A 62-year-old man comes to the emergency department after "coughing up a 6-ounce cupful of blood." He describes about 3 days of increased yellowish sputum production associated with mild increase in dyspnea on exertion. On the previous 2 days he had slight blood streaking in the sputum. He has no prior history of hemoptysis. He has no fever, chills, weight loss, or night sweats.
His past medical history is significant for HIV and tuberculosis treated 12 years ago with directly observed therapy for 9 months. He is compliant with highly active antiretroviral therapy. He is an ex-IV drug user with a 50-pack-year history of tobacco use.
On examination, the patient is very anxious-appearing with mild respiratory distress and some dried blood on his lips. Pulse is 104/min, respirations are 20/min, and SaO₂ is 90% on room air. Lung examination shows mild diffuse wheezing. He coughs up an additional 25 cc of blood while being examined.
Laboratory results are as follows:

The CT scan is shown below.

Which of the following is the most likely diagnosis?

Question

A 62-year-old man comes to the emergency department after "coughing up a 6-ounce cupful of blood." He describes about 3 days of increased yellowish sputum production associated with mild increase in dyspnea on exertion. On the previous 2 days he had slight blood streaking in the sputum. He has no prior history of hemoptysis. He has no fever, chills, weight loss, or night sweats.
His past medical history is significant for HIV and tuberculosis treated 12 years ago with directly observed therapy for 9 months. He is compliant with highly active antiretroviral therapy. He is an ex-IV drug user with a 50-pack-year history of tobacco use.
On examination, the patient is very anxious-appearing with mild respiratory distress and some dried blood on his lips. Pulse is 104/min, respirations are 20/min, and SaO₂ is 90% on room air. Lung examination shows mild diffuse wheezing. He coughs up an additional 25 cc of blood while being examined.
Laboratory results are as follows:

The CT scan is shown below.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Massive hemoptysis should always be considered a life-threatening condition that requires timely and effective management. There is no consensus on the exact definition of massive hemoptysis (ranging from 100-1000 mL in 24 hours). There is also no consensus on the optimal diagnostic approach to massive hemoptysis. CT scan offers the advantage of identifying a cause of bleeding, and bronchoscopy offers the advantage of possible treatment. Bronchiectasis, tuberculosis, mycetomas (aspergillomas), necrotizing pneumonia, and bronchogenic carcinomas are the main underlying causes. The initial management of massive hemoptysis is to identify the bleeding site, maintain a patent airway (affected side down, possible selective intubation or balloon tamponade), ensure adequate oxygenation and hemodynamics, and attempt to control the bleeding with rigid bronchoscopy. Bronchial artery embolization by interventional radiology has become the treatment of choice for continued bleeding. 11ec193a_969d_4786_853d_31865b85000d_MD0002_00 In this patient, the cause of the hemoptysis is aspergilloma, shown on the CT scan above. An aspergilloma is caused by colonization of Aspergillus in a previously existing cavity, due to treated tuberculosis in this patient. Hemoptysis occurs when the fungus ball erodes into a blood vessel. It is unlikely for tuberculosis (Choice E) to recur in this patient, who was treated for 9 months. CT scan above (Choice B) Bronchogenic carcinoma is rarely a cause of massive hemoptysis. The exception is terminal cases in which the tumor erodes into one of the great vessels. (Choice C) Chronic bronchitis can cause hemoptysis but rarely causes massive hemoptysis in the absence of a coagulopathy. (Choice D) Goodpasture's syndrome typically involves the kidney as well as the lung. Although it causes diffuse alveolar hemorrhage, massive hemoptysis is uncommon as the alveoli are capable of holding a large quantity of blood. Educational objective: Massive hemoptysis is a life-threatening emergency caused most frequently by bronchiectasis, aspergilloma, necrotizing pneumonia, and, rarely, bronchogenic carcinoma. Initial management includes airway protection and resuscitation. Rigid bronchoscopy is the procedure of choice, if a skilled physician is readily available. __________ References: Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/20090288) Hemoptysis and thoracic fungal infections. (http://www.ncbi.nlm.nih.gov/pubmed/20955879) Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? (http://www.ncbi.nlm.nih.gov/pubmed/12388502)

A 62-Year-Old Man Comes to the Emergency Department After "Coughing