Hemoptysis_Kawaoka

8/4/2019 Hemoptysis_Kawaoka

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Chief Complaint: Cough, hemoptysis, chest pain

Kelly Kawaoka, M.D.Loma Linda University Medical Center


2/18

Case Presentation

17 yo Hispanic female with Type I Diabetes Mellitus, multipleprevious admissions for diabetic ketoacidosis

Presented initially with 10 days of chest pain, cough, and laterdeveloped hemoptysis

Diagnosed with diabetic ketoacidosis (DKA) and pericarditissecondary to pneumonia by chest CT at an outside facility

Bronchoscopy revealed necrotic tissue on the left mainstembronchus

DKA resolved with appropriate treatment, but only minor

clinical improvement of respiratory status with antibiotics On presentation, afebrile, saturating well on 2 liters/minoxygen

Bilateral rhonchi, diminished on left with crackles, high-pitched expiratory wheezes


3/18

Labs/Imaging

White blood cell count: 19,700 per L

Serum glucose 268 mg/dL

HgbA1C 10.1%

Westergren sedimentation rate (ESR) >140 mm/hr[normal 0-20 mm/hr]

C-reactive protein (CRP) 8.5 mg/dL [0-0.8 mg/dL]

Chest CT Progressive consolidation in the lower left lobe with

persistent bilateral pleural effusions

Thickening of the left lower lobe mainstem bronchus

Enlarged subcarinal and left hilar lymph nodes


4/18

Chest CT

Mediasinal mass with infiltration into the left atrium


5/18

Hospital Course

Bronchoscopy: no viral cytopathic changes,atypia or malignant cells on washings

Chest tube drainage (3)

Video-Assisted Thoracoscopic Surgery (VATS)Pathology

Abscess, granulation tissue, chronic inflammation

Lymph node benign Inconclusive for infection or malignancy

Endoscopic ultrasound (EUS)


6/18

Endoscopic Ultrasound

Irregularly shaped hypoechoic mass in the left posterior

mediastinum measuring approximately 2.5 x 1cm


7/18

Pathology

Non-septated hyphae in an inflammatory background


8/18

Treatment

Ambisome started, changed to posaconazole

and rifampin slight clinical improvement

Repeat bronchoscopy confirmed Mucor

Pneumonectomy when the mass and

symptoms did not resolve with antibiotics


9/18

Case Discussion

Pulmonary zygomycosis

Rapidly progressive

Affects the immunocompromised

Present with fever and hemoptysis Spread locally to the mediastinum and heart or

hematogeneously to other organs

Most common etiology: hematologic malignancy

May see with diabetes, more frequent with rhino-orbital-cerebral infection


10/18

Conclusion

When available, transesophageal biopsy with

EUS is preferred over thoracoscopy high diagnostic yield

less invasive technique fewer complications

No other cases using EUS to diagnose Mucor

in the current literature


11/18

Learning Objectives

Know that diabetic patients are at higher risk fordeveloping infections

Know that fungal infections can be devastating in the

immunocompromised host Know that the diagnosis of pneumonia in an

immunocompromised host may require aggressiveprocedures, including bronchoscopy

Review the differential diagnosis of a mediastinalmass in children and adults

Review presentation of mediastinal masses


12/18

Mediastinal Masses: Ddx

Children Adults

Neurogenic tumors (P)

Enterogeneous cysts (A)

Neurogenic tumors (P)

Thymomas (A)

Thymic cysts (A)Lymphadenopathy* (M)

Hodgkins/Non-Hodgkins

lymphoma (A)

More often symptomatic,respiratory distress or

recurrent pulmonary infection

More often asymptomatic,

Vague complaints such as aching

pain or cough

A = anterior, M = middle, P = posterior

*Due to infectious, malignant/metastatic, idiopathic causes


13/18

Mediastinal Masses: Presentation

Airway compression Recurrent pulmonary

infection or hemoptysis

Esophageal compression dysphagia

Spinal column involvement paralysis

Phrenic nerve damage elevated hemidiaphragm

Recurrent laryngeal nerve damage hoarseness

Sympathetic ganglion compression Horner's Superior vena cava involvement SVC syndrome


14/18

References

Krasnik M; Vilmann P; Larsen SS; Jacobsen GK (2003).Preliminary experience with a new method of endoscopictransbronchial real time ultrasound guided biopsy fordiagnosis of mediastinal and hilar lesions Thorax.58(12):1083-6.

Tedder, M, Spratt, JA, Anstadt, MP, et al. Pulmonarymucormycosis: Results of medical and surgical therapy. AnnThorac Surg 1994; 57:1044.

Brown, RB, Johnson, JH, Kessinger, JM, Sealy, WC.Bronchovascular mucormycosis in the diabetic: An urgent

surgical problem. Ann Thorac Surg 1992; 53:854. UpToDate. Evaluation of Mediastinal Masses

http://www.utdol.com


15/18

Question

A 3-year-old female is transported by ambulance to theemergency department. She had been treated withamoxicillin for the past eight days for suspected pneumoniaand now presents with worsening of symptoms: cough, fever,

and most recently coughing up blood. Physical examinationincludes a respiratory rate of 40 breaths/min, heart rate of 85beats/min, oxygen saturation of 92% on room air, bloodpressure of 100/70 mm Hg, and temperature of 102.3F(39C). She is awake and alert but has difficulty speaking in

full sentences. On auscultation, you note diffuse cracklesthroughout her lung fields. Chest x-ray shows a mediastinalmass, which is confirmed to be anterior on CT.


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Question

After initial stabilization, the BEST next step

in the management of this patient is to

A. Administer methylprednisolone

B. Start a different oral antibiotic

C. Measure the pH of the bloody secretions

D. Transfuse packed red blood cells


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Answer - C

Hemoptysis, is uncommon in pediatrics, but acute lower respiratory tractinfection is the leading cause today, accounting for 40% or more of cases.Other causes include cystic fibrosis and congenital heart disease, both canpresent as recurrent bleeding. In children younger than 4 years of age,foreign body aspiration should be considered. Unlike in adults, neoplasmis an uncommon cause of hemoptysis in children.

The first step in the evaluation of a child who has hemoptysis is todetermine the source of the bleeding. Blood from hemoptysis is typicallybright red and frothy with an acidic pH rather than the dark or "coffeeground" alkaline material produced in hematemesis. Epistaxis generallycan be established after careful examination of the oropharynx andnasopharynx.

The source of the bleeding for the child in the vignette likely is eitherpulmonary infection or foreign body obstruction. Methylprednisolonemay be of benefit for a foreign body aspiration prior to bronchoscopy.The presence of the mediastinal mass makes this scenario less likely.


18/18

Answer - C

Initial therapy with antibiotics is appropriate only aftercollection of blood and sputum samples if pneumonia issuspected. IV antibiotics would be a more appropriate choicegiven that she has failed oral therapy. Most hemoptysis in

children resolves spontaneously without the need for invasivemeasures.

This child had one episode of hemoptysis without massivebleeding so would most likely not need a blood transfusion.

Patients whose hemoptysis does not resolve spontaneously

or who experience marked blood loss may requirebronchoscopy to determine the source of the bleeding.

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