SPONTANEOUS HEMORRHAGE INTO GIANT EMPHYSEMATOUS BULLA

Abstract

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary bullae are seen in emphysematous lungs and are usually of little consequence unless complicated by infection, pneumothorax or hemorrhage. Spontaneous hemorrhage into large emphysematous bullae has been rarely reported in patients with pre-existing coagulopathies or supra-therapeutic anticoagulation. CASE PRESENTATION: We present a 57-year-old man with history of severe bullous emphysema and peripheral artery disease on aspirin and warfarin who presented to the emergency department for massive hemoptysis. He coughed up about 3 cups of blood at home and continued to have hemoptysis in the hospital. Computed tomography angiography revealed fluid and mass like consolidations within a giant bullous lesion in right upper lung that was new from 3 days ago. He was hemodynamically stable, with a stable hemoglobin. His warfarin was held and was given intravenous vitamin K. He was monitored closely in the intensive care unit and was discharged home after a few days of stability. DISCUSSION: Bullous emphysema, also known as vanishing lung syndrome occurs due to lung damage from smoking. Lung parenchyma and airway destruction in emphysema results in stretching and breakage of alveolar walls creating large air spaces that cannot handle normal gas exchange during respiration. This results in incomplete exhalation and air trapping in the lungs that progressively enlarge, forming large bullae. Complications include infections, pneumothorax or hemorrhage.Pulmonary hemorrhage is most often due to blunt or penetrating chest trauma or associated with ruptured vascular malformations or infections particularly tuberculosis and fungal. Spontaneous hemorrhage into pre-existing emphysematous bullae has been described in patients with coagulation abnormalities, supra-therapeutic anticoagulation or anti-platelet agents. The most likely mechanism is infection causing angionecrosis within the bulla and thereby bleeding. After initiating supportive care, control of the bleeding can be achieved by coil embolization. Due to the rare possibility of pulmonary artery aneurysms pulmonary arteriography may be required if bronchial arteriography does not reveal abnormalities. Surgical resection of the lobe may be required if bleeding cannot be stopped. CONCLUSIONS: Spontaneous hemorrhage is a rare complication of large emphysematous bullae particularly in the setting of coagulation abnormalities, which can result in life threatening bleeding. Management involves correcting coagulopathy and coil embolization or surgical lobectomy if bleeding cannot be controlled. Reference #1: Withey S, Tamimi A. Spontaneous pulmonary haemorrhage into an existing emphysematous bulla. BMJ Case Reports. 2016 Reference #2: Bowler RP, Durham J, Schwarz MI. Massive hemoptysis from a pulmonary artery aneurysm associated with an emphysematous bulla. Chest. 1998;113(4):1130-1. Reference #3: Nakajima J, Yamamoto M, Kotsuka Y, et al. Hemoptysis from an emphysematous bulla developing after open-heart surgery: report of a case. Surg Today. 1997;27(3):266-8. DISCLOSURES: No relevant relationships by Sabin Bista, source=Web Response No relevant relationships by Deepak Chandra, source=Web Response no disclosure on file for Deepa Jayakrishnan; No relevant relationships by Navin Victor, source=Web Response