A presentation of massive hemoptysis in a patient with Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a systemic small-vessel vasculitis. When involving the lungs, small-vessel vasculitides typically cause capillaritis, leading to diffuse alveolar hemorrhage and submassive hemoptysis. In contrast, massive hemoptysis primarily originates from the bronchial arteries; therefore, small-vessel vasculitis is not considered when a patient presents with massive hemoptysis. The authors describe a patient with CSS who presented with the novel finding of massive hemoptysis. Computed tomography scans lacked alveolar infiltrates and bronchoalveolar lavage lacked hemosiderin-laden macrophages. Bronchoscopy demonstrated a raised mucosal lesion in the right mainstem bronchus and computed tomography angiogram revealed aberrant dilated bronchial arteries underlying the same region, suggesting this as the source of the hemoptysis. To the authors’ knowledge, the present report describes the first reported case of CSS to present with massive hemoptysis with likely involvement of the bronchial arterial circulation. CSS should be considered in patients with unexplained massive hemoptysis.     

隐源性咯血的介入诊断和治疗

目的 探讨隐源性咯血的支气管动脉造影 (BAG)的影像表现与病理机制之间的关系,为其诊断和出血定位寻求可靠依据。方法 1 选择隐源性咯血病人52例,包括以下两种情况：(1)常规影像学检查阴性 (胸部平片、断层阴性,部分病人同期CT及支气管碘油造影阴性) (2)一个肺叶或一侧肺内有少量病变,但BAG证实为非咯血病灶,而另叶或另段肺内有出血征象,计17例。全部病例行Seldinger穿刺技术,导管经主动脉置入双侧支气管动脉造影,确认有造影的直接或间接出血征象,行双重栓塞术。2 另选5例术前影像学检查证实为支气管病变、BAG检查证实为出血部位和出血原因的病例,因栓塞止血无效或其他病变而行手术切除。对5例手术切除标本进行病理镜下检查,分析其与BAG所见的相关性。结果 全部咯血病例,BAG均有不同程度的血管增生紊乱,典型者为扫帚状或网状增生、紊乱的血管束,严重者伴有肺内出血病灶。结合支气管扩张手术标本中的病理所见,如支气管周围支气管动脉的血管数增多、扭曲等,两者的血管改变呈一致性。结论 1 隐源性咯血的病理机制为支气管动脉损伤,而支气管动脉的损伤又为支气管动脉感染所致。故经BAG提示的血管异常改变可以为隐源性咯血的诊断和出血定位提供依据。2 支气管动脉造影和栓塞集诊断与治疗为一体,病人创伤小,且安全有效,在抢救大咯血方面具有实际意义,为控制大咯血提供了一种实用的新途径。     

A case of massive hemoptysis occurring after lung injury due to a torn segment of pleural calcification

A 64-year-old man was referred to our hospital because of little improvement of hemoptysis lasting three days after drug therapy. A chest roentgenogram and fiberoptic bronchoscopic examination performed on the second hospital day when the patient experienced a massive hemoptysis of about 2,000 ml revealed arterial bleeding from the left upper lobe. Even after extensive embolizations of the left upper bronchial, the first, second, third and 4th intercostal arteries, the patient's hemoptysis did not improve. On the 73rd hospital day the patient underwent left upper lobectomy. Macroscopic and microscopic examinations in the resected specimen revealed lung injury due to a torn segment of pleural calcification after tuberculous pleuritis, resulting in the massive hemoptysis. Although physicians encounter many patients complaining of hemoptysis and/or hemosputum, this case is considered to be very rare.     

A case of bronchial arterial aneurysm associated with recurrent massive hemoptysis]

A 69-year-old man was admitted to our hospital because of massive hemoptysis. Bronchial arteriography showed no abnormal findings. Bronchoscopic findings revealed a small, reddish elevated lesion on the posterior surface of the left upper lobe bronchus. Since the patient developed massive hemoptysis four times in a month, he underwent ligation and transection of the left bronchial artery, and bronchoplasty. Histopathologically, the resected tissue showed a bronchial arterial aneurysm without any inflammatory changes. We concluded that the aneurysm had developed in a malformed vessel.     

Etiology and treatment outcomes of massive hemoptysis

Massive hemoptysis is a life-threatening condition and can lead to asphyxiation. This is a retrospective review of 101 patients hospitalized with massive hemoptysis at Srinagarind Hospital, Khon Kaen, Thailand, between January 1993 and December 2002. The male to female ratio was 2.1:1. The average age was 47.1 (SD 16.8) years. Half the subjects were farmers and three-fourths had an underlying disease; most notably old pulmonary tuberculosis (41.6%). The mean duration of massive hemoptysis was 3.2 (SD 3.7) days. An initial hematocrit < or = 30% was found in 34.6% of patients, and a prolonged prothrombin time in 4.0%, and thrombocytopenia in 2.0%. Chest radiographs revealed unilateral, bilateral lesions and normal lungs in 57.4, 40.6, and 2.0%, respectively. A chest CT was done in 14.8% of patients. Bronchoscopy localized the bleeding and diagnosed the etiology in 19.8%. The most common causes of massive hemoptysis were bronchiectasis (33.7%), active pulmonary tuberculosis (20.8%) and malignancy (10.9%). Patients were grouped by treatment: 1) conservative (88); 2) emergency bronchial artery embolization (7); and, 3) emergency surgery (6). Of the 88 patients in group 1, the bleeding was stopped in 71 (80.7%) and recurred in 4. Of the 7 patients undergoing emergency bronchial artery embolization, the bleeding was stopped in 6 (86%) and recurred in 1. In the 6 patients who underwent emergency surgery, the bleeding was stopped in all and recurred in 1. Recurrent hemoptysis usually arose within 7 days of the first episode and was well controlled with bronchial arterial embolization. The mortality rate was 17.8%. Of the discharged patients, 36.1% had recurrent hemoptysis. Most of them occurred within one month after discharge. We conclude that, the most common cause of massive hemoptysis is benign rahter than malignant disease. Intensive care with conservative treatment should be applied vigorously. Bronchial artery embolization is an excellent, non-surgical alternative to control bleeding, and should be done before specific surgical intervention.     

超选择性支气管动脉栓塞术治疗大咯血的临床效果分析

目的探讨超选择性支气管动脉栓塞术治疗大咯血的临床价值。方法 52例大咯血患者经支气管动脉造影明确岀血动脉后行支气管动脉栓塞术,采用明胶海绵颗粒、明胶海绵条或联合弹簧钢圈进行栓塞。所有患者随访3～12月,观察栓塞术后有无再次岀血及并发症的发生。结果 52例患者均顺利完成支气管动脉栓塞术,于一周内咯血症状逐渐消失,其中6例患者分别于术后6月～10月后咯血复发,再次行性支气管动脉栓塞术咯血消失。无严重栓塞术后并发症发生。结论超选择性支气管动脉栓塞术是治疗大咯血安全、有效的治疗方法。     

重视肺动脉瘤性大咯血的诊断与介入治疗

肺部高压的支气管动脉与肺静脉构成体循环,低压的肺动脉与肺静脉构成肺循环,支气管动脉、肺动脉和肺静脉三种血管构成肺部两套循环系统。体循环的高压动脉形成动静脉畸形包括支气管动脉-肺静脉畸形和支气管动脉-肺动脉畸形,动静脉畸形的供养动脉、畸形血管团和引流静脉极易形成动脉瘤,动脉瘤破裂引发大咯血。而肺动脉瘤少见,易被漏诊,肺动脉瘤的血供可单独来源于肺循环或体循环,也可同时累及肺循环和体循环,肺动脉瘤破裂大咯血单纯体循环动脉栓塞难以控制。因此,要重视大咯血患者肺动脉瘤的诊断与介入治疗。     

Tracheobronchomegaly: an exceptional predisposing factor for pulmonary aspergillomas and massive hemoptysis

Mounier-Kuhn syndrome--or tracheobronchomegaly--is a rare congenital disorder characterized by significant dilation of the trachea and main bronchi. It is accompanied by ineffective cough and is often complicated by recurrent lung infections and bronchiectasis. Clinical presentation varies widely, ranging from forms with scarce involvement of functional capacity to others that progress to respiratory failure that can prove fatal. We report an exceptional case of massive hemoptysis secondary to the presence of pulmonary aspergillomas and bilateral bronchiectasis in which bronchial arteriography with embolization and surgical resection were insufficient for resolving the complications.     

A case of successful bronchial artery embolization for primary racemose hemangioma with massive hemoptysis]

We encountered a case of primary racemose hemangioma treatment with successful bronchial artery embolism for massive hemoptysis. A 56-year-old woman with massive hemoptysis was transported to our hospital. The source of the massive hemoptysis was observed to be from around a non-pulsatile polyp covered by normal mucosa occluding the truncus intermedius by fiberoptic bronchoscopy. We stopped the bleeding temporarily using differential lung ventilation, and then bronchial artery angiography was performed. The main right bronchial artery was enlarged, and enlarged and convoluted right peripheral bronchial vessels were also observed. We diagnosed the massive bleeding to be due to racemose hemangioma. A successful bronchial artery embolization (BAE) was performed with gelforms and metallic coils for the treatment of racemose hemangioma. There has been no recurrence of hemoptysis for one year after BAE. There have been many reports on massive hemoptysis as in this patient who were treated by lobectomy, nevertheless we would like to state BAE should be considered as a suitable treatments for primary racemose hemangioma with hemoptysis if there is no recognizable shunt artery.     

Two cases of primary racemose hemangioma of the bronchial artery

Two cases of primary racemose hemangioma of the bronchial artery are reported. The first case was admitted because of massive hemoptysis after transbronchial biopsy in another hospital. Bronchoscopic examination revealed a polypoid tumor of the left B4 bronchus, which was resected and diagnosed as racemose hemangioma. The second case was admitted because of massive hemoptysis. Bronchoscopic examination revealed polypoid tumor in the left B3b bronchus, which was resected and diagnosed as racemose hemangioma.     

支气管动脉栓塞治疗支气管扩张大咯血28例

目的回顾性分析支气管动脉栓塞治疗支气管扩张大咯血。方法对28例支气管扩张大咯血患者进行选择性支气管动脉造影，用明胶海绵颗粒等材料进行栓塞。结果左支气管动脉栓塞10例，右支气管动脉栓塞12例，左右支气管动脉共干6例。确定出血血管栓塞后，28例患者咯血停止，27例3日内未再咯血，有1例仍有咯血，1周后再行栓塞术后，咯血停止。结论支气管扩张大咯血进行内科保守治疗效果不佳而又无法耐受外科手术者，应及时行支气管动脉造影并栓塞治疗。     

Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography

BACKGROUND: Hemoptysis of pulmonary arterial origin is a diagnostic challenge in patients admitted to a respiratory ICU (RICU) for treatment of hemoptysis. Its early accurate recognition and treatment reduce morbidity and prevent mortality. Multidetector row CT angiography (MDCTA) is an accurate method for imaging the systemic vascular network. Our aim was to assess the MDCTA signs and role in managing hemoptysis of pulmonary arterial origin. METHODS: We performed a retrospective clinical and radiologic analysis of all consecutive patients who were referred for severe hemoptysis to our RICU and were treated by endovascular means between January 2004 and December 2006. We reviewed all of those cases with hemoptysis of pulmonary arterial origin. RESULTS: Of 272 patients who were referred for severe hemoptysis to the RICU, 189 patients were treated by endovascular means. Thirteen patients (nine men, four women; mean age, 45 years) had hemoptysis of pulmonary arterial origin. Signs of pulmonary arterial hemoptysis seen on MDCTA were of the following three types: pseudoaneurysm (n = 5); aneurysm of the pulmonary artery (n = 3); or the presence of a pulmonary artery in the inner wall of a cavity (n = 5). Hypertrophy of the bronchial arteries seen on MDCTA associated with any of these signs predicted the necessity to treat both the bronchial and pulmonary arteries. Pulmonary artery vasoocclusion was performed as a first treatment in eight patients with such an association (n = 1) or without such an association (n = 7) along with bronchial artery embolization. The remaining five patients were treated with systemic artery embolization, followed by surgery (n = 1), pulmonary artery vasoocclusion (n = 3), and death from massive hemoptysis (n = 1). CONCLUSIONS: MDCTA performed prior to endovascular treatment allows the correct identification and early appropriate management of severe hemoptysis of pulmonary arterial origin.     

致命性大咯血的病因及其选择性支气管动脉栓塞的疗效分析

目的了解致命性大咯血的病因及其选择性支气管动脉栓塞(bronchial artery embolization,BAE)的疗效。方法对2007年1月至2012年1月期间84例致命性大咯血患者进行病因分类,对2009年8月至2012年1月期间的30例致命性大咯血患者进行选择性支气管动脉栓塞治疗,观察其即刻、近期和远期疗效。结果致命性大咯血的病因分别为肺结核(63例,75.0%)、支气管扩张症(11例,13.1%)、肺曲霉病(6例,7.1%)、肺癌(2例,2.4%)和肺动静脉瘘(2例,2.4%)。对其中30例致命性大咯血患者(肺结核25例,肺曲霉病和肺动静脉瘘各2例,支气管扩张症1例)进行选择性支气管动脉栓塞治疗,即刻止血率达90.0%(27/30)。术后随访5~29个月(平均16个月),近期止血率93.3%(28/30),远期止血率达96.7%(29/30)。结论致命性大咯血的病因主要为肺结核,其次为支气管扩张症和肺曲霉病,BAE是治疗致命性大咯血的首选措施,具有安全、有效、高成功率优点,为基础肺疾病的治愈提供了条件。     

Arteriography and bronchial artery embolization for massive hemoptysis in 100 cases of tuberculous]

Bronchial arteriography and embolization with sponge gelatin were performed in 100 tuberculous patients of massive hemoptysis. Three direct signs and other six indirect ones were found in arteriographies, Those signs were roentgenographic abnormalities for defining bleeding sites. 100 massive hemoptysis cases were treated with sponge gelatin embolization in bronchial artery. The results are satisfactory, the success rate were 92.9%, 87.4% and 79.0% at one week, one month and three months respectively. The advantages of arterial embolization and the reasons of failures were discussed in this paper.     

支气管动脉栓塞术治疗大咯血的疗效分析

目的 :探讨支气管动脉栓塞术治疗大咯血的疗效。方法 :36例大咯血患者用明胶海绵颗粒行支气管动脉栓塞。患者肺部基础病变包括 :支气管扩张 13例 ,肺结核 11例 ,肺癌 9例 ,肺脓肿 1例 ,隐源性咯血 2例。结果 :2 9例即刻止血 (80 .6 % )。在 2年的随访中 ,术后 15d内复发大咯血并窒息死亡者 4例 ,另外 4例复发咯血者 ,3例再次行BAE治疗。支气管动脉栓塞术后因复发而行手术治疗者 2例。因此 ,2年随访总的有效率和复发率分别为 83.3%和 2 2 .8%。主要的并发症为自限性的短暂胸痛和发热。结论 :支气管动脉栓塞术是大咯血的一种安全、微创、高效的治疗方法     

大咯血患者支气管动脉栓塞与支气管镜介入治疗的对照研究

目的 探讨大咯血行支气管动脉栓塞与支气管镜介入治疗的临床价值.方法 对64例大咯血患者行支气管动脉栓塞或支气管镜介入治疗.结果 支气管动脉栓塞组患者即刻止血率、临床治愈率、有效控制率、无效率分别为82.4%、88.2%、5.9%、5.9%,支气管镜介入止血治疗组则分别为53.3%、60.0%、26.7%、13.3%.结论 支气管动脉栓塞较支气管镜介入止血具有止血效果迅速、明显、确切等优点.     

少见病因致咯血四例临床分析

目的提高临床对少见原因引起咯血的诊疗水平。方法对4例已经明确诊断的少见原因引起咯血患者的临床资料进行分析，并结合文献复习。结果4例咯血病因分别是肋间动脉-肺动脉瘘（intercostal—to—pulmonary arterial fistula，IPAF）、肺内错构瘤（pulmonary hamartoma，PH）、单纯性左肺动脉缺如（absence of the left pulmonary artery，ALPA）、原发性肺动脉高压（primary pulmonary hypertension，PPH），均为临床少见病例。IPAF首选支气管动脉造影及栓塞；肺内错构瘤为肺部良性肿瘤，结合病史和影像一般可以获得初步诊断，确诊及治疗依赖手术；ALPA影像检查可以获得诊断，如果合并大咯血，手术治疗是最佳的临床选择；PPH经X线胸片、超声心动图即可获得初步诊断，右心导管检查是确诊的可靠依据。结论咯血为呼吸系统常见症状之一，但少见原因引起的咯血容易误诊。遇到不明原因的咯血患者应详细询问病史并结合临床检查，才能获得正确的诊断及治疗。     

Left ventricular pseudoaneurysm with infective pericarditis: a rare cause of intractable hemoptysis

A 52-year-old man with diabetes presented with recurrent, massive hemoptysis following pericardiectomy for pyopericardium secondary to Streptococcus viridans infection. Chest radiograph and bronchoscopic examinations revealed no bronchial cause. Computed tomography of the chest and echocardiography showed a pseudoaneurysm of the left ventricle. Surgical exploration confirmed that the pseudoaneurysm communicated with the left lung parenchyma and was the cause of recurrent intractable hemoptysis.     

Primary racemose hemangioma of bronchial artery]

A 38-year-old woman was admitted to the hospital because of massive hemoptysis. A chest X-ray film disclosed an infiltrative shadow. A bronchoscopic examination revealed a small, pulsatile, papillary protrusion in the orifice of the middle lobe bronchus, and massive bleeding from the protrusion was observed during the examination. Bronchial arteriography showed convolution and mild hypervascularization of the right bronchial artery. A middle lobectomy was performed, and the protrusion was histologically shown to be a primary racemose hemangioma of the bronchial artery.     

Moderate hemoptysis of unknown etiology.

The underlying cause and treatment of hemoptysis should be addressed promptly to avoid potentially life-threatening complications. We report on a previously healthy 11-year-old white boy who presented with acute hemoptysis. On bronchoscopy, bleeding was noted from the right upper and lower lobes. Right bronchial arteriography revealed multiple regions of abnormal "blushing" throughout the right bronchial arterial distribution which was successfully controlled by right bronchial arterial embolization. In spite of an extensive work-up, we were not able to determine the cause of bleeding. The patient has been followed for 18 months without any recurrence and without evidence of any systemic disease. Our patient does not fit any diagnostic category of pulmonary bleeding and further case reports are needed to delineate this entity.