48-year-old man with sudden onset of 3-4 episodes of massive hemoptysis. Overview

  • Presenting Complaint
  • Patient History
  • Review of Systems
  • Physical Examination
  • Diagnostic Test
  • Diagnostic Imaging
  • Diagnosis and Management
  • Discussion

A 48-year-old man was admitted to hospital with sudden onset of 3-4 episodes of massive hemoptysis.

  • History of presenting
  • Past Medical/Social hoistory
  • Past surgical history
  • Family history
  • Current Medication
A 48-year-old man was admitted to hospital with sudden onset of 3-4 episodes of massive hemoptysis.  The total volume was> 500 mL within a 24-hour period.  He was also complaining of worsening shortness of breath associated with cough.
positive for hypertension
no previous diagnosed history of COPD, autoimmune disease, tuberculosis,
no previous bleeding disorders.
Previous PPD test negative.
Personal history-smoker
none
positive for DM in father
hydralazine 100 MG PO tid for BP
  He denies any chest pain.  No history of fever, chills, skin rashes or joint pains or hematuria. no history of trauma

General

BP 125/70, RR 16, TEMP 101 F , Norm cephalic, conjunctivae/corneas clear. PERRL, EOM's intact. Septum midline. Mucosa normal. No drainage or sinus tenderness.

Heent

no thyromegaly, conjunctiva normal , normal dentition, no JVD

Neck

no carotid bruits, trachea midline, no lymphadenopathy,

Cardiovascular

RRR, extra heart sounds auscultated.- 4/6-PANSYSTOLIC murmur was best heard over the cardiac apex

Lungs

CRACKLES RIGHT MID LUNG FIELD, respiratory distress , no retractions. No wheezing.

Abdomen

Soft, Non tender on palpation , normal BS, no hepatosplenomegaly. No rebound

Extremities

extremities normal, atraumatic, no cyanosis or edema, pulses positive and symmetric

Skin

normal turgor, no rashes,

Neurological Exam

no focal neurological deficits, normal power, sensations normal. reflex within normal range
  • Bio Chemistry
  • Pathology
  • Microbiology
  • Hematology
  • Miscellaneous

Sodium: 136 meq/L( normal 135-145 meq/L)

Potassium: 3.7 meq/L (normal 3.5-5.0 meq/L)

Chloride: 101 meq/L(normal 96-108 meq/L)

Bicarb: 23 meq/L(normal 22-30 meq/L)

Magnesium: 2.1 mg/dl ( normal 1.7 to 2.2 mg/dL )

Phos.: 2.9 mg/dl ( normal 2.8 to 4.5 mg/dL)

Bun: 22 mg/dl ( normal 6-23 mg/dL)

Creat: 1.5 mg/dl ( normal 0.7 -1.3 mg/dL)

Liver Enzymes - SGOT/AST: 22 U/L ( normal 1-35 )

SGPT/ ALT: 33 U/L ( normal 1-45 )

GGT: 24 U/L ( normal 8-38 )

Direct Bilirubin: 0.2 mg/dl ( normal 0.1-0.3 )

Total Bilirubin: 1.1 mg/dl ( normal 0.1 - 1.2 )

Hemoglobin: 9.5 mg/dl

Hematocrit: 22 %

White Count: 9000 ( normal 4,500 to 11,000 WBCs per microliter )

Platelets: 170,000 platelets per microliter of blood ( normal 150,000 to 450,000 platelets per microliter of blood)

Differential: normal

CRP: WNL

ESR: WNL

  • CT Scan
  • Xray
  • MRI
  • Ultrasound
  • Echo
  • Endoscopic
  • Miscellaneous

airspace consolidations in the right upper and middle lobes with faint, bilateral ground glass opacity and left atrial enlargement

mild cardiomegaly and consolidations on the right  lung

 

Ejection fraction of 45% with normal ventricular size, an enlarged left atrium and severe mitral regurgitation (Grade IV) with significant prolapse of the mitral valve (P1).pulmonary artery systolic pressure was elevated, with minimal aortic and tricuspid regurgitation

  1. fiberoptic bronchoscopy -DIFFUSE alveloar hemorrhage in right middle lobe with no evidence of endobronchial mass lesion seen on  bronchoscopic examination , persistently pinkish color seen in the retrieved bronchoalveolar lavage fluid.

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FINAL DIAGNOSIS

 

MITRAL VALVE REGURGITATION CAUSING HEMOPTYSIS

Etiology of this MR INCLUDE  myxomatous infiltration of the valve with consequent mitral valve prolapse., ischemic MR, Marfan’s syndrome, Ehlers-Danlos syndrome, traumatic MR, endocarditis, and acute rheumatic myocarditis. He has  no physical findings to suggest vasculitis and connective tissue.

disease. The patient fully recovered after valvuloplasty of mitral valve. Usually causes bilateral lung shadows, but approximately 8% of mitral regurgitation, the localized right upper lobar bleeding is observed which is attributable to the uneven distribution of regurgitant jet flow.  This can often be explained by the anatomical features of the pulmonary vein. Regurgitant jet flow resulting higher hydrostatic pressure in the right upper and middle lobe pulmonary veins than in the right lower lobe.  Also the drainage of the right middle lobar pulmonary vein into the right upper lobar pulmonary vein results in this combination.

The present case suggests that acute MR with sporadic primary mitral valve prolapse can be a cause of alveolar hemorrhage with unilateral pulmonary consolidation. In patients with hemoptysis and unilateral consolidation, careful physical examination and cardiac evaluation (such as echocardiography) may assist an early diagnosis. Surgical repair of the mitral valve should be considered, as hemoptysis may aggravate the condition resulting in relapse.

 

 

Case reviewed by MedCase Editor

Designation: MD

Board Certified ABIM

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