clinical

Recurrent haemoptysis
Rumi Khajotia
Nalini Somaweera

Keywords: emergencies; general practice; respiratory tract diseases

Case study
A man, 56 years of age, presents to his
general practitioner after coughing up half
a cupful of fresh, bright red blood every
day for 1 week. He has no other medical
complaints. He reports previous pulmonary
tuberculosis 12 years ago treated with 6
months of standard therapy. Routine follow
up was discontinued after 5 years after no
evidence of reactivation. He is a nonsmoker,
does office clerical duties and is not known
to have diabetes or hypertension.
On examination, he is pale with a pulse rate Figure 1. Chest radiograph showing scarring in
of 126 beats per minute. His blood pressure the right upper zone with areas of cavitation
is 90/62 mmHg and his respiratory rate
24 breaths per minute. His chest moves
symmetrically and the percussion note is
resonant bilaterally. Auscultation reveals
normal vesicular breath sounds bilaterally
except for the presence of a few rales at the
right infraclavicular region anteriorly. An
urgent chest radiograph is taken (Figure 1)
and the patient is immediately hospitalised.

Question 1
What do you see on the chest radiograph? Figure 2. Chest radiograph showing fairly
large cavity with a rounded nodular opacity
Question 2
(red arrows)
What other investigations would you perform in
this patient?
Question 6
Question 3 What is the management of this condition?
What would your initial differential diagnoses be?
Answer 1
Question 4 The chest radiograph shows scarring in the right
What is the final diagnosis? upper zone with areas of cavitation (Figure 1).
There is one fairly large cavity measuring
Question 5 3.5x3 cm, within which is a rounded nodular
What is the pathophysiology of this condition? opacity (Figure 2 – marked by red arrows).

128 Reprinted from Australian Family Physician Vol.40, No. 3, march 2011
 Recurrent haemoptysis clinical

hemoptysis in patients with cavitary aspergilloma

There is an area with the appearance of ground consists of living and dead fungal elements,
of the lung: value of percutaneous instilla-
glass that is surrounding the nodular opacity inflammatory cells, epithelial cell debris and tion of amphotericin B. AJR Am J Roentgenol
(Figure 2 – marked by a white arrow), which fibrin.4 1993;161:727–31.
9. Giron J, Poey C, Fajadet P, et al. CT-guided per-
gives it a characteristic ‘halo appearance’. cutaneous treatment of inoperable pulmonary
Answer 6
aspergillomas: a study of 40 cases. Eur J Radiol
Answer 2 Prompt referral and treatment is important 1998;28:235–42.
10. Mal H, Rullon I, Mellot F, et al. Immediate and
Investigation would occur in parallel with and patients may require resuscitation and long-term results of bronchial artery emboliza-
resuscitation and immediate management. airway management. Definitive treatment tion for life-threatening hemoptysis. Chest
Sputum examination for acid fast bacilli smear options include oral itraconazole (effective 1999;115:996–1001.
11. Pratap H, Dewan RK, Singh L, et al. Surgical treat-
and culture for cytology and fungal culture in approximately 60% of patients5) although ment of pulmonary aspergilloma: a study of 72
would be performed as well as full blood treatment may need to be longer than 6 months.6 cases. Indian J Chest Dis Allied Sci 2007;49:23–7.
12. Demir A, Gunluoglu MZ, Turna A, et al. Analysis
examination looking particularly for anaemia Intracavitary instillation of amphotericin B using
of surgical treatment for pulmonary aspergilloma.
and at eosinophil counts. Test also for human bronchoscopy or CT guided percutaneously Asian Cardiovasc Thorac Ann 2006;14:407–11.
immunodeficiency virus serology and aspergillus placed catheters, has been reported as a safe
precipitin antibody (IgG, IgE, IgA levels). A and successful treatment.7–9 For massive
computed tomography (CT) scan of the chest haemoptysis (>300 mL per day) emergency
would provide more detail and fibreoptic bronchial artery embolisation10 or emergency
bronchoscopy and bronchoalveolar lavage of lobectomy may be required. This is technically
the right upper lobe may provide a definitive difficult because of the combination of fibrotic
diagnosis. and vascular tissue.11,12

Answer 3 Authors
Rumi Khajotia MBBS, MD, DM, FAMA, FAMS,
Differential diagnoses include active is Associate Professor, Department of Internal
pulmonary tuberculosis (reinfection or Medicine, International Medical University
reactivation), malignant change in scar tissue Clinical School, and consultant pulmonologist,
(adenocarcinoma), lung abscess, bronchiectasis, Department of Internal Medicine, Hospital
aspergilloma in a chronic tuberculous cavity, Tuanku Ja’afar, Seremban, Negeri Sembilan,
Malaysia. xeruker@yahoo.com
pneumonia (bacterial or fungal) with cavitation,
Nalini Somaweera MBBS, MD, is Senior
Wegener granulomatosis and sarcoidosis.
Lecturer, Department of Radiology, International
Answer 4 Medical University Clinical School, Seremban,
Negeri Sembilan, Malaysia.
The recurrent haemoptysis and radiographic
features (cavity with a nodular opacity Conflict of interest: none declared.
surrounded by a halo appearance) are typical of References
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Treatment of pulmonary aspergilloma with itra-
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the walls of the tuberculous cavity. This leads to 7. Giron JM, Poey CG, Fajadet PP, et al. Inoperable
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injection with glycerin and amphotericin B paste
clinical feature of recurrent haemoptysis that in 15 cases. Radiology 1993;188:825–7.
occurs in over 50% of cases.1,3 The fungal ball 8. Lee KS, Kim HT, Kim YH, et al. Treatment of

Reprinted from Australian Family Physician Vol.40, No. 3, march 2011 129