Pulmonary hemorrhage due to bronchiectasis

Case contributed by Dr Siobhan Lee

Presentation

Non-smoker with recurrent pleuritic chest pain and LRTIs, presenting with acute hemoptysis.

Patient Data

Age: 45 years
Gender: Female

Initial CTPA

CT

CTPA demonstrates right middle lobe and lingula bronchiectasis, with chronic atelectasis. On the right, ground glass opacity surrounds consolidation in the medial segment.

Ground glass centrilobular nodules in the lower lobes bilaterally and right middle lobe, most conspicuous in the right basal segments.

Endobronchial material in the right middle and lower lobe bronchi.

1 week later

CT

CT angiogram demonstrates increased right middle lobe consolidation with surrounding ground glass change and progression of the ground glass centrilobular nodules in the right lower lobe and lingula. Endobronchial material in the right main bronchus, filling the right middle lobe bronchus.

Prominent arterial collaterals supply the regions of bronchiectasis and chronic consolidation/atelectasis in the right middle lobe (via the right internal mammary artery) and the lingula (via the left gastric artery).

Case Discussion

Pulmonary hemorrhage is one the less common causes of airspace consolidation, and can be superimposed on acute or chronic infection. This case demonstrates progression of the ground glass nodules in a centrilobular distribution within dependent portions of the lung over a week of ongoing hemoptysis, due to aspiration of blood products into the alveolar spaces.

The patient was treated for community acquired pneumonia, with concurrent tranexamic acid. Follow up CT chest 1 week later showed improvement in the right middle lobe consolidation and ground glass nodules. Further 2 weeks later, the patient underwent bronchial catheter angiography, with successful embolization of the right bronchial artery. The fistulous vessel supplying the right middle lobe was confirmed to arise from right internal mammary artery and demonstrated communication with the right pulmonary vein, so was not considered safe to embolize.

This appearance of bronchiectasis involving the right middle lobe and lingula is typical for Mycobacterium avium complex (MAC) infection (Lady Windemere syndrome). However,  in this case, the patient had a known history of chronic bronchiectasis attributed to recurrent infections, but has not been shown to have Mycobacterial infection. 

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