INTRODUCTION: Fiberoptic bronchoscopy (FB) with transbronchial biopsy (TBBX) is a commonly used tool in assessing the etiology of pulmonary parenchymal infiltrates in immunocompromised patients.
CASE PRESENTATION: A 31 year-old male, non-smoker, underwent orthotopic liver transplant in May of 2010 for nonalcoholic steatohepatitis. Two months later, the patient was diagnosed with a pulmonary embolism, for which warfarin therapy was initiated. Five months post-operatively, the patient was hospitalized for abdominal pain and diarrhea. Cytomegalovirus (CMV) DNA quantitative serology was positive for which intravenous ganciclovir was prescribed. Warfarin was held. Aspirin 81mg daily was continued. Mycophenolate mofetil was discontinued but the patient remained on cyclosporine. Pathology from colonoscopy with biopsy was consistent with CMV colitis. Warfarin remained on hold and intravenous unfractionated heparin (IVUFH) was initiated. The patient also noted a nonproductive cough and dyspnea in association with findings of groundglass opacities in the bilateral lower lung fields on computed tomography (CT) of the chest. A bronchoscopy was scheduled. The IVUFH was held for 8 hours prior to the bronchoscopy. There was no thrombocytopenia or renal dysfunction. Pre-procedure PTT was 1.2 times the upper limit of normal (ULN) and INR was 1.40. FB with bronchoalveolar lavage (BAL) and TBBX of the middle lobe was completed without complication. IVUFH was resumed, without a bolus, 8 hours after completion of the procedure. No bacterial, fungal, or viral organisms were isolated from the BAL. Pathology revealed mild peribronchial chronic inflammation with immunostains negative for CMV. Six days following the procedure, the patient developed right-sided pleuritic chest pain and hemoptysis requiring transfer to the intensive care unit. Warfarin had previously been restarted and INR was 1.70 with PTT of 2.4 times the ULN. The patient was given four units of fresh frozen plasma and both warfarin and IVUFH were discontinued. CT scan of the chest revealed no evidence of a pulmonary embolism but was notable for a rounded consolidation predominantly within the right major fissure with partial extension into the middle lobe measuring 11.7 x 6.9 x 7.3 cm, consistent with a pulmonary hematoma. Repeat bronchoscopy revealed a large clot occluding the lateral segment of the middle lobe bronchus. Twenty-four hours later, the hemoptysis resolved. Anticoagulation for the prior pulmonary embolism was not resumed and a retrievable inferior vena cava (IVC) filter was placed. Four weeks later, anticoagulation was not restarted as the hematoma had not decreased in size. The IVC filter was not retrieved given the presence of a 40% occluding intraluminal thrombus. Two months after the episode of hemoptysis, the patient developed another pulmonary embolism and anticoagulation was restarted without incident. In consultation with hematology, the patient was recommended lifelong anticoagulation. Four months following the episode of hemoptysis, the pulmonary hematoma diminished to half of the original size and at six months it has nearly resolved.
DISCUSSION: Although generally well-tolerated, bleeding is the most commonly recognized complication of FB with TBBX in immunocompromised patients. Bleeding is typically minor (less than 100 mL), clinically insignificant, and occurs within the first 24 hours following the procedure. To our knowledge, this is the first reported case of FB with TBBX causing hemoptysis and pulmonary parenchymal hematoma in a liver transplant patient. This phenomenon has rarely been reported to occur 4 to 30 days following FB with TBBX in lung transplant recipients.
CONCLUSIONS: Physicians must be cognizant of pulmonary hematoma as a rare complication of FB with TBBX which can occur beyond 24 hours of procedure completion and appears to occur more frequently in patients who are immunocompromised.
Reference #1 Jain P, Sandur S, Meli Y, et al. Role of Flexible Bronchoscopy in Immunocompromised Patients With Lung Infiltrates. Chest. 2004; 125:712-722.
DISCLOSURE: The following authors have nothing to disclose: Amanda Godfrey, Daniel Ouellette, Krishna Thavarajah
No Product/Research Disclosure Information