Fatal haemoptysis caused by a ruptured Rasmussen's aneurysm

Abstract

Fatal haemoptysis caused by a ruptured Rasmussen's aneurysmA 47-year-old woman with a past history of pulmonary tuberculosis presented to our institution with out-of-hospital cardiac arrest because of massive haemoptysis after severe coughing. On arrival, immediate cardiopulmonary resuscitation with chest compression, endotracheal intubation and intravenous epinephrine 1 mg with an interval of 3 min for asystole was performed. Twelve minutes later she was defibrillated twice with 150 joules and intravenous epinephrine of 1 mg with an interval of 3 min for ventricular fibrillation was given. Return of spontaneous circulation with a blood pressure of 181/98 mm Hg and a pulse rate of 80 beats/min was achieved 4 min later. Fluid replacement, blood transfusion, tranexamic acid and pitressin were given for persistent gushing of fresh blood from the endotracheal tube. It was suspected that the bleeding originated from the pulmonary or bronchial vessels. Laboratory evaluation revealed a white blood cell count of 13 100/mm 3 with 43.2% segmented neutrophils and 50.4% lymphocytes, haemoglobin 8.5 g/dl and platelet counts of 134310 3 /mm 3 . Thoracic contrastenhanced 64-slice multidetector computed tomographic angiography (MDCTA) demonstrated a vascular lesion 29 mm in diameter originating from a branch of the pulmonary artery (PA) with contrast media extravasations indicating a ruptured Rasmussen's aneurysm (figures 1 and 2). Pulmonary angiography with embolisation was attempted and a thoracic surgeon was consulted. However, cardiopulmonary resuscitation, defibrillation, fluid replacement, epinephrine and pitressin were prescribed for pulseless electrical activity and recurrent ventricular fibrillation. Four hours later the patient died after return of spontaneous circulation. Sputum culture 1 month later confirmed tuberculosis.Massive haemoptysis has a mortality rate of >50%. The prevalence of haemoptysis originating from the PA is <10%. Rasmussen's aneurysm has a prevalence of 5%.1 MDCTA can demonstrate the PA and pseudoaneurysm of PA in the adjacent cavity.1 2 The mortality rate for emergency surgery in unstable haemodynamic patients is high, so radiological endovascular embolisation of endovascular embolisation with coils is recommended first in these patients. Learning points< Massive haemoptysis is a life-threatening condition associated with a mortality rate of >50% and ruptured Rasmussen's aneurysm should be considered in patients with massive haemoptysis, especially if there is a history of pulmonary tuberculosis.1 < Rasmussen's aneurysm is a rare phenomenon caused by weakening of the pulmonary artery wall from adjacent cavitary tuberculosis, with a prevalence of 5%.1 < Mandatory radiological studies should include thoracic MDCTA and digital substrate angiography to differentiate between bleeding from pulmonary or bronchial origins. 1 2 < Surgical or angiographic interventions with endovascular embolisation is recommended in this life-threatening condition.

Rasmussen’s Aneurysm in a Child with Multidrug Resistant Pulmonary Tuberculosis

“…Rasmussen's aneurysm is an extremely rare entity with a prevalence of 4% in autopsy findings of chronic cavitary TB [3]. It results from the weakening of the pulmonary artery wall from an adjacent cavity, leading to pseudoaneurysm formation [4]. It may lead to rupture and life-threatening massive hemoptysis with a mortality rate ranging from 50 to 100% [5].…”

Bilateral multiple pulmonary artery aneurysms associated with cavitary pulmonary tuberculosis: a case report

“…Furthermore, patients presenting with massive hemoptysis are usually treated with a bronchial artery embolization procedure [47]. However, such an embolization procedure technique requires special care especially in pseudoaneurysms as they are easily prone to rupture with resultant fatal bleeding [39, 43, 47]. …”

Idiopathic Asymptomatic Aneurysms of Pulmonary Artery and Ascending Aort: A Case Report

“…In Hughes-Stovin syndrome, recurrent venous thrombosis and PAA are seen. Focal pulmonary artery enlargement is seen in PAA which is called 'Rasmussen's aneurysm' after pulmonary tuberculosis [7] Only 5 patients were diagnosed as idiopathic pulmonary artery aneurysm in a series of 51 pulmonary artery aneurysm repair in Mayo clinic [8] We do not have precise information about the treatment of pulmonary artery aneurysm and indications for surgical repair. In terms of surgical outcome, mortality and morbidity data are not available because a large series of PAA patients is not published.…”