Hemoptysis

Jud W. Gurney, MD, FACR

DIFFERENTIAL DIAGNOSIS

Common

Bronchogenic Carcinoma
Metastases
Infection
- Tuberculosis
- Aspergilloma
- Lung Abscess
Bronchiectasis
Bronchitis
Pulmonary Emboli

Less Common

Diffuse Alveolar Hemorrhage
Cardiac Causes
- Congestive Heart Failure
- Mitral Stenosis

Rare but Important

Pulmonary Artery Aneurysm
Arteriovenous Malformation (AVM)
Broncholithiasis
Pseudosequestration
Kaposi Sarcoma

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Hemoptysis definition
- Expectoration of blood that originates from airways or lung
- Massive hemoptysis: > 300 mL in 24 hours
- Majority have identifiable etiology
  - Cryptogenic hemoptysis 3-15%
- Bronchial arteries most common source of bleeding
Bronchial artery anatomy
- Orthotopic origin: Arises from descending aorta at level of 5th or 6th thoracic vertebra
- CT location
  - Right bronchial artery at level of carina
  - Left bronchial artery(s) at level of proximal left main bronchus
- Classic branching pattern
  - Type 1: 1 right intercostobronchial trunk and 2 left bronchial arteries (40%)
  - Type 2: 1 right intercostobronchial trunk and 1 left bronchial artery (20%)
  - Type 3: 1 intercostobronchial trunk, right bronchial artery, 2 left bronchial arteries (20%)
  - Type 4: 1 intercostobronchial trunk, right bronchial artery, 1 left bronchial artery (10%)
- Ectopic origin: Bronchial arteries arise from other than expected site
- Bronchial artery diameter > 2 mm abnormal

Helpful Clues for Common Diagnoses

Bronchogenic Carcinoma
- Hemoptysis usually seen in advanced cancers, accounts for up to 20% of cases of hemoptysis
- Smokers > 40 years old with cryptogenic hemoptysis: 5% will develop lung cancer within 3 years
- Carcinoid tumors
  - Often highly vascular, may enhance with intravenous contrast
Metastases
- Hemorrhagic metastases: Commonly from choriocarcinoma, renal cell carcinoma, melanoma, thyroid
- CT: Multiple variable-sized nodules surrounded by ground-glass opacities
Tuberculosis
- Common cause of hemoptysis, generally seen in those with active cavitary disease
- Rasmussen aneurysm: Pulmonary artery aneurysm arising adjacent to cavitary wall, hemoptysis may be massive
Aspergilloma
- Saprophytic mycelia growth in preexisting cavity
- Hemoptysis may be massive
Lung Abscess
- Hemoptysis may be massive; foul-smelling sputum typical
Bronchiectasis
- Accounts for up to 25% of hemoptysis, may be massive
- Distribution clue to etiology
  - Central bronchiectasis: Allergic bronchopulmonary aspergillosis, tracheobronchomegaly, Williams-Campbell syndrome
  - Upper lobe bronchiectasis: Cystic fibrosis, tuberculosis, allergic bronchopulmonary aspergillosis
  - Ventral bronchiectasis: Mycobacterium avium complex
  - Lower lobe: Postinfectious, aspiration
Bronchitis
- Accounts for 20% of cases of hemoptysis
- Dieulafoy disease: Abnormal dilated submucosal vessels from chronic inflammation
- CT usually normal; may have bronchial wall thickening; focal ground-glass opacities and consolidation suggest active hemorrhage
Pulmonary Emboli
- Hemoptysis from pulmonary infarcts
- Infarcts in < 10% of embolic episodes
- Infarcts are pleural-based, wedge-shaped, with no contrast enhancement

Helpful Clues for Less Common Diagnoses

Diffuse Alveolar Hemorrhage
- Inflammatory process involving blood vessels (large, medium, or small)
- Spectrum includes Wegener granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome
- CT: Nonspecific lobular ground-glass opacities admixed with consolidation; crazy-paving pattern more common as hemorrhage resolves
- Hemoptysis in 66%
Cardiac Causes
- Frothy blood sputum in congestive heart failure (accounts for 5% of cases of hemoptysis)
- Patients with mitral stenosis may have repeated bouts of hemorrhage leading to hemosiderosis

Helpful Clues for Rare Diagnoses

Pulmonary Artery Aneurysm
- Causes: Swan-Ganz-induced pseudoaneurysm, Behçet syndrome
- Swan-Ganz pseudoaneurysm: Mortality 45-65%
  - Usually lower lobe segmental artery in perihilar location
Arteriovenous Malformation (AVM)
- Epistaxis presenting features in hereditary hemorrhagic telangiectasis (HHT)
- AVM vessels have thin walls, at risk for rupture
- Rupture more common in pregnancy
Broncholithiasis
- Hemoptysis in 50%
- Peribronchial calcified lymph node that distorts or narrows adjacent airway
Pseudosequestration
- Pure vascular pulmonary sequestration; lung and bronchi normal
- Also refers to transpleural systemic-pulmonary artery anastomoses (most commonly seen with pulmonary artery stenosis)
Kaposi Sarcoma
- AIDS-related multicentric neoplasm involving skin, lymph nodes, GI tract, and lungs
- Diffuse peribronchial nodules emanating from hilum