A case of diffuse alveolar hemorrhage secondary to fat embolism after long bone fracture

Fat embolism syndrome (FES) is a known complication of long bone fractures, frequently presenting with hypoxemia. Diffuse alveolar hemorrhage (DAH) is a rare complication of the condition. Imaging characteristics are frequently non-specific to FES, as are findings on bronchoalveolar lavage. No specific treatment exists, though steroids and albumin can be considered. We present the case of an 18 year old male who presented to the emergency room after a motorcycle collision. His CXR was initially clear, but he developed pulmonary infiltrates, a new oxygen requirement, and hemoptysis. Bronchoscopy confirmed DAH by serial lavage, and BAL was notable for abundant lipid-laden macrophages by Oil-red-O stain. He improved with methylprednisolone and albumin. This case highlights the need for a high index of suspicion both for FES, and for DAH as a complication that may develop days after trauma. We review treatment paradigm for this serious condition.