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C h est I ma g e
A fatal cause of hemoptysis Chen-Yi Liao, En-Hua Huang1, Shao-Ting Chou
Departments of Internal Medicine and 1Radiology, Kaohsiung Armed Forces General Hospital, Lingya District, Kaohsiung, Taiwan, ROC Address for correspondence: Dr. Chen-Yi Liao, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Zhongzheng 1st Road, Lingya District, Kaohsiung, Taiwan, ROC. E-mail:
[email protected]
An 87‑year‑old Taiwanese man with history of hypertension and type 2 diabetes mellitus presented with progressive hemoptysis with increasing frequency and amount for 5 days. He had a spiking fever and tachycardia. Laboratory investigation showed leukocytosis, normocytic anemia and a very high C‑reactive protein level. Sputum for acid‑fast bacilli was negative. An upright posteroanterior view of chest radiography revealed a mass lesion encircling the aortic arch [Figure 1a], and computed tomographic scan with contrast of the chest demonstrated a contrast extravasation outside the aortic arch enclosed by a necrotic tissue with air bubbles suggestive of a ruptured mycotic aneurysm over aortic arch [Figure 1b and c]. The patient underwent empiric antibiotic treatment, resection of the necrotic lung and vascular tissue with final culture results of Escherichia coli and successful thoracic endovascular graft repair. This case demostrateed a mycotic aneurysm of the aortic arch with rupture manifested by hemorrhage following aneurysmal rupture or uncontrolled systemic sepsis. Hematogenous dissemination of microorganisms, direct involvement of the intima, or extension from a nearby septic focus caused by E. coli species are infrequently observed.[1] Hemoptysis is a rare manifestation of ruptured mycotic aneurysm over the aortic arch and usually results from subsequent aortobronchial fistula.[2,3] Imaging studies including computed tomography angiography and magnetic resonance angiography can aid in confirming diagnosis if a widened mediastinum or a bizarre shadow of aortic arch appears. Empiric antibiotic use, aggressive surgical Access this article online Quick Response Code:
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Figure 1: (a) Chest radiography revealed a mass lesion encircling the aortic arch. (b and c) Chest-computed tomography demonstrated a contrast extravasation outside the aortic arch enclosed by a necrotic tissue with air bubbles suggestive of a ruptured mycotic aneurysm over aortic arch distal to left subclavian artery
resection of the infected aorta and necrotic tissue with vascular reconstruction, or thoracic endovascular graft repair are the mainstays of treatment.[3] Financial support and sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
REFERENCES 1. 2. 3.
Yano M, Hayase T, Furukawa K, Nakamura K. Mycotic pseudoaneurysm of the ascending aorta caused by Escherichia coli. Interact Cardiovasc Thorac Surg 2013;16:81‑3. Chung SL, Ding YA. Fatal hemoptysis in dissecting aortic aneurysm and salmonellosis: A case report. Zhonghua Yi Xue Za Zhi (Taipei) 1999;62:817‑22. Heneghan RE, Singh N, Starnes BW. Successful emergent endovascular repair of a ruptured mycotic thoracic aortic aneurysm. Ann Vasc Surg 2015;29:843.e1‑6.
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DOI: 10.4103/2320-8775.159880
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How to cite this article: Liao CY, Huang EH, Chou ST. A fatal cause of hemoptysis. J Assoc Chest Physicians 2016;4:39.
© 2016 The Journal of Association of Chest Physicians | Published by Wolters Kluwer - Medknow
