A Bag of Blood: Massive Hemoptysis of Unclear Etiology

Abstract

Massive hemoptysis is life threatening, and an understanding of appropriate diagnostic and treatment techniques is imperative. This case illustrates an example of a case of hemoptysis without clear cause, in the setting of antiplatelet therapy. A 51 year old lady with a history of systolic heart failure, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD) with recent myocardial infarction discharged two weeks prior on dual anti-platelet therapy (DAPT), presented to the hospital after coughing up half a grocery bag full of blood. A CT scan that showed a RUL nodule, emphysema, and atelectasis but no etiology for hemoptysis, and she was found to have a new LV thrombus. Bronchoscopy showed copious amounts of blood and a blood clot extending from the RUL to the RLL, but no clear source of bleeding. She was readmitted two weeks later with continued hemoptysis, and had another inconclusive bronchoscopy as well as negative aortogram and bronchial angiography. Her second CT scan mentioned an incidental cardiac bronchus, an increased RUL spiculated nodule, and bilateral lower lobe consolidations. She was discharged on warfarin and clopidogrel with no further bleeds. Massive hemoptysis is most often caused by a bleed in the bronchial arteries, and is diagnosed best with arterial phase contrast-enhanced CT angiography. Hemoptysis is considered life-threatening when it causes respiratory failure or hypotension. There are a myriad of potential causes including infection, malignancy, iatrogenic, structural defects including bronchiectasis, or rheumatological. In an acute episode, the patient should be turned on their bleeding side to preserve the nonbleeding lung, and can be selectively intubated to isolate the bleed. If performing a bronchoscopy, the bronchoscope can be wedged into the area of the bleed to encourage clotting, and while iced saline is not well studied it is often used. Bronchial blockers are an option for isolating the bleeding lung, but the definitive treatment is bronchial artery embolization (BAE), which has an initial success rate of 70-99%, with the feared complication of spinal cord ischemia occurring in 1.4-6.5% of cases. The cause of bleeding in this patient was unclear, but likely induced by the dual antiplatelet treatment. Cardiac bronchi, an exceedingly rare anatomic variant, can cause of hemoptysis, which could have been a possibility. There are a few cases describing massive hemoptysis on DAPT without another clear cause, and none describing the best forward action in the setting of LV thrombus and recurrent hemoptysis.