SESSION TITLE: Cardiovascular Cases I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: Most common etiologies of massive hemoptysis include bronchiectasis, tuberculosis, aspergilloma, malignancy, vasculitides, valvular heart diease and pulmonary arterio-venous malformations. Bronchial artery to pulmonary artery fistula (BAPAF) have been reported to cause massive hemoptysis,but usually arise in background of chronic inflammation, malignancy or trauma. The literature with BAPAF causing massive hemoptysis in absence of significant parenchymal lung disease is extremely limited. We are presenting one such case.
CASE PRESENTATION: 58 year old male with a history of type 2 Diabetes Mellitus and ESRD came with multiple episodes of hemoptysis,cumulative more than 600 ml in a day. He did not have previous history of hemoptysis. He remained hemodynamically stable and did not require intubation for airway protection. His lung fields were full with no adventitious sounds. CT of the chest did not reveal parenchymal abnormalities other than mild emphysema. Bronchoscopy revealed blood spilled throughout the the tracheobronchial tree, but no mass or source of active bleeding identified. He was discharged to home in view of clinical stability and spontaneous resolution of hemoptysis.He returned to the ER 10 days later with recurrent massive hemoptysis. Chest CT remained unchanged. Bronchial angiography revealed bronchial artery pseudoaneurysms with BAPAF in the right upper and lower lobes. The right upper lobe pseudoaneurysm and AVF were treated with micro-coil embolization. Patient did not have any further recurrence of hemoptysis at 6 month follow up.
DISCUSSION: BAPAF is a rare cause of massive hemoptysis, which has been described in setting of chronic lung inflammation including infections, malignancies, status post thoracic surgery and post-trauma. CT chest and bronchoscopy in search of these conditions were unrevealing in our patient. There was no history of chest trauma or surgery. He did not have constitutional symptoms or other systemic involvement, other than his baseline ESRD and DM.There are 2 reported cases of BAPAF in absence of predisposing conditions. One reported a pediatric patient, but CT finding did reveal consolidation unlike our case, and the other one did not have hemoptysis.
CONCLUSIONS: It is important to consider BAPAF as a differential diagnosis in patients presentingwith hemoptysis, particularly if imaging and bronchoscopy are unrevealing. It is not impossible to have isolated BAPAF in absence of predisposing lung parenchymal/airway or systemic diseases, which can result in life threatening complications like massive hemoptysis.
Reference #1: Yon JR, Ravenel JG. Congenital bronchial artery-pulmonary artery fistula in an adult. J Comput Assist Tomogr. 2010 May-Jun;34(3):418-20.
Reference #2: Nugent Z, Oliveira V, Maclusky I, Amaral J, Connolly B, Yang CL. Bronchial artery-pulmonary artery malformation as a cause of cryptogenic hemoptysis. Pediatr Pulmonol. 2012 Nov 5.
DISCLOSURE: The following authors have nothing to disclose: Kelly-Ann Patrice, Abhishek Sharma
No Product/Research Disclosure Information