Spontaneous pulmonary haemorrhage into an existing emphysematous bulla

Abstract

SUMMARYA patient with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis presented dyspnoeic with productive cough and large-volume haemoptysis, 1 month after coronary stenting and commencement of clopidogrel. A chest radiograph showed a wellcircumscribed opacity in the left lower zone with surrounding consolidation, where previously an emphysematous bulla had been. A CT scan of the thorax confirmed a 14 cm bulla in the left lower lobe, which was 70% filled with blood with associated surrounding consolidation. A diagnosis of pulmonary haemorrhage into an existing emphysematous bulla with co-existing infective exacerbation of COPD was performed. Owing to his significant comorbidities, the patient was managed conservatively, returning to baseline over several days. He had two further admissions due to pulmonary infection over 2 months, where the haematoma was nominally smaller, and died during the second of these. BACKGROUND

Acute COPD exacerbation presenting with pronounced intrabullous haemorrhage and haemoptysis

“…Two publications describe surgically managed spontaneous pulmonary haemorrhage without anticoagulation or coagulopathy 11 12. Furthermore, there is one case published in which a pulmonary haematoma occurred during pulmonary infection and which was likely facilitated by dual antiplatelet therapy 6. However, in our case, a presumed bacterial infection triggered an acute COPD exacerbation with pronounced intrabullous haemorrhage in the absence of antiplatelet or anticoagulation therapy.…”

“…Intrapulmonary or intrabullous haemorrhage are rarely reported in patients without an anticoagulation therapy. There is one recent report describing a bullous haematoma during acute COPD exacerbation with dual antiplatelet medication 6. Here, we present a unique case of acute exacerbation of COPD with bullous emphysema, complicated with intrabullous haemorrhage and haemoptysis without anticoagulation therapy.…”

Pulmonary Artery Bleed from an Eloesser flap

“…Spontaneous pulmonary haemorrhage is exceedingly rare and mainly described in case reports. Most of these reported cases are secondary to progressive necrosis of erosive lesions such as malignancies/cysts/bullae into the pulmonary artery, anticoagulation use or platelet dysfunction 6–11. We believe angionecrosis from chronic inflammation to be the aetiology of our patient’s haemorrhage as he presented with an open thoracic window in the form of an Eloesser flap.…”

January 2024 Critical Care Case of the Month: I See Tacoma

“…It may occur when a bulla enlarges leading to rupture of intrabulla vessels. The presence of a large blood clot in the bulla can have very similar radiologic features to a mycetoma (4)(5)(6). The resolution of the mass was thought to be too rapid and not consistent with a mycetoma.…”