Pulmonary metastases from renal cell carcinoma simulating alveolar haemorrhage

A. SUPERVIA*, V. CURULL~, J. M. COROMINAS$, I. CAMPODARVE* AND C. SANJUAS~ Departments of *Internal Medicine, TRespiratory Medicine and $Pathology, Hospital de1 Mar, Passeig Maritim 2.5, 08003 Barcelona, Spain Introduction The study of bronchoalveolar lavage (BAL) cells is useful in the diagnosis of alveolar haemorrhage (AH) (l-3). Thus, in a patient with consistent radiologic and clinical features, the discovery of a high percent- age of haemosiderin-laden macrophages on BAL confirms the diagnosis of AH (14). We present the case of a patient with clinical and radiologic features consistent with AH. Two fibre- optic bronchoscopies were performed with a 2 month interval between each, which showed a high percent- age of haemosiderin-laden macrophages on BAL. However, the definitive diagnosis was pulmonary metastases from renal cell carcinoma. Case Report The patient was a 67-year-old man, an ex-smoker, moderate drinker and allergic to sulphonamides. Relevant medical history included ischaemic heart disease which had required aorto-coronary bypass and nephrectomy for renal cell carcinoma, 2 years and 3 months prior to admission, respectively. He was admitted to our service because of progressive dyspnoea, asthenia, anorexia and weight loss. Physi- cal examination revealed pallor and bilateral crackles on lung auscultation. Laboratory data included haemoglobin 104 g I- ’ (10.4 g dl - I), haematocrit 0.33 (33%) mean corpuscular volume (MCV) 81 fl, erythrocyte sedimentation rate (ESR) 110 mm h - i, urea 12.5 mmol 1 - ’ (35 mg dl - ‘) and creatinine 141 mol l- ’ (1.6 mg dl ‘); room air arterial blood gas (ABG): pH 7.39, PCO, 4.8 kPa, PO, 7.1 kPa. Chest X-ray revealed a bilateral diffuse alveolar pattern predominantly in lower fields (Plate 1). Fibre optic bronchoscopy disclosed slightly hyper- aemic mucosa and 70% macrophages with 50%