Digging into a Cavitary Lesion – Virtual Morning Report – August 5, 2022

Dr. Daniel Boctor presented a fascinating case at virtual morning report on August 5th. The discussion highlighted many important themes including the differential diagnosis and management of hemoptysis, the differential diagnosis for a cavitary diagnosis, and *spoiler alert* the diagnosis of a Rasmussen Aneurysm.

65M w/ IDDM presenting with acute onset hemoptysis.
Chest X-Ray

Differential Diagnosis for Hemoptysis

There is a broad differential for hemoptysis, including but not limited to the following list:

  • Pseudo-hemoptysis
    • Upper Airway Bleeding
    • Upper GI Bleed
    • Serratia pneumonia
  • Primary Vascular
    • AV Malformation
    • Pulmonary Embolism
    • PA Rupture
  • Parenchymal Abnormality
    • Pneumonia
    • Tuberculosis
    • Lung Abscess
    • GPA
  • Tracheobronchial Abnormality
    • Bronchiectasis
    • Neoplasm
    • Bronchitis
    • Airway Trauma
  • Other
    • Coagulopathy

Remember, when managing hemoptysis, your first job is to triage.

  1. Triage: Is this massive hemoptysis (>150cc/24 hour or >100cc/1 hour)? Is there impaired gas exchange or hemodynamic instability attributable to hemoptysis?
  2. ABCs: Always start here! Does your patient require urgent intubation? (Remember, always position your patient with the “bad lung down” when concerned for massive hemoptysis to prevent blood pooling in the unaffected lung)
  3. IV Access and Resuscitation: make sure you have sufficient access, resuscitate appropriately, and correct any bleeding diathesis
  4. Imaging: Start CXR, then CT chest, then bronchoscopy if needed

This patient was found to have a cavitary lung lesion infiltrating the left pulmonary artery – the likely culprit for the bleed! So what cavitates?

Our spectacular ID consultant, Dr. Jen Babik, and Rheumatology consultant, Dr. Sarah Goglin discussed bacterial (nocardia, TB), fungal (yeast, endemic fungi, molds), and autoimmune (GPA) causes.

Dr. Boctor taught us about the final diagnosis in this case – a rare diagnosis called the Rasmussen Aneurysm. These aneurysms can cause massive hemoptysis, with mortality associated with pulmonary artery rupture. Whereas tuberculosis can often cause hemoptysis via bronchial artery hypertrophy and weak bronchopulmonary communications, a Rasmussen’s Aneurysm leads to the formation of granulation tissue in place of the tunica media and adventitia of the pulmonary artery, ultimately leading to pseudoaneurysm formation and rupture. These aneurysms will likely ultimately need embolization or coiling, in addition to long term treatment of active pulmonary tuberculosis with RIPE therapy.

Stay tuned for more fascinating cases from morning report across the three hospital sites: Zuckerberg San Francisco General Hospital, UCSF – Parnassus campus, and the San Francisco VA Medical Center.

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