Hemoptysis in a Patient with Lingular Pneumonia

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 53-year-old African American female (AAF) was admitted to the hospital with a chief complaint (CC) of coughing up blood for one day. She was seen two days ago in the ED with a cough, diagnosed with bronchitis and prescribed Augmentin. Her CXR did not show any infiltrates. She started to cough up blood with the sputum, and to have shortness of breath (SOB). She also had sore throat, runny nose, and chills.

Past medical history (PMH)

COPD (Chronic Obstructive Pulmonary Disease).

Medications

Augmentin (amoxicillin and clavulanate) and tramadol (Ultram).

Allergies

Erythromycin, rash.

Social history (SH)

Smoker, half a pack a day (ppd) for 15 years.

Physical examinaton

VS 36.7-103-18-112/58.
SpO2 91% on RA.
In NAD.
HEENT: Erythematous pharynx.
Chest: (B) wheezing, LLL dullness to percussion.
Abdomen: Soft, NT, ND, +BS.
CVS: Clear S1S2.

What is the most likely diagnosis?

The patient has hemoptysis which is a medical emergency and a potentially life-threatening condition. You should attempt to measure the approximate amount of bloody sputum.

The DDx for hemoptysis can be remembered by the mnemonic BATTLE CAMP:

Bronchitis, bronchiectasis
Aspergillosis
TB
TU
Lung abscess
Embolism (PE)

Cocaine use
AV M
Mitral stenosis
Pneumonia

What laboratory workup would you order?

CBCD, CMP, ABG.
Repeat the CXR despite the previous CXR being done only 2 days ago.
EKG.
INR/PTT.
Type and screen 2 U PRBC.
Spiral CT to R/O PE?


CBC, BMP; CBCD (click to enlarge the images).

What happened?

The CXR showed a lingular infiltrate. The spiral CT confirmed the infiltrate and ruled out PE. CBCD revealed WBC of 18,000 with 70% bands.

Moxifloxacin IV was started. Blood and sputum culture were negative.

The patient was afebrile and had no further hemoptysis. The PPD was negative and the follow-up CXR showed a resolving infiltrate. Her condition improved and she was discharged.


Lingular pneumonia, Lateral CXR; CXR report (click to enlarge the images).


Lingular pneumonia on CT chest; CT report (click to enlarge the images).


Lingular pneumonia on CT (lung windows) (click to enlarge the images).


Pneumonia treatment (click to enlarge the images).

Final diagnosis

Lingular pneumonia with hemoptysis.

What did we learn from this case?

Hemoptysis is a medical emergency. Occasionaly, the cause may be less dangerous such as bronchitis or pneumonia. Any patient with hemoptysis needs urgent evaluation and treatment.

Further reading


Blood clot cast of the bronchi of a patient with lung cancer who bled into the airway. Image source: unboundedmedicine.com, used under the license of Creative Commons.

Haemoptysis in Oxford handbook of clinical medicine By Murray Longmore, Ian B. Wilkinson, Supraj R. Rajagopalan:



Published: 02/12/2004
Updated: 08/02/2009

2 comments:

  1. Great case. Thanks for the OHCM link.

    ReplyDelete
  2. I saw a 32 y/o wf with cough x2 wks.cxr showed fullness in the left suprahilar soft tissue. A ct scan of the chest showed lingular infiltrate. Pt was treated with Avelox. Pt Improved.

    ReplyDelete