To the Editors:
A previously healthy 31-month-old girl was referred to the hospital for pallor and intermittent abdominal pain. Evaluation of her laboratory results revealed a low hemoglobin (4.8 g/dL), low mean corpuscular volume (71.1 fl), and low iron (10 μg/dL) and ferritin (19.8 ng/dL) values that, which were suggestive of iron deficiency anemia. Physical examination revealed a soft and nontender abdomen with no distention. Repeated fecal occult blood tests and abdominal imaging studies were negative. A transfusion of red blood cells with subsequent oral and intravenous iron supplementation ameliorated the symptoms.
One month after the initial visit, the patient developed a productive cough followed by tachypnea with occasional hemoptysis. Pulmonary auscultation was normal without crackles on physical examination. Repeat laboratory evaluation revealed a low hemoglobin (6.0 g/dL), low iron (16 μg/dL) and normal ferritin (73.7 ng/dL). Chest radiography revealed diffuse bilateral patchy alveolar infiltrates. Chest computed tomography images (Fig. 1) and the presence of hemosiderin-laden macrophages in the sputum (Fig., Supplemental Digital Content 1, https://links.lww.com/INF/C289) confirmed the diagnosis of pulmonary hemosiderosis (PH). Serum IgG concentrations (38 U/mL) and stool antigen tests for Helicobacter pylori were positive, although the laboratory evaluation was negative for antinuclear antibodies, antineutrophil cytoplasmic antibodies, antiglomerular basement membrane antibodies, and cow’s milk–specific IgE. Therapy with steroids was initiated with a good response. She is currently receiving tapered doses of steroids under continued surveillance.
PH is a rare cause of alveolar hemorrhage in children and its pathophysiology is obscure.1H. pylori infection is not only responsible for gastrointestinal manifestations but also plays a potentially pathogenic role in several extraintestinal diseases, such as refractory iron deficiency anemia and certain autoimmune diseases;2 however, no cases of PH associated with H. pylori infection have previously reported. Although a causal relationship is not proved, we suggest that H. pylori infection may be the unidentified etiology for some cases of idiopathic PH.
Hisanori Fujino, MD, PhD
Yoshihiko Takano, MD
Ako Tatsumi, MD
Shinya Hida, MD
Shinichi Sumimoto, MD, PhD
Department of Pediatrics
Osaka Red Cross Hospital
1. Taytard J, Nathan N, de Blic J, et al.French RespiRare® group. New insights into pediatric idiopathic pulmonary hemosiderosis: the French RespiRare(®) cohort. Orphanet J Rare Dis. 2013;8:161
2. Iwańczak B, Francavailla R.. Helicobacter pylori
infection in pediatrics. Helicobacter. 2014;19(Suppl 1):46–51