A 55-year-old man, who was a former smoker and had chronic silicosis caused by 14 years of work in the granite industry, was admitted to the hospital after an episode of hemoptysis. The amount of blood expectorated was estimated at more than 200 mL. He also had a one-month history of productive cough with blood in the sputum. He had previous history of tuberculosis, with the last episode approximately two years prior, when he received isoniazid, rifampin, and pyrazinamide for two months, followed by four months of isoniazid and rifampin. He had been asymptomatic since then.
On physical examination, the patient was emaciated and pale. His blood pressure was 100/70 mmHg, his pulse was 104 beats/min, and his respiratory rate was 20 breaths/min. Lung auscultation revealed rhonchi and wheezing in both lungs. No other alterations were seen in the physical examination. A blood chemistry screening was normal, including negative finding by anti-HIV. Immunodiffusion tests were negative for Aspergillus.
A chest radiograph (Figure 1) and high-resolution computed tomography (HRCT) of the thorax (Figure 2) showed bilateral conglomerate masses, one with cavitation, associated with multiple small nodules, in addition to calcifications of the hilar and mediastinal lymph nodes, paracicatricial emphysema, architectural distortion, and enlargement of the central pulmonary arteries. No other parenchymal findings were suggestive of active tuberculosis.
The expectorated sputum was negative for acid-fast bacilli and the patient underwent a bronchoscopy that showed evidence of active bleeding. Direct examination of the bronchoalveolar lavage was negative for tuberculosis, fungi, or malignancy. Culturing was positive for Mycobacterium tuberculosis and negative for fungi.
Because of the enlarged pulmonary arteries, Doppler ecocardiography was performed, showing left ventricular diastolic function, mild tricuspid regurgitation, and pulmonary arterial hypertension with a systolic pulmonary artery pressure of 48 mmHg. The patient underwent an angiogram of the common bronchial trunk that showed marked hypervascularity and enlargement of left bronchial artery, which was selectively catheterized and subsequently embolized with polyvinyl alcohol particles (PVA). Bleeding stopped after embolization. The patient was treated for tuberculosis with isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by seven months of isoniazid and rifampin. After the embolization and clinical treatment for tuberculosis, the patient progressed well, with improvement in his respiratory symptoms, and no rebleeding after a follow-up of two years.