6 Patterns > Acute Lung Injury Pattern > Subpatterns > w/ Hayline Membranes > Drug Associated DAD

Drug Associated DAD

The classic features of drug associated DAD include metabolic abnormalities of the pneumocytes and macrophages and consist of extensive foamy cytoplasmic changes. 

SEE BELOW FOR SAMPLE SIGNOUT

DAD drug.jpg

If you are considering a diagnosis of Drug Associated DAD, the biopsy should show the following features:

  • Hyaline membranes

  • Edema

  • Intense cytoplasmic vacuolization of type 2 pneumocytes and macrophages

Pink biopsy of ALI from Low Power

Hyaline Membranes with Fibrin and Extensive Organization

Foamy Cytoplasmic Change

Foamy Cytoplasmic Change

Biopsies with the following features may not be Drug Associated DAD:

  • Robust lymphoplasmacytic interstitial inflammation (consider CTD)

  • Pleuritis (consider CTD)

  • Necrosis, neutrophils, granulomas, and viral cytopathic effect (consider infection)

  • Lymphoid follicles (consider CTD)

  • Interstitial giant cells or poorly formed granulomas (consider chronic HP)

  • Foreign material (consider aspiration or intravenous)

  • Alveolar hemosiderin laden macrophages and capillaritis (consider alveolar hemorrhage syndrome)

  • Background fibrosis (consider acute on chronic ILD)

Clinical Presentation

  • Patients will present acutely or subacutely with shortness of breath and cough

  • May have a history of other medical conditions for which they are taking drugs (A-fib and Amiodarone for example).

  • Risk factors for lung injury include duration of drug exposure, dose, trauma, major surgery

Radiology

  • Extensive bilateral ground glass opacities with possible consolidation

Sample Signout

If you are suspicious for an infectious etiology for the ALI biopsy, consider the following approach to signing the case out:

Acute and organizing diffuse alveolar damage with  extensive cytoplasmic foamy changes in the pneumocytes and macrophages suggestive if an adverse drug reaction (see comment)

Comment:  The biopsy shows an acute and organizing acute lung injury process with exquisite cytoplasmic vacuolization of the cytoplasm in the pneumocytes and macrophages.  This constellation of features is suggestive of an adverse drug reaction.  Correlation with a detailed medication list (including supplements) is suggested.