INTRODUCTION:Hemoptysis can range from blood-streaked sputum to frank blood without sputum. There are numerous causes of hemoptysis, but it is rare in a young individual without any history of trauma or foreign body aspiration.
CASE PRESENTATION:A 21-year-old white male presented with hemoptysis for the past two years. His hemoptysis has been clear sputum with blood streaks which worsens when he lays on his right side, exerts himself, or is exposed to dust. He denies fever, chills or rigors. He has had 20 pound weight loss and intermittent night sweats over the past year. The patient has a past medical history of bipolar disease, 16 pack year history of smoking, and occasional marijuana abuse. He was recently incarcerated for 6 months and in the past has had multiple negative PPD tests. He denies any recent travel and occupational or environmental exposures. He works as a roofer installing shingles. He is not on any medications and physical examination was unremarkable. Posterior-anterior (PA) and lateral chest roentogram revealed a mass in the right middle lobe along the right heart border. He had a computerized tomography (CT) scan of the chest with intravenous contrast which showed a 3.8 by 2.6 cm right middle lobe mass abutting the superior vena cava (SVC) and pericardium. The lesion was partially calcified in the center. A flexible bronchoscopy was performed and did not reveal any endobronchial lesions. The bronchoalveolar lavage (BAL), cytology brushings, and transbronchial biopsies were all negative for infection and malignancy. He underwent a video-assisted thoracoscopic surgery (VATS) to remove the mass. Frozen-section intra-operatively was reported as adenocarcinoma (bronchoalveolar). However, the final pathology report revealed pneumocytoma (sclerosing hemangioma).
DISCUSSIONS:Sclerosing hemangioma was first described by Liebow and Hubbel in the 1950’s. It is usually a solitary lung nodule with metastasis being very rare. It is more commonly seen in women and usually is an incidental finding on chest radiograph.Pneumocytoma has two unique histologic features. The first is the marked proliferation of sclerotic, small blood vessels with areas of hemorrhage. The hemorrhage causes hemosiderin-laden histiocytes, cholesterol clefts, and calcifications. The second histologic feature is the cell population of mononuclear cells with pale cytoplasm and pneumocyte-like cuboidal cells. It is now believed the origin is from type II pneumocytes. Occasionally neuroendocrine tumor components and areas of mucin production occur as seen in this case.
CONCLUSION:Pneumocytoma is a rare, benign tumor of the lung seen mostly in middle-aged women. The pathogenesis of this tumor is not known, but there have cases of local metastasis to the neighboring lymph nodes. The prognosis of sclerosing hemangioma is excellent. It is usually found as an incidental finding and should be considered in the wide differential for hemoptysis.
DISCLOSURE:Harjyot Sohal, None.