Hemoptysis: Benign or Not?

Q:What is an appropriate workup for hemoptysis in an adult?Historically, tuberculosis (TB) was the most common cause of hemoptysis. Classic operas, such as La Traviata and La Bohme, featured dramatic scenes of hemoptysis, often with the heroine dying following episodes of deep passion and coughing. Hemoptysis can occur in a wide spectrum of clinical diseases. ^1,2 Lung cancer and airway inflammation (bronchiectasis and bronchitis) have now surpassed TB as the most common etiologies. The cause of hemoptysis often cannot be determined ^1,2; however, vasculitis from interstitial lung disease is now recognized to be responsible for many cases of hemoptysis previously considered idiopathic.³ In patients younger than 40 years, hemoptysis is generally associated with inflammatory disease.

History. The first step in making the diagnosis is a careful history taking. Determine when and how hemoptysis occurred and have the patient describe the expectorated blood. It is important to distinguish hemoptysis from blood that may be spit out after a nosebleed or a minor mouth injury, such as biting the tongue. Blood-streaked sputum in a patient with acute or chronic bronchitis is usually benign. Minor hemoptysis occurs frequently in smokers with chronic bronchitis. "Pure red blood" (1 to 2 tablespoonsful or more) mixed with sputum is a common finding in lung cancer. Hemoptysis that accompanies sudden shortness of breath sometimes results from a pulmonary embolus.

Physical examination. The examination may offer clues in some patients, although often it does not point to a clear diagnosis. Finger clubbing suggests lung cancer, bronchiectasis, or a lung abscess. Telangiectasia of the finger beds and around the lips suggests multiple pulmonary arteriovenous malformations (Rendu- Osler-Weber disease) or hereditary hemorrhagic telangiectasia.⁴ A family history is particularly helpful here. The triad of petechiae, ecchymoses, and splenomegaly suggests a blood dyscrasia, usually a leukemia. Very rarely, one may hear the rumble of a tight mitral stenosis⁵ or the bruit of an arteriovenous malformation.

Diagnostic tests. A complete blood cell count will reveal underlying thrombocytopenia or a blood dyscrasia. Urinalysis results are often abnormal in patients with a pulmonary-renal syndrome. In a patient with hemoptysis, uremia may suggest Wegener granulomatosis or Goodpasture disease. Because many rare diseases present with hemoptysis, further evaluation is usually warranted. A simple spirogram reveals abnormalities in lung mechanics. Airflow obstruction is associated with a high risk of lung cancer in heavy smokers.^6,7 A restrictive pattern suggests the full spectrum of interstitial lung diseases. A chest radiograph is ordered routinely. Apical opacities may indicate fungal disease, TB, or atypical mycobacterial infection. Sputum bacteriology or fungology can confirm the specific diagnosis. A mass, nodule, or atelectasis suggests lung cancer. CT can detect early lung cancer in high-risk patients and is effective in identifying the ground-glass appearance of "capillaritis" (small-vessel vasculitis), which seems to be an increasingly common cause of hemoptysis.⁸ CT is also useful in evaluating hemoptysis in patients who have a non-localizing chest film (Figure). About 20% to 30% of patients with hemoptysis-even those with endobronchial lesions such as lung cancer or pulmonary adenomas-have normal chest radiographs. Fiberoptic bronchoscopy is usually indicated to locate the bleeding site and determine the diagnosis.^1,2 Bronchoscopy can identify small intraepithelial lung cancers- which CT may not detect ⁹and broncholiths, which commonly present with hemoptysis.¹⁰ The cause of hemoptysis must be found, particularly if bleeding recurs in a patient with a history of smoking; this is usually not difficult if a systematic approach is followed. Ultimately, a histologic or microbial diagnosis should be made. In the rare case of a pulmonary vascular abnormality, angiography may be diagnostic. ^5,11

References:

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