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. 2025 Jul 2;25(1):513.
doi: 10.1186/s12887-025-05850-y.

Emphysema: an ignored radiologic sign of diffuse alveolar hemorrhage

Fu-Ce Lu #  1 , Qing Wei #  1 , Yan Li  1 , Jing Liu  1 , Xun Chen  1 , Chun-Yan Li  2 , Jing-Jing Zeng  3 , Xiaobo Zhang  2 , Guang-Min Nong  4 , Yuan-Han Qin  5
Affiliations

Emphysema: an ignored radiologic sign of diffuse alveolar hemorrhage

Fu-Ce Lu et al. BMC Pediatr. .

Abstract

Background: Diffuse alveolar hemorrhage (DAH) is characterized by the presence of diffuse ground glass opacities and/or consolidation on chest CT. Emphysema has been reported occasionally. Nevertheless, the pathogenesis, incidence, imaging subtypes, and clinical impact of emphysema in patients with DAH are still unclear.

Methods: This was a retrospective clinical study. Children with DAH who were admitted to our hospital between January 2013 and December 2019 were included. All chest CT images of the patients were analyzed by two board-certified thoracic radiologists. The clinical features of the patients with diffuse emphysema were further analyzed. A matched case-control study was performed to explore the risk factors for developing diffuse emphysema.

Results: Ninety-four patients were included. Chest CT scans revealed emphysema in 28 patients (29.8%). Paraseptal emphysema (n = 24) was the most common imaging subtype. The median interval between the onset and development of emphysema was 11.0 months (n = 18, range: 2-113 months). Nine cases developed diffuse emphysema, in which six cases had persistent dyspnea and exercise intolerance, nine cases had persistent ground-glass opacities and 8 cases had a delay in initial treatment of 12 or more months. Compared to those in the matched control group, the interval between the onset and start of regular therapy with glucocorticoids was significantly longer in the cases with diffuse emphysema (median interval 13.5 vs. 1.5 months, P < 0.01).

Conclusions: In cases with DAH, emphysema is a relatively common but ignored radiologic sign and diffuse emphysema seems to be a sign of irreversible lung function impairment. A delay in initial treatment is a risk factor for developing diffuse emphysema.

Keywords: Chest CT; Delay of initial treatment; Diffuse alveolar hemorrhage; Emphysema.

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Conflict of interest statement

Declarations. Ethical approval and consent to participate: The present study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (2023-E047-01). Informed consent was obtained from all the subjects and/or their legal guardian(s) in the case of minors (younger than 16 years of age). All the methods and procedures carried out in this study were in accordance with relevant guidelines and regulations. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Emphysema in the children with DAH: CT findings. Chest CT scans revealed diffuse centrolobular emphysema in a 15-year-old girl (A), nondiffuse centrolobular emphysema in a 6-year-old boy (B), diffuse Paraseptal emphysema in a 10 year-old girl (C) and nondiffuse Paraseptal emphysema in a 7-year-old girl (D). A 12 year-old girl was the only one case with the presence of panlobular emphysema (E). Both centrolobular and Paraseptal emphysema were present in a 14-year-old girl(F)
Fig. 2
Fig. 2
Radiologic characteristics of DAH with diffuse emphysema. A girl developed diffuse emphysema with the presence of diffuse ground-glass opacities on the chest CT 6 years after the onset (A). Chest CT re-examinations at 6 months (B) and 12 months (C) later still revealed the presence of ground-glass opacities besides the diffuse emphysema
Fig. 3
Fig. 3
Pathological features of DAH with emphysema. The lung biopsy findings revealed abnormal airspace enlargement distal to the terminal bronchioles and destruction of the alveolar walls, which fulfilled the diagnosis of emphysema (A) (H&E 10 × 4). Inflammation cells infiltration and mild fibrosis in the alveolar septa were present in the 2 cases with diffuse emphysema (B, C) (H&E 10 × 10). Marked accumulation of hemosiderin-laden macrophages in the alveolar spaces were present in a case with diffuse emphysema (D) (H&E 10 × 4)
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