was diagnosed with anemia in a work place medical check-up and came to our hospital for further investigations. She had experienced general fatigue and orthostatic dizziness for 6 months without fever or respiratory symptoms, including cough, sputum, hemoptysis, or dyspnea. She had undergone annual medical check-ups previously, which had shown no abnormalities, including anemia. She had no history of weight loss, epimenorrhagia, hematuria, or melena. She had no significant positive medical history and was not on any regular medication or supplements. Full-Text PDF" @default.
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• W4379800019 date "2023-06-01" @default.
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• W4379800019 title "Response" @default.
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• W4379800019 doi "https://doi.org/10.1016/j.chest.2023.02.013" @default.
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