INTRODUCTION: Endobronchial telangiectasias are a rare cause of hemoptysis. They have been reported in association with scleroderma, CREST and hereditary hemorrhagic telangiectasia (HHT). We present a case of a patient with hemoptysis and bronchial telangiectasias successfully treatment with electrocautery.
CASE PRESENTATION: A 67-year-old male presented with two month of persistent hemoptysis. He had no history of fevers, chills, weight loss, or tuberculosis exposure. He had no history of recurrent epistaxis, mucocutaneous bleeding, or melena, and no family history of hereditary hemorrhagic telangiectasia. He had no history of Raynaud's syndrome or dysphagia.His past medical history included smoking, alcoholic liver cirrhosis, remote nephrectomy for living donor transplantation, chronic renal insufficiency, gout, right carotid stenosis. His medications included spironolactone, pantoprazole, aspirin, codeine and citalopram.Physical examination revealed normal vitals signs and pulse oximetry. Cardio-pulmonary examination was normal. Abdominal ascites was present. No pulmonary or hepatic bruits were present. Palmar telangiectasias were present, but oral mucosal telangiectasias were not. Calcinosis or sclerodactyly was absent. Chest radiographs and computed tomography scanning of the thorax were unremarkable. Flexible bronchoscopy was performed under conscious sedation and demonstrated two areas of telangiectasias. The first was at the right upper lobe carina and covered an area ∼1 cm2 [Figure 1]. The second smaller telangiectasia was seen in a left lower lobe basilar segment. Hot biopsy forceps with soft electrocoagulation at 60 watts were used to simultaneously biopsy and coagulate the lesions (Forceps: FD-6C-1, Olympus America, Melville, NY; Electrosurgical generator: ICD350, ERBE USA Inc., Marietta, GA). No bleeding was noted. Pathology was consistent with telangiectasias [Figure 2]. Further investigations revealed a normal arterial blood gas, serum C3 and C4, rheumatoid factor. Antinuclear antibodies were positive at 1/2560 dilution with a nucleolar pattern, no anticentromere antibodies were seen. Testing for Jo-1, RNP, Scl-70, Sm, SS-A/Ro, SS-B/La, Ribo-P and chromatin was negative. On follow-up six months later the patient had no recurrence of hemoptysis.
DISCUSSIONS: Endobronchial telangiectasias causing hemoptysis have been reported in the setting of hereditary hemorrhagic telangiectasia (HHT), scleroderma, and CREST syndrome. Isolated bronchial telangiectasias have been reported in one case.Previously reported management of symptomatic endobronchial telangiectasias has been conservative, with no reports of endobronchial electrocoagulation for treatment of these lesions. Our experience, as well as published data on the utility of endobronchial electrocoagulation in bleeding endobronchial lesions , lead us to consider this modality for this patient. The use of endobronchial electrocoagulation is appealing due to its simplicity, low cost and low side effect profile. Specifically, the risk of airway perforation is very low and less likely than with laser therapy. The multifocal nature of the lesions would also make surgical resection problematic. The use of a hot biopsy forceps allows simultaneous coagulation of the lesion and sample collection for histopathological examination. This allows examination for an underlying malignant lesion as the cause of hemoptysis and vascular proliferation.
CONCLUSION: This patient had endobronchial telangiectasias with clinical and serological features of CREST. Longterm control of endobronchial bleeding was obtained by endobronchial electrocoagulation of the lesions.
DISCLOSURE: Andrea Loewen, None.