An 88-year-old woman visited our emergency department due to hemoptysis. She had hypertension, diabetes mellitus, and dementia due to cerebral infarction. She also had interstitial pneumonia and had been followed up at our hospital but had voluntarily interrupted treatment.
At the time of this admission, her vital signs were normal, and fine crackles were heard from bilateral lower lungs. White blood cells count was increased (19,140 /microL) and serum level of C-reactive protein was slightly increased (3.71 mg/dL). Her hemoglobin level was 8.0 g/dl, hematocrit was 23.1 %, Mean Corpuscular Volume was 80.5 fL, platelet count was 290,000 /microL. Antinuclear antibody, perinuclear-antineutrophil cytoplasmic antibody (ANCA) and C-ANCA were all negative. The result of Interferon-Gamma Release Assay was indeterminate. Chest radiography (Figure 1(Fig. 1)) showed bilateral reticular shadows but no finding of cavity lesions. Contrast-enhanced chest CT showed a honeycomb lung in the right lower lung field and infiltrative shadow and ground glass shadow in the left lower lung field (Figure 2A(Fig. 2)). A contrast-enhancing aneurysm was seen within the infiltrative shadow in the left lower lung, but no obvious cavitary lesion was seen (Figure 2B-D(Fig. 2)).
We thought the patient's hemoptysis was caused by an aneurysm in the lower left lung field. We performed angiography (Figure 3(Fig. 3)) and successfully performed endovascular coil embolization of an aneurysm in the pulmonary artery. After these treatments, sputum screening tested positive for acid-fast bacillus. She was diagnosed with pulmonary TB based on the result of polymerase chain reaction positive for mycobacterium TB. She was treated with isoniazid (INH), rifampicin (RFP), and ethambutol (EB) without pyrazinamide (PZA) due to problems with liver function. No recurrence of hemoptysis was observed after successfully treating pulmonary TB.
Contrast-enhanced chest CT on admission revealed grand-grass shadow and findings of honeycomb lung in bilateral lower lungs, and infiltrating shadow in the lower left lung field (A).