WHERE DID THE BLOOD COME FROM? HEMOPTYSIS RESULTING FROM AN UNUSUAL ABERRANT VESSEL.

Abstract

Background Hemoptysis is the expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma. Hemoptysis is a frightening symptom for the patients and often is a manifestation of significant underlying pathology. Common causes of hemoptysis include pneumonia, congestive heart failure, cancer, vasculitis, pulmonary embolus, or tuberculosis. We are describing an interesting case of hemoptysis with an uncommon etiology. Case Presentation A 70-year-old healthy female presented with acute onset of submassive hemoptysis without any chest pain, shortness of breath, fever, or chills. The patient was hemodynamically stable, and her physical examination was unremarkable. She had a similar episode 4 years ago, which had resolved spontaneously. Chest radiography showed a lingular infilterate without any effusion. Bronchoscopy revealed a blood clot in the left lingual, and in an attempt to remove the clot, severe bleeding occurred. Bleeding was controlled by instilling epinephrine. Pulmonary angiography was then performed and the identified bleeding vessel was embolized. However, the patient continued to have hemoptysis with fresh blood. This raised the suspicion for an additional source for bleeding. Repeat angiography located an aberrant vessel to the left pulmonary artery, which was an arteriovenous malformation off the aortic arch; which was subsequently embolized. Bronchoscopy was performed again to clear off the old blood clots from airways and to rule out any other source of active bleeding. The patient9s hemoptysis resolved, and she was discharged home. Discussion Review of the literature shows that most cases of hemoptysis result from the erosion of systemic rather than pulmonary arteries, with the exceptions of arteriovenous malformations and pulmonary artery aneurysms. Our patient had an unusual aberrant vessel to left pulmonary artery as the most likely source of bleeding. The availability of endobronchial techniques and bronchial arterial embolization helped us control the bleeding. Mortality rates have been reported as high as 80% in those with hemoptysis, and up to 30% of cases have cryptogenic hemoptysis. This case illustrates the importance of having a broad diffrential diagnosis of hemoptysis until a definitive source can be located.