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A5402 - Hemoptysis Caused by an Enlarging Aspergilloma
Author Block: S. Ershadi, P. Buddhadev, P. Jha; Medical College of Wisconsin, Milwaukee, WI, United States.
Introduction: An aspergilloma is a cavity filled with hyphae, cellular debris, mucus, fibrin, and blood that can be a life-threatening cause of hemoptysis if untreated. Case Description: A 67-year-old female with rheumatoid arthritis (RA), antiphospholipid antibody syndrome on warfarin, and chronic pulmonary aspergillosis (CPA) presented with three days of hemoptysis. She presented similarly 7 months ago with URI symptoms. CT chest showed an enlarged aspergilloma that was the likely etiology of her hemoptysis. An embolization of her left upper lobe (LUL) bronchial artery was performed prior to discharge. No antifungal treatment was given as her RA was uncontrolled on her immunosuppressant regimen. On this admission, the patient denied infectious symptoms, and vitals were stable except for tachypnea. Physical exam was only notable for diffuse bilateral inspiratory crackles. Pertinent labs included: INR 1.9, hemoglobin 8.8 (chronic), platelets 264,000, WBC 6.4. Chest X-ray showed the LUL aspergilloma similar to prior image two years ago. Her warfarin was held, but hemoptysis continued and hemoglobin fell to 7.9. CT chest showed the LUL aspergilloma slightly larger than prior with unchanged hypervascularity, and a bronchoscopy did not show any definitive bleeding source. Upon further investigation, it was noted that she had an embolization in 2013 of left lateral thoracic artery (LTA) and lateral internal mammary artery (LIMA) branches supplying her aspergilloma. During her current admission, a bronchial angiogram showed irregular tortuous branches off the LTA supplying the lesion. In addition, multiple irregular/hypertrophied arteries supplying the lesion through the LIMA were noted proximal to prior coil embolization. Both irregular arterial supplies were embolized, the patient’s hemoptysis then resolved, and she was discharged the next day in stable condition. Discussion: Although it is common for patients with hemoptysis to have bronchial artery embolization (BAE), one study found that 30-50% of patients have a re-bleeding episode within 3 years, especially if they are not on antifungal therapy for chronic cavitary pulmonary aspergillosis (CCPA). This study concluded that BAE should be used for controlling massive hemoptysis but repeat procedures may be needed in the future. Another study concluded that patients need definitive treatment of CPA after BAE for massive hemoptysis to ensure long-term success. The cause of this re-bleeding could be due to additional arterial supply from the chest wall. This case demonstrates the importance of treating BAE as a temporizing measure in the setting of hemoptysis due to CPA, and these patients need definitive surgical or medical treatment.