A 45-year-old non-smoker male patient presented to the emergency department of a territorial hospital complaining for hemoptysis. On the day of admission, he reported that he had expectorated approximately 50ml of bright red blood. He denied any other symptoms, including fever, cough, dyspnea or chest pain. On his medical history he reported a similar episode of hemoptysis 5 years ago the cause of which remained unknown despite clinical investigation which included computed tomography (CT) of the chest, immunologic examinations and fiberoptic bronchoscopy. The patient denied any other medical problem and was not receiving any medication.
On physical examination, he was a pleasant apparently healthy man with body temperature 36,8  C, pulse rate 110 beats/min, blood pressure 130/80 mmHg, respiratory rate 21 breaths/min and oxygen saturation 95% on room air. Auscultation disclosed mild crackles in the right lower lobe. No other abnormal findings were found in the rest of the physical examination. In the laboratory tests, the patient's hemoglobin was 13.1g/dL, hematocrit: 40.7%, white blood cell count was 7410 cells/muL (77.6% neutrophils and 15.1% lymphocytes), and platelet count was 161 000/muL, D-Dimers: 436mug/L (normal values up to 500mug/L) while the values for urea nitrogen, creatinine and electrolytes were within the normal range. Immunologic tests revealed only slightly increased Antinuclear Antibodies (ANA) (1:160). Sputum Gram stain, cultures for common bacteria and examination for M Tuberculosis were negative. ECG was normal.
The patient's chest x-ray on admission, revealed an area of consolidation in the middle lobe. Computed tomography of the chest revealed some bronchiectasis along with an area of consolidation in the middle lobe. The patient was admitted and received oxygen therapy, intravenous amoxycilline-clavulanic acid and intravenous tranexamic acid at a dose of 1 g four times daily.
During the following days, the patient continued to experience streaks of blood in his sputum on a daily basis sometimes accompanied by dyspnea and tachypnea, and 2 days later, a new episode of massive hemoptysis occurred, and the patient was transmitted to our hospital for further evaluation and treatment. On admission to our hospital the patient underwent a CT angiography of the thoracic aorta and its branches (including bronchial arteries) which revealed some mild anatomical abnormalities in the bronchial arteries suppling the right lower lobe and ground glass opacities in the middle and right lower lobe, without showing a specific bleeding origin (Fig. 1). Although the examination was not sensitive enough, it also gave the impression of a thrombus in the left main artery. Thus, a CT pulmonary angiography was performed which revealed a large thrombus on the left main artery involving the pulmonary arteries for the left upper, the lingual, and the left lower lobe (Fig. 2). An ultrasonography was performed and the presence of a thrombus in the lower extremities and the pelvis was excluded. Echocardiography did not reveal any cardiac abnormalities. Although the leg and pelvis ultrasonography was negative, an inferior vena cava temporary filter (ALN Optional Vena Cava Filter, ALN, France) was placed via femoral approach since anticoangulant treatment was contraindicated. Tranexamic acid was discontinued.
A few hours later the patient experienced a new episode of massive hemoptysis and became severely dyspneic. On clinical examination he was found to be tachypneic, tachycardic and hypotensive. Oxygen saturation had dropped to 78% on room air. An emergency angiography was performed with the aim of embolizing any potential sources of bleeding from the bronchial circulation. Selective angiography from the right bronchial artery revealed extravasation of contrast from three different branches of the middle lobe and embolization was performed using a micro-catheter (Progreat , Terumo, Japan) and N-butyl-2-cyanoacrylate (NBCA; Histoacryl ) diluted in a 1:3 ratio, with oily X-ray contrast agent Lipiodol . Final angiogram demonstrated complete occlusion of the target vessels without any sign of bleeding (Fig. 3). Following this procedure, the patient was stabilized and returned to the ward. Hemoptysis has been ceased.
However, the patient became febrile and developed chest pain in the right hemithorax together with cough and expectoration of dark bloody sputum. Post-procedural chest CT revealed a consolidation of the right lower lobe suggestive of a pneumonia (Fig. 4). High-flow oxygen was administered to achieve target saturation of 94-98%. Blood cultures were collected (their result was available a few days later and they were negative) and antimicrobial therapy was changed to meropenem and linezolide. 3 days after bronchial embolization, the patient's symptoms improved and hemoptysis was completely settled down. The patient received treatment with subcutaneous fondaparinux (in a dose of 7.5mg administered subcutaneous once daily) and underwent monitoring of anti-Xa activity twice a week. The patient was discharged a few days later with the advice to continue treatment with fondaparinux and to return 3 months later for the removal of the inferior vena cava filter. By that time his symptoms had disappeared and he had remained free of hemoptysis. Follow up chest CT demonstrated complete resolution of the consolidation and no other signs of parenchyma disease.
Chest CT revealing multiple foci of ground glass opacity in the middle and right lower lobe.