Hemoptysis as an Unusual Presenting Symptom

Abstract

A 70-year-old woman with a known chronic dissecting aneurysm of the descending thoracic aorta presented with new-onset back pain and hemoptysis. The hemoptysis was thought to be the result of invasion of the bronchial tree by the aneurysm. During surgical repair, a lesion that appeared to be a pulmonary abscess was discovered to be adhering to the aortic tissue, and the patient underwent a localized pulmonary resection. The pathology report of the surgical specimens revealed squamous cell carcinoma of the lung with infiltration of the aortic wall. The patient died of lung cancer 6 months later. Hemoptysis was an unusual presentation in a case of lung cancer that had invaded a stable chronic aortic aneurysm. (Tex Heart Inst J 2002;29:136–9)

Massive hemoptysis is a relatively uncommon phenomenon and can be attributed to many causes, including infection, malignancy, trauma, iatrogenic sources (for example, pulmonary artery catheterization), and cardiovascular disease. ¹ Most often, patients who have thoracoabdominal aneurysms present with pain secondary to expansion or erosion of the aneurysm into adjacent structures. Less commonly, such patients present with hemoptysis secondary to erosion into the tracheobronchial tree, which is often fatal.

We present an unusual case of a patient with a known chronic dissecting aneurysm of the descending thoracic aorta who presented with back pain and hemoptysis.

Case Report

In July 1999, a 70-year-old woman presented at our institution with dyspnea, multiple episodes of hemoptysis, and severe back pain, all of which had begun 18 hours previously. She had a known, chronic, 6-cm, dissecting aneurysm of the descending thoracic aorta. In addition, she had a history of poorly controlled hypertension, gastroesophageal reflux, irritable bowel syndrome, hypercholesterolemia, chronic obstructive pulmonary disease, and smoking. Five months before this hospital admission, she had begun experiencing dyspnea that was worse than her usual baseline state, and she was diagnosed with a chronic, stable, dissecting thoracoabdominal aneurysm. At that time, a computed tomographic (CT) scan with contrast material revealed a large thoracic aortic aneurysm with possible extravasation into the adjacent soft tissue of the left hemithorax. A dissection could be seen, extending from the proximal descending thoracic aorta down to the left iliac artery. A magnetic resonance angiogram (Fig. 1) confirmed the presence of the aneurysm, with chronic dissection, a large posterior false lumen, and proximal thrombus. The area of “possible extravasation” seen on CT scan was thought to be atelectasis with no acute process. In view of these findings, along with the patient's age and the presence of moderately severe obstructive pulmonary disease, we deemed conservative medical management to be the best option.

Fig. 1 Magnetic resonance angiogram of the thoracic aorta with dissection. The true lumen (*) is located anteriorly and defined posteriorly by the dissected intimal flap (arrow). A proximal thrombus can also be seen (arrowhead).

The patient was admitted to the intensive care unit for monitoring while she and her family decided on the course of action. An electrocardiogram showed sinus rhythm with left ventricular hypertrophy, repolarization abnormality, and a possible old inferior myocardial infarction. The laboratory data are presented in Table I. The chest radiograph, obtained on admission, showed a new left-sided pleural effusion, which strongly suggested an aneurysmal leak into the left chest cavity. After extensive discussion with the patient and her family, we all agreed that surgical intervention, despite the attendant high risks, offered the best chance of survival.

TABLE I. Laboratory Results

Under mild hypothermic cardiopulmonary bypass, the patient underwent resection of a dissecting aneurysm of the descending thoracoabdominal aorta through a left thoracotomy. Femoral venous cannulation was used for venous drainage, and aortic arterial inflow was directed through the distal portion of the descending thoracic aorta—the anticipated site of the distal anastomosis. Intraoperatively, the aneurysm measured 7 to 8 cm in diameter and appeared inflammatory in nature. Of note, the left lower lobe of the lung was completely collapsed and adherent to the aneurysm. This area of lung tissue was thought to be a pulmonary abscess and was purulent and necrotic. The tissue was locally resected. In addition, the aneurysm was found to be adherent to the mid-level of the esophagus. The underlying esophageal tissue required repair after the aortic tissue had been dissected free. The total duration of cardiopulmonary bypass was 52 minutes.

On the day after the operation, the pathology report regarding the lung abscess specimen revealed moderately differentiated squamous cell carcinoma. The aortic specimen showed infiltration by squamous cell carcinoma and thrombus material (Fig. 2). This unanticipated finding explained the cause of the patient's hemoptysis.

Fig. 2 The aortic wall shows infiltration by nests and cords (arrows) of malignant cells with some primitive glandular structures. The morphology is consistent with primary adenosquamous cell carcinoma of the lung. The aortic lumen is indicated by an asterisk.

The patient's postoperative course was complicated by respiratory insufficiency, which required reintubation, and transient renal insufficiency. The patient was discharged from the hospital on postoperative day 19. She died of lung cancer 6 months later.

Discussion

Hemoptysis has numerous causes; most cases are associated with a chronic infectious process. ^2,3 Bronchitis is the most common infectious cause, followed by active tuberculosis and bronchiectasis, respectively. Hemoptysis occurs in more than 50% of lung cancer cases, and can be the result of direct invasion of the bronchial arteries, tumor manipulation during diagnostic fiberoptic bronchoscopy, ⁴ or distal ischemia and avascular necrosis. ⁵ Direct aortic invasion by an infectious process has also been described as a cause of hemoptysis. ⁶ Treatment of patients with hemoptysis requires prompt investigation of the source and the degree of bleeding. ¹

An aortic aneurysm or dissection that ruptures into the lung parenchyma or erodes into a bronchus can lead to acute and massive hemoptysis, which constitutes a surgical emergency. ⁷ Aorto-bronchopulmonary fistulas account for 85% of cases of hemoptysis that occur in conjunction with a descending thoracic aneurysm. Presenting symptoms typically include back pain, cough, dyspnea, and hemoptysis. ^8–12 The bleeding is frequently massive, but can also be relatively light. ¹³ Chest radiographic findings generally include a widened mediastinum and fluid (blood) in the pleural space. ⁹ The surgical mortality rate in patients with ruptured thoracoabdominal aneurysms is high compared with that of patients undergoing elective resection. ¹⁴

In this patient, we initially thought that a known dissecting aneurysm had ruptured into the pulmonary tree, leading to hemoptysis and back pain. We were surprised to find that the hemoptysis was actually caused by invasion of the weakened aortic wall by lung cancer.

Intraoperative anesthetic management of this patient was challenging. She had a long-standing history of poorly controlled hypertension, primarily due to noncompliance. The hypertension predisposed her to great intraoperative lability in blood pressure, which is of particular concern in a patient with a leaking aneurysm. We anticipated that her poor pulmonary status would be problematic in view of the need for intraoperative single-lung ventilation. Her cardiac status was unknown, but she was clearly at risk of undiagnosed coronary artery disease. Her age (70 yr) was also a risk factor. In a large retrospective analysis, ¹⁵ early and long-term results of surgery for thoracic aortic aneurysm (of all types) demonstrated poorer outcomes in patients older than 70 years compared with those younger than 70 years, especially for emergency procedures. ¹⁵ Although transesophageal echocardiography (TEE) is frequently used intraoperatively to assess cardiac function, we did not use it because of the urgency of the situation and the patient's unstable condition. ¹⁶ In retrospect, this was fortunate because of the adherence of the aortic tissue to the esophagus. Introduction of the TEE probe would most likely have led to esophageal perforation with uncontrolled massive upper gastrointestinal hemorrhage.

In a patient with a large descending thoracoabdominal aneurysm, there is always a risk of left bronchial compression with bronchial wall weakening and tracheal deviation. In this situation, the use of a left-sided double-lumen endotracheal tube to provide single-lung ventilation can lead to inadvertent bronchial rupture and exsanguination. In this patient, a right-sided double-lumen tube was initially advanced into the right mainstem bronchus under direct fiberoptic bronchoscopic guidance (rather than blindly, as is frequently done). Immediately upon intubation of the patient, we began the lung separation in order to prevent blood from entering the unaffected lung. This is especially important when patients are placed in the lateral decubitus position with the unaffected lung in the dependent position.

This case of a 70-year-old woman with a known, chronic, dissecting thoracic aneurysm is unusual in that the patient presented with hemoptysis as a result of direct invasion of the aorta by undiagnosed lung cancer.