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Haemoptysis in a patient with a history of thoracic surgery should generate great alarm. Clinicians should not be distracted by concurrent haematemesis.
A man aged 42 attended his local casualty department with a history of ‘coughing up’ and ‘vomiting’ blood. Three days previously he had awoken with pleuritic pain which he attributed to muscle strain from karate training. The pain persisted, and on the day of presentation he experienced a gurgling sensation in the back of his throat and then expectorated and vomited 500 mL of fresh red blood. The only history of note was a patch-graft repair of coarctation of the aorta 27 years earlier. His pulse was 75/min and blood pressure 130/80 mmHg. On chest and abdominal examination nothing remarkable was found; peripheral pulses were symmetrical. A chest radiograph (Figure 1) showed no parenchymal lesions but the thoracic aorta at the site of the aortic knuckle was prominent. With no previous films available for comparison the implication of this finding was initially overlooked. Attention focused on the history of haematemesis. He underwent upper gastrointestinal endoscopy next day but there was no evidence of active or recent bleeding. On review of the chest radiograph a consultant radiologist suspected a thoracic aneurysm. An intravenous contrast enhanced CT scan of his chest then showed a 4 cm by 3 cm mass, associated with the proximal descending aorta, that filled with contrast (Figure 2). The patient expectorated a further 200 mL of blood and was transferred immediately to the regional cardiothoracic centre. On arrival, he was anxious and nauseated and his arterial blood pressure rose steadily. At a pressure of 170/100 mmHg he was started on an infusion of sodium nitroprusside. While preparations were made for urgent surgery he experienced a further episode of haemoptysis and his blood pressure fell to 90/60 mmHg. The nitroprusside infusion was stopped and he was transferred to the operating theatre. Full cardiopulmonary bypass was established through the femoral vessels, he was cooled to 18 °C to protect the brain and spinal cord, and the proximal descending aorta was replaced with a woven Dacron prosthesis during a short period of circulatory arrest. He made a good recovery.
Massive haemoptysis, defined as expectoration of between 200 mL and 1000 mL of blood in 24 hours, is rare and accounts for less than 1.5% of all cases of haemoptysis1. It may be caused by primary diseases of the lung parenchyma or of the aorta. Historically, tuberculosis and bronchiectasis were the most common primary lung diseases that caused massive haemoptysis but, as their incidence declined, bronchitis and carcinoma of the lung became more important1. Disruption of the aorta often results in sudden death from exsanguination into the hemithorax. However, in some cases local inflammation causes the lung to adhere to the aorta with formation of an aortopulmonary fistula. The onset of haemoptysis then offers a small window of opportunity to save the patient. Before 1960, mycotic aneurysms caused by tuberculosis, syphilis, and other infections were the leading causes of aortopulmonary fistula due to aortic disease. Today the predominant causes are atherosclerosis and thoracic aortic surgery2.
Haemoptysis in any patient with a history of thoracic surgery must be treated with the utmost suspicion. Concurrent haematemesis must not distract the clinician from the diagnosis. Blood may appear in the back of the throat without the patient being certain of its origin. While inhaled irritants elicit a cough reflex, warm blood may elicit either no response or a gag reflex. Consequently, the blood may seem to have been vomited. Matters may be further confused because some blood is swallowed and vomited later. A careful history, examination and plain radiographs should point to the diagnosis. A mediastinal mass on plain chest radiographs demands urgent investigation with cross-sectional imaging or angiography and early involvement of cardiothoracic surgeons.