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Pulmonary Manifestations of Systemic Disease: Systemic Disease |

Hemiparesis With Hemoptysis FREE TO VIEW

Rahul Mutneja, MBBS; Aaron Glucksman, MD; Tapas Bandyopadhyay, MD
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University of Connecticut Health Center, Farmington, CT


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(4_S):A476. doi:10.1016/j.chest.2016.02.495
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SESSION TITLE: Systemic Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: A Pulmonary arterio-venous malformation (PAVM) is a direct communication between the branches of pulmonary artery and pulmonary veins and may be congenital or acquired. These lesions are anatomical right to left shunts and may cause strokes as well as high output heart failure and hypoxemia. Increased blood flow and increased venous distensibility secondary to progesterone effect in pregnancy may increase PAVM growth and its associated complications. Majority of subjects are diagnosed in the first three decades of life.

CASE PRESENTATION: A 36-year-old female presented to us with complaints of “blood in her mouth”. She initially noted it two years ago during her only pregnancy. This subsided spontaneously. She subsequently had two further episodes four weeks apart prior to current presentation during menstruation. She also has history of two episodes of transient ischemic attacks with a negative neurological work up. Prior workup included a normal Gastrointestinal and Otolaryngologic evaluation. Her vitals and physical exam was entirely normal. Initial laboratory investigations revealed a normocytic anemia. Blood chemistry, coagulation parameters, and serologies were normal. A computed tomography angiography (CTA) of the chest revealed an opacity in the left lower lobe suggestive of arteriovenous malformation (AVM). A bronchoscopy was negative for endobronchial lesions or bleeding. The patient underwent embolization of the AVM feeding artery with an amplatzer plug with resolution of her symptoms.

DISCUSSION: PAVM can be congenital or acquired, with the former being more common. Majority of the congenital PAVM's are associated with hereditary hemorrhagic telangiectasia (HHT)1. PAVM may be asymptomatic or present with a classic triad of dyspnea, cyanosis and clubbing. Hemoptysis can occur from intrabronchial rupture of PAVM or endobronchial telangiectasia. Pregnancy has been associated with an increased rate of PAVM growth and its associated complications2. A high index of suspicion is needed for diagnosis. Diagnosis is made by CTA, calculation of shunt fraction and contrast echocardiography. Treatment options include embolotherapy3 or lung resection if embolization fails.

CONCLUSIONS: 1. PAVM are rare causes of hemoptysis, stroke and hypoxia 2. Identification is important due to association with Hereditary Hemorrhagic Telangiectasia and associated complications 3. PAVM tend to increase in size and be more symptomatic during pregnancy 4. Embolization of the feeding artery is highly effective in treatment.

Reference #1: Khurshid I, Downie GH. Pulmonary arteriovenous malformation. Postgrad Med J. 2002;78(918):191-197.

Reference #2: Esplin MS, Varner MW. Progression of pulmonary arteriovenous malformation during pregnancy: case report and review of the literature. Obstet Gynecol Surv. 1997;52(4):248-253.

Reference #3: Lee DW, White RI, Jr., Egglin TK, et al. Embolotherapy of large pulmonary arteriovenous malformations: long-term results. Ann Thorac Surg. 1997;64(4):930-939; discussion 939-940.

DISCLOSURE: The following authors have nothing to disclose: Rahul Mutneja, Aaron Glucksman, Tapas Bandyopadhyay

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