A 55-year-old man comes to the emergency department after coughing up blood earlier this morning. The patient estimates that he coughed up 100 mL of blood at home and another 50 mL in the emergency department. He reports 4 hospital admissions for pneumonia in the past 18 months, but this is the first episode of hemoptysis. He has a chronic cough with yellow-green sputum production that is sometimes foul-smelling. The patient gets winded after climbing 2 flights of stairs or walking uphill. He is an ex-smoker with a 10-pack-year history. Physical examination is notable for crackles at the right lung base and scattered bilateral wheezes. There is no jugular venous distension or lower-extremity edema. What is the most likely mechanism of hemoptysis in this patient?

Question

A 55-year-old man comes to the emergency department after coughing up blood earlier this morning.  The patient estimates that he coughed up 100 mL of blood at home and another 50 mL in the emergency department.  He reports 4 hospital admissions for pneumonia in the past 18 months, but this is the first episode of hemoptysis.  He has a chronic cough with yellow-green sputum production that is sometimes foul-smelling.  The patient gets winded after climbing 2 flights of stairs or walking uphill.  He is an ex-smoker with a 10-pack-year history.  Physical examination is notable for crackles at the right lung base and scattered bilateral wheezes.  There is no jugular venous distension or lower-extremity edema.  What is the most likely mechanism of hemoptysis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c077_cd9a_8f63_d5325cebb408_MD0005_00 Recurrent infections and daily cough with mucopurulent sputum production are suggestive of bronchiectasis. Damage to the bronchial walls from infection (such as pneumonia in this patient) or inflammation predisposes to repeated infections, setting up a cycle of further airway damage and recurrent infection. The chronic airway inflammation and edema can lead to rupture of superficial blood vessels and cause hemoptysis. Pulmonary infections overall are the most common cause of hemoptysis, accounting for up to 70% of cases. (Choice A) Granulomatosis with polyangiitis (formerly Wegener's granulomatosis) can cause chronic rhinosinusitis and present with hemoptysis, but it most commonly presents with constitutional symptoms such as fever and migratory arthralgias. (Choice B) Mitral stenosis or left heart failure can raise pulmonary capillary pressure, causing hemoptysis. Patients with congestive heart failure are likely to have bilateral (rather than unilateral) basal crackles from pulmonary edema, jugular venous distension, and possibly lower-extremity edema. (Choice C) Chest radiography is important to rule out malignancy in patients with hemoptysis. However, copious sputum production with recurrent infections is highly suggestive of bronchiectasis. In addition, this patient's age and relatively limited tobacco exposure make this diagnosis less likely. (Choice E) Chronic cough alone does not cause hemoptysis, and this patient has no other signs of coagulopathy. Educational objective: Hemoptysis is frequently caused by pulmonary infection, which may be chronic or acute. The chronic inflammation and localized edema associated with bronchiectasis predispose to blood vessel infiltration and rupture. References: Hemoptysis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/16225028)

A 55-Year-Old Man Comes to the Emergency Department After Coughing