COUGH-INDUCED DIFFUSE BRONCHIAL HEMORRHAGE

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bleeding from the tracheobronchial tree is usually caused by neoplasms, bronchitis, bronchiectasis, mucosal infections, and/or iatrogenic mucosal erosions. We present a rare case of petechial tracheobronchial hemorrhage developing after a severe bout of cough. CASE PRESENTATION: An 81-year-old male with past medical history of Acquired immunodeficiency syndrome (AIDS), combined pulmonary fibrosis and emphysema, pulmonary hypertension, and chronic hypoxemia on supplemental oxygen (3 L/min), presented with gradually worsening dyspnea and non-productive cough over 6 months. Computed tomography (CT) scan of the chest showed a right upper lobe cavitary lesion for which further evaluation with diagnostic flexible fiberoptic bronchoscopy was planned. His home medications included low dose aspirin (81 mg) daily for the primary prevention of cardiovascular disease. He did not have any prior history of hemoptysis or coagulopathy. The patient received aerosolized topical anesthesia with nebulized lidocaine orally prior to bronchoscopy after which he developed a strong coughing fit. Patient was intubated with a laryngeal mask and flexible bronchoscopy was performed under monitored anesthesia care using Propofol. Inspection of the airways incidentally showed numerous mucosal petechiae with oozing of blood in the entire tracheobronchial tree distal to the vocal cords [Figure 1]. Patient was admitted due to worsening hypoxia and hemoptysis post procedure. He had mild hemoptysis for the next two days after which it resolved without any intervention. Broncho alveolar lavage cultures showed Mycobacterium avium intracellulare complex for which he was treated. DISCUSSION: We describe an unusual case of diffuse bronchial hemorrhage that, given the clinical course, developed due to severe coughing fit immediately prior to bronchoscopy. Only a few cases of cough induced diffuse bronchial hemorrhage, also called as the "hemorrhagic bronchial mucosa syndrome", have been previously reported [1-3]. The presence of mucosal petechiae with evidence of bleeding is a characteristic finding and usually improves with conservative management. It has been postulated that high intrathoracic pressures during coughing can increase intravascular pressure resulting in local vessel damage and bleeding [3]. Immunocompromised status due to AIDS, old age, use of aspirin, and pulmonary hypertension may have been additional risk factors predisposing to hemorrhage in this case. CONCLUSIONS: Diffuse bronchial hemorrhage or "hemorrhagic bronchial mucosa syndrome” is a rare complication that can occur during bronchoscopy due to severe coughing and measures to prevent coughing should be considered. Reference #1: Panjwani A. Hemorrhagic bronchial mucosa syndrome. The Egyptian Journal of Internal Medicine. 2015;27(4):151-153. Reference #2: Hira HS. Cough-induced Tracheobronchial Mucosal Bleeding. J Bronchology Interv Pulmonol. 2011;18(1):51-52. Reference #3: Milman N. Diffuse bleeding from the bronchial mucosa on flexible bronchoscopy in lung transplanted patients: 'the hemorrhagic bronchial mucosa syndrome'. Respiration. 2009;77(4):416-419. DISCLOSURES: No relevant relationships by Steven Shaw, source=Web Response No relevant relationships by Abhishek Singla, source=Web Response