Are Zebras Simply Striped Horses?

Patient presentation: A 46-year-old man was transferred from an outside facility to our inpatient pulmonary service with alveolar hemorrhage, transfusion-requiring anemia, and incidentally found obstructive hypertrophic cardiomyopathy (HCM). Two weeks earlier, he presented to a regional hospital with persistent cough, progressive dyspnea, orthostasis, and new low-volume hemoptysis. On admission to the outside hospital, the patient was hypoxic and urgently intubated after he failed to respond to noninvasive positive pressure ventilation. A bronchoscopy demonstrated blood within the airways. Bronchoalveolar lavage (BAL) revealed a bloody return containing a large percentage of hemosiderin-laden macrophages. Cytology and cultures of the BAL were negative for infection or malignancy. He was extubated but continued to have intermittent bouts of dyspnea, hypoxia, and bilateral alveolar infiltrates on chest imaging. Therefore, a right lung lower-lobe wedge biopsy was performed. The biopsy specimen was not immediately available for review at the time of transfer but was interpreted elsewhere as demonstrating hemosiderosis without capillaritis. A systolic murmur prompted a transthoracic echocardiogram (TTE), which reported obstructive HCM.