Two Women with Hemoptysis

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Two Women with Hemoptysis

• Ellen Barbouche, MD
• Primary Care Conference
• 8 June 2005
• NO FINANCIAL DISCLOSURE

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Objectives

• Review differential diagnosis of hemoptysis
• Update role of imaging in evaluation of
  hemoptysis
• Explore specific diagnoses of presented cases
• Clinical features
• Diagnostics
• Treatment and outcomes

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Patient 1, History

• 46 year old female with hypertension
• 25 pack/year history tobacco, 1 ppd
• Investment broker and horsewoman
• Productive cough for 5 days
• Blood streaked sputum for 24 hours
• No shortness of breath, rhinitis, or fever
• Slight pleuritic, anterior chest tightness

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Patient 1, Exam

• T 97.8, P 100, BP 124/92, pulse ox 97
• Purulent right posterior nare
• No cervical, supraclavicular, or axillary nodes
• Bilateral rhonchi, clear after cough
• Heart RRR, no S3, no murmur

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Patient 2, History

• 42 year old, previously healthy
• 25 pack/year history tobacco, 1ppd
• Machinist for 6 months and horsewoman
• One week cough, occasional bloody sputum
• Slight dyspnea
• No rhinitis, chest pain, or fevers
• Swollen, painful right ankle

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Patient 2, Exam

• T 97.0, P 88, RR 12, BP 128/78, pulse ox 98
• Nares without mucus or lesion
• Lungs clear bilaterally
• Heart RRR, no murmur, gallop, or rub
• No cervical, supraclavicular, or axillary nodes
• Hot, red, swollen left ankle

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Hemoptysis

• Distinguish from upper respiratory tract or GI
• Airways disease MOST COMMON
• Tertiary hospital study bronchiectasis,
  bronchogenic carcinoma, bronchitis
• Hirshberg, B et al. Chest 1997112440.
• Pulmonary parenchymal disease
• Pulmonary vascular disease
• Other

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Evaluation of Hemoptysis

• History and physical
• Chest radiograph
• Lab guided by history
• Possible CT versus bronchoscopy
• High resolution chest CT demonstrated more tumors
  than bronchoscopy, but not bronchitis
• McGuinness, G et al. Chest 19941051155.

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Patient 1, Chest Radiograph
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Patient 1, Initial Course

• Treatment with azithromycin for community
  acquired, atypical pneumonia
• 2 week follow up
• Decreased cough intensity and sputum production
• Decreased, but persistent, dime-sized hemoptysis

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Patient 1, Chest Radiograph
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Patient 1, Chest CT
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Patient 1, Pulmonary Consult

• Bronchoscopy
• Organizing pneumonitis with 49 eosinophilia
• Cultures negative

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Acute Eosinophilic Pneumonia

• Idiopathic, possibly hypersensitivity reaction to
  inhaled antigen
• 110K US military in Iraq March 2003-2004
• Schorr, AF et al. JAMA 20042922997.
• Resolution of AEP despite smoking
• Kitihara, Y et al. Int Med 2003421016.
• Classic presentation one week febrile illness
  with cough and dyspnea
• 2/3 patients progress to respiratory failure
  requiring mechanical ventilation
• Philit, F et al. Am J Resp Crit Care Med
  20021661235.

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Acute Eosinophilic Pneumonia

• Peripheral eosinophilia develops later in course,
  not at presentation
• CXR subtle reticular opacities progressing to
  bilateral, diffuse mixed alveolar and reticular
  opacities
• CT bilateral, patchy ground-glass or reticular
  opacities
• BAL gt 25 eosinophilia

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AEP, Treatment

• Uniformly responsive to steroids
• Typically continue steroids 2-4 weeks after
  symptom and CXR abnormality resolution
• Allen, JN et al. AM J Resp Crit Care Med
  19941501423.

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Patient 1, Post Rx CT
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Patient 2, Chest Radiograph
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Patient 2, Laboratory

• WBC 18.9K, 15K neutrophils
• Hemoglobin 10.3, Platelets 275K
• Sedimentation rate 47, CRP 5
• Creatinine 1.1
• UA Protein 1, WBC 6-10, RBC gt50
• C-ANCA gt11280
• ANA negative

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Wegeners Granulomatosis,Respiratory Involvement

• Multisystem vasculitis
• Classic respiratory tract and kidneys
• Limited respiratory tract largely
• Symptoms
• Rhinorrhea, often bloody, with oral or nasal
  ulcers
• Cough, hemoptysis, and pleuritic pain
• Fever, malaise, eye symptoms, arthritis, rash

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Wegeners, Laboratory Findings

• Leukocytosis, normocytic anemia, elevated
  sedimentation rate
• C-ANCA
• Positive gt90 limited OR classic
• Majority autoantibodies to proteinase 3
• Minority p-ANCA with myeloperoxidase antibodies
• UA
• Limited Wegeners normal UA
• Renal involvement may elevate creatinine, and
  show proteinuria or active sediment

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Wegeners Chest Radiography

• Nodules, possibly cavitary
• Single or multiple
• Approximately 50 cavitary
• Alveolar opacities
• lt 5 alveolar hemorrhage
• Pleural opacities
• Cordier, JF et al. Chest 99097906

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Wegeners Diagnosis

• Histopathologic evidence of vasculitis and
  granuloma
• Most likely from lung biopsy
• Renal biopsy more likely to show focal segmental
  necrotizing glomerulonephritis
• Jennette, JC et al. Am J Kidney Dis 199424130.
• Compatible clinical presentation

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Wegeners Treatment

• Cyclophosphamide, with or without steroids
• Serious morbidity and mortality due to
  cyclophosphamide
• 60-80 recurrence
• WGETRG NEJM 2005352351.

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Patient 2, Course

• Difficult due to chest pain, likely related to
  Wegeners
• Severe anemia due to renal insufficiency,
  pulmonary hemorrhage, and cyclophosphamide
• Very gradual improvement, though not yet able to
  work

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Hemoptysis, Conclusions

• Multiple possible sources of hemoptysis
• Bronchiectasis, bronchoalveolar carcinoma,
  bronchitis most common from lower respiratory
  tract
• Most effective work up history and physical plus
  chest radiography
• Above guide lab, HRCT, and bronchoscopy

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Specific Diagnoses

• Acute Eosinophilic Pneumonia
• Idiopathic
• Frequently very severe
• Excellent response to steroids

• Wegeners Granulomatosis
• Vasculitis affecting respiratory tract kidneys
• Usually c-ANCA
• Dangerous treatment with frequent recurrences