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Blood Clot Cast Following Hemoptysis and Resulting in Atelectasis

1976; Elsevier BV; Volume: 69; Issue: 1 Linguagem: Inglês

10.1378/chest.69.1.131a

1931-3543

James B. Skatrud, Robert Gilbert, J. Howland Auchincloss, Shamsudden Rana,

Hemodynamic Monitoring and Therapy

To the Editor: Atelectasis secondary to bronchial occlusion by a blood clot cast following hemoptysis has been reported as a complication of pulmonary tuberculosis1Wilson JL Hemoptysis in tuberculosis followed by massive pulmonary atelectasis.Am Rev Tuberc. 1929; 19: 310-313Google Scholar, 2Hennel H Massive pulmonary atelectasis.Arch Intern Med. 1929; 44: 604-620Crossref Scopus (4) Google Scholar but has received little attention in the recent literature. A 70-year-old woman was admitted to our service with progressive dyspnea and pleuritic chest pain. Ventilation and perfusion scans were consistent with multiple pulmonary emboli. Because of increasing dyspnea and hypoxemia, the patient was intubated and placed on assisted ventilation. Heparin was administered, and a tracheotomy was performed. Nine days after admission, she had a major hemoptysis followed by severe respiratory distress. Chest x-ray films revealed a new density in the right lower lobe with extensive opacification of the right base, suggesting right lower and right middle lobe collapse. Fiberoptic bronchoscopy three days after the severe hemoptysis demonstrated a glistening polypoid mass on the posterior lateral wall of the bronchus intermedius (Fig 1). A second bronchoscopic examination two days later revealed the same lesion. On the next day, the patient coughed up a cast of the bronchial tree through the tracheostomy tube (Fig 2). A third bronchoscopic examination revealed no trace of the previous mass, and chest x-ray films over the next few days showed almost complete clearing. Pathologic examination revealed the cast to be a blood clot containing necrotic debris.Figure 2Expectorated blood clot cast; scale in centimeters.View Large Image Figure ViewerDownload (PPT) The appearance of a blood clot cast on bronchoscopic examination is probably quite variable and related to both the age of the clot and the nature of the debris trapped within it. The cast in our patient appeared quite different from that of the apparently much more recent clot shown by Stradling3Stradling P Diagnostic Bronchoscopy. Williams and Wilkins Co, Baltimore1973: 111Google Scholar Persistent atelectasis following hemoptysis should suggest the presence of a blood clot cast; had we strongly considered this possibility when we first observed the mass, gentle attempts at removal would probably have been successful.