A 63-year-old male, never-smoker, alcoholic and a known diabetic and hypertensive, was admitted to our hospital with a 7 days history of low-grade fever and cough with expectoration and recent development of mild hemoptysis, two days prior to admission.
He reported no weight loss. His vitals were stable and chest radiograph revealed left upper lobe cavitating lesion. Flexible bronchoscopy was done which showed bleeding from the apicoposterior segment of the left upper lobe. His postbronchoscopy sputum and bronchial washings were positive for acid-fast bacilli (AFB).
One day after admission, the patient developed an episode of massive hemoptysis of more than 400 mL that later continued amidst resuscitative measures.
He was adequately resuscitated. CTPA (Computed Tomographic Pulmonary Angiography) was done, which showed an aneurysm measuring 8.6 x 7.3 mm along the apical segmental branch of the left upper lobar pulmonary artery suggestive of Rasmussen's aneurysm. Dense consolidation in the apicoposterior and lingular segments of the left upper lobe-probably secondary to pulmonary hemorrhage and thick-walled cavities in the apical segment of left upper lobe were also noted. (Fig. 1 & Fig. 2).
His hemoptysis further worsened and an urgent attention of interventional radiologist was sought. He underwent emergent embolization procedure. Initially a 5F cobra catheter was used to catheterize the right bronchial and intercostal arteries. These runs appeared unremarkable for any abnormal findings. Left bronchial artery had to be catheterized with Mikaelson catheter, this run revealed significant blush in the left upper zone with associated pseudoaneurysm. Microcatheter was used to obtain purchase distally into the largest branch of the left bronchial artery. The runs were reviewed to rule out any significant spinal vascular contribution before injecting PVA particles. PVA particles of 500-700 mum mixed with saline and contrast were injected under subtracted fluoroscopy. Angiogram revealed absent parenchymal blush and non-opacification of the previously detected aneurysm. (Fig. 3 & Fig. 4).
Check angiography of the serial intercostal arteries on either side did not reveal any significant bronchial supply. The left subclavian artery, left internal mammary artery, the cervical branches of the left subclavian artery were angiographically assessed and they appeared unremarkable for significant supply to the left upper lobe cavitary lesion.
Post procedure, there was no further hemoptysis and patient's clinical status improved. He was discharged with instruction to continue antitubercular therapy as advised. Patient completed treatment course for six months. He was followed for more than a year and half from discharge and there was no further recurrence of hemoptysis.
Contrast enhanced CT of the upper chest reveals large area of consolidation in the apicoposterior segment of the left upper lobe with air bronchograms and small foci of cavitation.