an interesting case of hemoptysis

Dr.Prof.P.Vijayaragavan unit.Dr. A.Vijayalakshmi. M7 unit.

Mr.Kuppusamy,.55 years male Admitted with the complaints of coughing of

blood for 4 days.H/o present illness; He had 4 days of hemoptysis which was

large in quantity around 5 glasses on the day of admission.

H/o dry cough present 4 days. H/o breathing difficulty present for 4 days H/o giddiness present for 4 days. H/o loss of weight and loss of appetite

present for 3 months.

There was no h/o PND,Orthopnea. No h/o chest pain,no h/o wheeze, No h/o fever.Past history; 3 months back he had one bout of

heamoptysis ,for which he was treated in a private hospital conservatively.The details not available.

No h/oT.B, Asthma, DM, HT, Epilepsy. Personal history; Smoking for 25 years.

Consumes alcohol, Chewing tobacco and pan, mixed diet.

Family history-Nil relevent.

On General examinations; Patient is conscious Oriented.Afebrile.Tachypnea present. Clubbing present. No cyanosis ,no pedal oedema, not icteric, RR rate 28/min. Pulse;82/min. BP;110/70 mm of Hg. CVS.-S1, S2 heard. No murmur.

Respiratory system; Inspection Trachea seems to be in the midline. Apical impulse in the 5th ICS. Symmetrical chest wall. No scoliosis, no Kyphosis. Movements of chest wall equal.

Palpation; Trachea is in the midline. Movements of chest wall is equal. Percussion Equal resonant note in all the area. Auscultation;NVBS+Abdomen examinationSoft.No organomegaly.

CNS Examination- NFND.

IMPRESSION-? Pulmonary Tuberculosis. To rule out Cardiac cause for

hemoptysis.

INVESTIGATIONS; HB- 10gm% TC-7600 P50, L42 ESR- 12/26 Pcv-30 Platelets- 2.6 lakhs MCV-87.2 MCH24 MCHC-32.4 Urea-25 Creatinine-1.1

Chest clinic- Sputum c/s –negative. Sputum for AFB negative. Mantoux test -10 mm induration. X-Ray chest-slight mediastinal

widening. ECG –WNL. PLANNED FOR CT.

Following that MRI was taken Which shows…..,

Lipid profile-

Total cholestrol 180mg/dl Tg-139 HDL 26 LDL 71 VLDL27 CRP-POITIVE 24mg VDRL-NR

LFT-

Total bilirubin-0.8mg SGOT-32 IU SGPT-27 IU Alkaline phosphate-31 Protein 5.9 Albumin 3.6

Echocardiography; Normal LV function. No RWMA. Normal valves. Descending thoracic Aorta aneurysm

5.3 cm in size.

Final DiagnosisAneurysm of Descending aorta, leaking into left lung and pleural cavity presenting as hemoptysis.

Thoracic Aortic Aneurysm. It is less common than abdominal

aortic aneurysm.

Classification- Ascending Aortic aneurysm Arch of aorta Descending aorta.

Thoracic aortic aneurysm is common in white race.

Sex; Men affected more than women 2 to 3 times.

Age –at diagnosis the patient ‘s age may be in 60 to 70 years as it is mostly asymtomatic.

In atherosclerosis it can occur at 40 to 50 years.

Etiology- 1.Atherosclerosis-very common. 2.Connective tissue disorders.(Takayasu’s

aortitis,Rheumatoid arthritis) 3.Marfans syndrome. 4.Ehlers –Danlos syndrome. 5.Syphilis. 6.Infectious Aortitis. 7.TB can sometimes lead to thoracic aortic

aneurysm.

Pathophysiology- Degenerative changes in the wall of the

aorta lead to cystic medial necrosis. This causes damage to collagen and elastin, loss of smooth muscle cells and increased amounts of basophilic ground substance in the medial (elastic) layer of the aorta. The ascending TAA is usually more affected by cystic medial necrosis. Descending aortic aneurysm is a primary consequence of Atherosclerosis.

In Marfans syndrome fibrillin gene mutation is responsible for this structural lipoprotein changes causing dilatation of aortic wall.

75% of bicuspid aortic valve have evidence of cystic medial necrosis.

Usually aneurysms of Fusiform nature is true aneurysm .In this all the layer of aorta is involved.

In pseudoaneurysm-saccular type a small blister or bleb present on the side of aorta.

Clinical manifestations- Mostly asymptomatic. If symptoms occurs ,it may be due to

copression of trachea causing wheezing, dyspnea, cough, hemoptysis, or recurrent pneumonitis.

Compression of esophagus causes dysphagia.

Compression of recurrent laryngeal nerve causing hoarseness of voice.

Vascular consequences include aortic regurgitations due to dilatation of aortic root,Thromboembolism causing stroke, lower extremity ischemia, renal infarctions, or mesenteric ischemia also can occur.

Angina sometimes occurs in one quarter of patients due to direct compressions of intra thoracic structures or erosions into bones.Typicaly the pain is steady, deep, boring and at times severe.

X-Ray chest- Mediastinal widening. CT-Less accurate. MRI-Very accurately detect and size

thoracic aneurysms. Transthoracic aorta is an excellent modality

for imaging the aortic root. Trans esophageal echo is an excellent for

Visualization for entire aorta. Not usually done because of it semi invasive nature.

CONTRAST AORTOGRAPHY is

the best investigation for

Aneurysm of aorta.

Medical; Long term Beta blocker therapy.And

control of hypertension. Surgical- Operative repair with placement of

prosthetic graft is indicated in patients with symptomatic thoracic aortic aneurysm and in patients with aortic diameter of >5.5 to6 cm or has increasing by>1cm per year.

Surgical repair with synthetic graft or own blood vessel graft can be done.

Endovascular stent graft can be done. Prevention of aneurysm – 1.stop smoking. 2.BP control. 3.Exercise. 4.Healthy weight. 5.Eat healthier diet.