Hemoptysis (Case 10)
Sudheer Nambiar MD and Pratik Patel MD
Case: The patient is a 70-year-old African-American woman who was admitted with massive hemoptysis. Seven months before this admission, she had been diagnosed with pulmonary tuberculosis based on the presence of acid-fast bacilli in her sputum. Tuberculous arthritis was confirmed by ankle cartilage biopsy. Antituberculous treatment with isoniazid, rifampin, pyrazinamide, and ethambutol was prescribed, and excision drainage and internal fixation of her right ankle was performed. One month before this admission she had presented with massive hemoptysis. At the time of that admission, coarse crackles were auscultated over her left lower chest.
Differential Diagnosis
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Tuberculosis |
Pulmonary embolism |
Diffuse alveolar hemorrhage syndromes |
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Lung cancer |
Aspergilloma (mycetoma) |
Speaking Intelligently
Hemoptysis, the expectoration of blood, can range from blood streaking of sputum to the presence of gross blood in the absence of any accompanying sputum. Bronchitis, neoplasms such as bronchogenic carcinoma, and bronchiectasis are the most common causes of hemoptysis depending upon the patient population studied. Bronchitis is more likely to cause blood-tinged sputum, while bronchiectasis and tuberculosis are more often associated with massive hemoptysis. Although the term hemoptysis typically refers to expectoration of blood originating from the lower respiratory tract, it must be recognized that blood from the upper respiratory tract and the upper gastrointestinal tract (i.e., pseudo-hemoptysis) can be expectorated and can mimic blood coming from the lower respiratory tract. The term massive hemoptysis is reserved for bleeding that is potentially life-threatening.
PATIENT CARE
Clinical Thinking
• Massive hemoptysis is a rare but always a potentially life-threatening event.
History
• Question the patient regarding recent epistaxis, vomiting, or retching.
Physical Examination
• Gingival thickening and nasal septal perforation suggest Wegener granulomatosis.
Tests for Consideration
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$4 |
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$4 |
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$12 |
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$15 |
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$732 |
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$2087, $338 |
| Clinical Entities | Medical Knowledge |
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Tuberculosis |
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Pφ |
Following a marked decline in the incidence of TB in the United States over several decades, the incidence escalated dramatically and peaked in 1992. In the United States, important risk factors for TB infection are as follows: close contact with a person infected with TB; immigration from an endemic area (e.g., Africa, Asia, or Latin America); exposure to persons with untreated cases of TB in congregate living facilities (e.g., homeless shelters, correctional facilities, nursing homes, or other health care facilities); age; and residence in high-incidence locations (e.g., inner cities or foreign endemic areas). HIV-associated TB accounts for approximately 10% of TB cases in the United States; among TB patients between 25 and 44 years of age, 22% are known to be infected with HIV. A majority of TB cases in the United States now occur in foreign-born individuals emigrating from countries with high rates of endemic TB. The majority of cases of TB are caused by Mycobacterium tuberculosis, and the lungs are the major site of infection. Pulmonary manifestations of TB include primary, reactivation, endobronchial, and lower lung field infection. Reactivation TB represents 90% of adult cases in the non-HIV-infected population and results from reactivation of a previously dormant focus seeded at the time of the primary infection. |
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Low-grade fever lasting 14–21 days, chest pain, fatigue, cough, sputum production, night sweats, weight loss, arthralgias, and pharyngitis are some common symptoms. The physical examination is usually normal; pulmonary signs included pain to palpation and signs of an effusion. Complications of TB (i.e., hemoptysis, pneumothorax, bronchiectasis, and in some cases extensive pulmonary destruction) can also involve the lung. Most common sites of extrapulmonary involvement include the pleura, lymph nodes (particularly cervical and hilar), central nervous system (CNS) (as meningitis or tuberculoma), genitourinary system, blood, and bone marrow. TB can cause massive hemoptysis by sudden rupture of a Rasmussen aneurysm; this is an aneurysm of the pulmonary artery that slowly expands into an adjacent cavity because of inflammatory erosion of the external vessel wall, causing it to rupture. |
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Dx |
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