A 56-year-old male presented with massive hemoptysis for 2 days. He had been experiencing low grade fever and recurrent episodes of streaky hemoptysis for 5 months. He was managed conservatively at a peripheral centre and was referred to our institute with ongoing episodes of hemoptysis amounting to 15-20 ml per episode. He had been previously treated for pulmonary tuberculosis about 18 years earlier. The hemogram, coagulogram, and routine blood biochemistry were within normal limits: hemoglobin of 8.2 g/dl, total leukocyte count of 7900/mm3 (70% neutrophils, 26% lymphocytes, 2% monocytes, 2% eosinophils) and erythrocyte sedimentation rate (ESR) of 65 mm in the first hour. Platelet count and coagulation profile were normal.
A chest radiograph showed fibrotic opacities and few thin-walled cavities in the left upper zone and an ill-defined nodular opacity in the right middle zone. MDCT angiography was done on a 64-channel multidetector scanner (Brilliance CT, Philips Medical systems, Cleveland, OH, USA) at our institution. The imaging parameters were: detector collimation, 64 x 0.625 mm; pitch, 1.108; gantry rotation time, 0.75 second; reconstructed section thickness, 0.9 mm; reconstruction interval, 0.45 mm; field of view, 350 mm; filter, sharp C; window center, 50; window width, 350; tube voltage, 120 kV; and planned tube current-time product, 250 mAs. High resolution lung window images were obtained with the following parameters: reconstruction section thickness, 0.8 mm; reconstruction interval, 0.4 mm; filter Y sharp; window center, -500, and window width, 1500. Through an intravenous antecubital catheter, 70 ml of nonionic contrast (Iomeron, 400 mg of iodine per ml; Bracco Pharmaceuticals, Milan, Italy) was injected by a power injector (Stellant; Medrad, Indianola, PA) with a flow rate of 4.5 ml/sec, followed by 40 ml saline chase at the rate of 4.0 ml/sec. The region of interest was placed in the descending thoracic aorta, and scanning was automatically initiated once a selected threshold (150 HU) was reached using a bolus tracking method.
MDCT revealed a necrotic nodular lesion and associated fibrotic components in the right middle lobe with areas of ground glass appearance and scattered tiny nodules in adjacent lung parenchyma. Small pocket of air was also present inside the necrotic lesion. MDCT angiography images showed multiple hypertrophied arteries inside the lesion with a small aneurysm (3 x 5 mm) [Figure 1a]. The right bronchial artery was mildly enlarged and could be traced to the parenchymal abnormality in the right middle lobe [Figure 1b]. MDCT also revealed fibrotic opacities in the left upper lobe with two small, thin-walled cavities and bronchiectatic changes in the left upper lobe [Figure 1c]. Based on clinical history and radiological findings, a diagnosis of reactivate tuberculosis with aneurysm formation was made.
The right bronchial artery was catheterized with a 5-F renal curve catheter. Selective arteriography confirmed the diagnosis of aneurysm of the right bronchial artery [Figure 2a]. Then, a microcatheter (Asahi Intec, Moriyama-ku, Nagoya-shi, Aichi 463-0024,Japan ) was advanced coaxially into the right bronchial artery and therapeutic embolization was performed with 300-500 mum polyvinyl alcohol (PVA) particles (Contour, Boston Scientific, Natick, MA 01760-1537, USA). Post-embolization angiogram showed occlusion of feeding vessels and aneurysm [Figure 2b]. Patient was put on antimycobacterial drugs and discharged 2 days later. On follow-up after 2 months, the patient had no recurrence of hemoptysis.