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.
HINT: Patients with massive hemoptysis most likely have a single focus of bleeding.
HINT: Wandering alveolar infiltrates found on chest radiograph in a child presenting with respiratory distress is highly suggestive of pulmonary hemorrhage (regardless of whether the patient presented with hemoptysis).
DIFFERENTIAL DIAGNOSIS LISTDiffuse
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
HINT: An inhaled foreign body must always be considered in any child with hemoptysis.
HINT: Pneumonia, bronchitis, lung abscess, and laryngotracheitis can be associated with hemoptysis.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.”
Pulmonary Hemosiderosis
