Hemoptysis



Hemoptysis


Suzanne E. Beck



INTRODUCTION

Hemoptysis is the expectoration or coughing up of blood from the respiratory tract. Bleeding from the respiratory tract can range from blood-streaked sputum to coughing up of massive quantities of bright red blood. Although bleeding into the lungs and airways is uncommon in children, massive hemoptysis (loss of >8 mL blood/kg or 240 mL blood/24 hours) is a life-threatening condition requiring immediate evaluation and therapy. Hemoptysis may be the result of pulmonary hemorrhage and should be distinguished from hematemesis or bleeding from the nasopharynx. Pulmonary hemorrhage can be diffuse or focal; associated with underlying cardiopulmonary disorders including congenital heart disease or airway anomalies; related to underlying systemic conditions; infectious; or idiopathic. The most common cause of hemoptysis in children is infection or conditions complicated by infections (such as cystic fibrosis, lung abscess, tuberculosis and bronchiectasis). Inflammatory disorders which erode into the bronchial circulation or conditions that place the bronchial circulation under systemic vascular pressure are likely to cause severe hemoptysis.




DIFFERENTIAL DIAGNOSIS LIST


Diffuse


Isolated



  • Lung immaturity


  • Cow milk hyperreactivity (Heiner syndrome)


  • Pulmonary capillary hemangiomatosis


  • Idiopathic (pulmonary hemosiderosis)


Associated with Other Organ Dysfunction



  • Nephritis (Goodpasture, nephritis with immune complexes, nephritis without immune complexes)



  • Myocarditis


  • Celiac disease


  • Diabetes


  • Collagen vascular disease


  • Wegener granulomatosis


  • Henoch-Schönlein purpura and other systemic vasculitis


  • Lymphangioleiomyomatosis


  • Tuberous sclerosis


  • Systemic necrotizing vasculitis, hypersensitivity angiitis, mixed connective tissue disease, Behcet disease


Secondary



  • Congestive heart failure


  • Congenital heart disease (e.g., congenital pulmonary vein stenosis—pulmonary veno-occlusive disease)


  • Tetralogy of Fallot with pulmonary atresia and multiple collaterals and pulmonary arterial stenosis


  • Mitral stenosis with left atrial hypertension


  • Clotting disorders


  • Malignancy


  • Immunosuppression (e.g., s/p bone marrow transplantation)


  • Diffuse alveolar injury (penicillamine, propylthiouracil, cocaine, radiologic contrast agents, nitrofurantoin, cytotoxic agents, trimellitic anhydride, radiation, smoke inhalation, insecticide (paraquat) inhalation, acid aspiration, oxygen toxicity, sickle cell disease (acute chest syndrome))


Focal


Conducting Airways



  • Bronchitis


  • Bronchiectasis (e.g., cystic fibrosis)


  • Airway anomalies (bronchogenic cysts, bronchial adenoma, unilateral pulmonary agenesis, bronchial artery aneurysm, Ehlers-Danlos syndrome)


  • Vascular anomalies (hemangioma, angioma, arteriovenous malformation or fistula, hereditary hemorrhagic telangiectasia)


  • Foreign body aspiration


  • Tracheostomy complication


  • Trauma (contusion, suctioning, intubation)


Parenchymal



  • Trauma


  • Pneumothorax


  • Infection (Bacterial: Pneumococcus, Staphylococcus, Meningococcus, Group A Streptococcus, Mycoplasma, Bordetella pertussis, Pseudomonas, leptospirosis; Viral: influenza virus, varicella-zoster virus, hepatitis B virus, HIV; Fungal: Aspergillus, Histoplasma, Coccidioides, Blastomyces; Parasitic: visceral larva migrans, filariasis, toxoplasmosis, hydatidosis, Arthropod Infestation: hemorrhagic fevers)


  • Infarction (pulmonary embolism)


  • Cavitary lesions (e.g., tuberculosis, abscess, histoplasmosis)


  • Neoplasms (Benign: hemangiomas, angiomas, pulmonary sequestration, inflammatory pseudotumor, enteric cysts; Malignant: bronchial adenoma, sarcoma, teratoma; Metastatic: sarcoma, Wilms tumor, osteogenic sarcoma)


Others



  • Catamenial hemoptysis


  • Factitious (Munchausen by proxy syndrome)



DIFFERENTIAL DIAGNOSIS DISCUSSION




Cystic Fibrosis

Cystic fibrosis is the most common nontraumatic cause of pulmonary hemorrhage in the United States, which is typically due to endobronchial infection and inflammation and less commonly due to rupture of a bronchial artery that may be life threatening, and is discussed in Chapter 23, “Cough.”


Bronchiectasis

Bronchiectasis is discussed in Chapter 23, “Cough.”

Sep 14, 2016 | Posted by in PEDIATRICS | Comments Off on Hemoptysis

Full access? Get Clinical Tree

Get Clinical Tree app for offline access