Expanding cavitary lung lesions may lead to erosion of thoracic or extrathoracic blood vessels and hemoptysis. Hemoptysis in pulmonary aspergillosis usually stems from the bronchial vasculature, and invasion of major blood vessels is more common in tuberculosis or pulmonary malignancies. We present a case of massive hemoptysis due to invasive aspergillosis eroding the subclavian artery and successful treatment with an endovascular stent.
An 82-year-old male presented with a twelve hour history of intermittent hemoptysis and pre-syncope. Admission hemoglobin level was 8.0 g/dL. He was being treated for an expanding left upper lobe cavitary lesion previously diagnosed as chronic necrotizing aspergillosis. CT scan of the chest and arteriography revealed a new pseudoaneurysm on the inferior margin of the left subclavian artery (Figure 1). The pseudoaneurysm communicated directly with the inflammatory rim of the lung cavity suggesting a direct erosion of the arterial wall. An endoluminal stent graft was placed into the subclavian artery over the pseudoaneurysm. (Figure 2). Hemoptysis completely resolved within 48 hours of the procedure.
Intrathoracic vascular pseudoaneurysms may arise in a variety of necrotizing pulmonary processes that extend to involve nearby blood vessels. Most recognized is Rasmussen’s aneurysm of the pulmonary artery in cavitating pulmonary tuberculosis, a rare cause of massive hemoptysis. Vascular pseudoaneurysms from expanding aspergillosis-related lung cavities have been reported, but only one prior case report was found describing involvement of the subclavian artery. Aspergillosis-related pseudoaneurysms are almost exclusively found in severely immunocompromised patients. Our patient was only mildly immunocompromised from recent use of corticosteroids and had structurally abnormal lungs from COPD. The progression of the previously known cavitary lesion was likely a treatment failure of itraconazole due to inadequate absorption from concomitant use of a proton pump inhibitor.
This case illustrates a rare complication from expanding pulmonary aspergillosis as an unusual cause of hemoptysis. Secondly, it emphasizes the importance of recognizing the state of mild immunosuppression as a risk factor for the development of chronic necrotizing aspergillosis and the need to initiate aggressive appropriate antifungal therapy.
Lorenzo Klein, No Financial Disclosure Information; No Product/Research Disclosure Information