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An Unusual Cause of Refractory Life-Threatening Hemoptysis: A Multidisciplinary Challenge FREE TO VIEW

Huthayfa Ateeli, MBBS; Laura Meinke, MD; Janet Campion, MPH; Carlos Cantu, MD; Michael Flores, MD
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University of Arizona, Tucson, AZ

Chest. 2013;144(4_MeetingAbstracts):624A. doi:10.1378/chest.1701622
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SESSION TITLE: Cancer Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Massive hemoptysis may be caused by airway diseases, vascular malformations, neoplasms, vasculitides, and infections. In some cases the cause remains elusive, even following thorough investigation. Here, we present a case in which the cause is found only on autopsy.

CASE PRESENTATION: An 85 year-old male presented with a month-long history of hemoptysis. He endorsed dyspnea and chest pain but denied fever. Past medical history was significant for coronary artery disease and essential thrombocytosis. Aspirin therapy had been held. He had a 30 pack-year smoking history and denied risk factors for tuberculosis. A chest x-ray done at initial presentation revealed a right upper lobe infiltrate. He was treated for community acquired pneumonia. The patient presented with worsening hemoptysis several days later. Chest CT showed multiple patchy consolidations without masses, adenopathy or thromboembolism. Sputum cultures grew MRSA and Vancomycin was started. Bronchoscopy showed blood in the left lower lobe. Bronchial arteriogram was normal. Due to continued hemoptysis, patient was transferred to our hospital. During repeat bronchoscopy patient developed profound hypoxia, massive hemoptysis and hemodynamic instability. He was intubated and underwent immediate pulmonary angiogram. No bleeding source was localized. In the ICU, patient continued to have hemoptysis and required 8 units of packed red blood cells. Pulmonary angiogram with selective arteriograms of the intercostal arteries, descending thoracic aorta, axillary and subclavian arteries were performed, without identification of a bleeding source. A comprehensive bleeding tendency assessment was normal. Vasculitis work up was negative. Repeat bronchoscopy showed active multi-lobular bleeding without endobronchial lesions. Cytology tests were negative. Patient continued to deteriorate and care was withdrawn based upon previously stated wishes. Autopsy showed “extensive pulmonary hemorrhage secondary to high-grade sarcoma involving multiple areas of the lungs.”

DISCUSSION: Pulmonary sarcomas are very rare, comprising less than 1% of all lung cancers. Despite aggressive analysis, the exact nature of the malignancy in this patient could not be ascertained. If diagnosed early, resection may be curative. However, given the paucity of cases, little is known about the natural history of this malignancy, or about the most appropriate therapy.

CONCLUSIONS: Thorough investigation may fail to reveal the cause of massive hemoptysis. In such patients, one must consider the possibility of an underlying, yet elusive malignancy.

Reference #1: Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest. 2001;120(5):1592.

Reference #2: Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.

Reference #3: Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of hemoptysis. Arch Intern Med 1991; 151:2449.

DISCLOSURE: The following authors have nothing to disclose: Huthayfa Ateeli, Laura Meinke, Janet Campion, Carlos Cantu, Michael Flores

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