Fatal Hemoptysis Due to Lung Abscess and Pulmoaortic Fistula: Discussion

22 Feb

On the fourth hospital day, hemoptysis occurred after repositioning the endotracheal tube. Bronchoscopy showed moderate tracheitis and blood in both mainstem bronchi. A large blood clot was removed from the right side. A bleeding site could not be identified. Culture of the bronchial washings grew normal flora. An AFB smear was negative and cytologic findings were benign. Computed chest tomography (Fig 3) demonstrated a mass in the upper part of the left chest. The radiologist thought it was extrapleural and lay between the great vessels and the left lung. The adjacent left upper lobe had areas of consolidation. Bilateral effusions were present. The aorta was heavily calcified, but no aneurysm was seen. Images obtained after contrast did not reveal an intimal flap. A chest surgeon was consulted and felt the patient was not a surgical candidate regardless of diagnosis. No further diagnostic studies were done. The patient was supported with blood products and antibiotics, but massive hemoptysis occurred and the patient died. buy zoloft online

At autopsy, the left lung weighed 1,100 grams. A 6 X 6 cm abscess was present in the medial aspect of the left upper lobe and was adherent to the descending thoracic aorta. Numerous Gram-positive cocci were seen microscopically and Staphylococcus aureus grew from postmortem cultures from the abscess. A small communication was noted between the abscess and the aorta. There was no evidence for mycotic aneurysm of the aorta or other great vessels.
Several aspects of the case presentation bear comment. The cause of the hemoptysis remained obscure until autopsy. Plain roentgenograms of the chest never showed the typical features of lung abscess. Computed tomography certainly added information, but could not define the nature of the lesion or even localize the lesion as being in the lung. Air space disease was present but was suspected to be aspirated blood. Bronchoscopy added little and was difficult as is often the case when hemoptysis is massive. Sputum cultures, even those obtained at the time of bronchoscopy, never grew staphylococcal organisms. Arteriography would have been the next diagnostic procedure, but also would have been nondiagnostic.
Hemoptysis may occur in up to 40 percent of patients with lung abscess, but massive hemoptysis complicates fewer than 10 percent of these cases. Where pathologic material is available, involvement of the pulmonary artery is the most common site of bleeding. Mortality from massive hemoptysis of any cause is high and this appears to be true when the cause is lung abscess as well. Surgery must always be considered. In a series by Crocco et al, four patients treated without surgery died, whereas the two who went to surgery survived. In the series by Thoms et al, the one patient who did not have surgery died, whereas the seven who went to surgery survived.
The finding of a lung abscess at autopsy was a surprise. The premortem diagnosis was mycotic aneurysm, which has been reported as a cause of fatal hemoptysis. Massive hemoptysis due to pulmoaortic fistula has previously been reported in the setting of trauma and an aortic patch graft. We suspect that the marked atherosclerosis present in this case was a predisposing factor.

Figure 3. CT scan of the chest demonstrating the mass seen in Figure 2. The mass is of acute onset and lacks air bronchograms, suggesting that it lies outside the lung in the mediastinum.

Figure 3. CT scan of the chest demonstrating the mass seen in Figure 2. The mass is of acute onset and lacks air bronchograms, suggesting that it lies outside the lung in the mediastinum.