Page 5 / April 07
Where is the blood coming from? Upper airway, gastrointestinal bleeding and systemic bleeding should be ruled out first. The presence of bright red colored, coughing or gurgling noise perceived by the patient and discomfort in one hemithorax are the characteristic of hemoptysis. While coffee-ground appearance, food particles, acidic pH and nausea symptom would suggest hematemesis.
The differential diagnosis of hemoptysis includes infectious cause such as necrotizing pneumonia and tuberculosis. However, necrotizing pneumonia caused by Staphylococcus aureus, Streptococcus pneumoniae, or Pseudomonas aeruginosa usually presents with lobar pneumonia, pleural effusion or lung abscess and rapidly progressive clinical deterioration. Tuberculosis should be considered due to associated symptoms as weight loss, failure to thrive and contact with visitors from endemic area. Due to her digital clubbing and persistent findings on chest x-rays, bronchiectasis (with or without cystic fibrosis), pulmonary sequestration and pulmonary arterio-venous malformations should be a high probability. Regarding the previous diagnosis of asthma, Allergic Bronchopulmonary Aspergillosis (ABPA) should be kept in mind. Wegener's granulomatosis, idiopathic pulmonary hemosiderosis are less likely and usually present with diffuse, bilateral densities on the chest x-ray.
A history of frequent coughing during eating should be considered as a possibility of aspiration. A diagnosis asthma is doubtful due to the presence of chronic cough despite proper asthmatic treatment. Gastroesophageal reflux disease and chronic aspiration should be kept in the back of our minds.
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ANSWER:
Where is the blood coming from? Upper airway, gastrointestinal bleeding and systemic bleeding should be ruled out first. The presence of bright red colored, coughing or gurgling noise perceived by the patient and discomfort in one hemithorax are the characteristic of hemoptysis. While coffee-ground appearance, food particles, acidic pH and nausea symptom would suggest hematemesis.
The differential diagnosis of hemoptysis includes infectious cause such as necrotizing pneumonia and tuberculosis. However, necrotizing pneumonia caused by Staphylococcus aureus, Streptococcus pneumoniae, or Pseudomonas aeruginosa usually presents with lobar pneumonia, pleural effusion or lung abscess and rapidly progressive clinical deterioration. Tuberculosis should be considered due to associated symptoms as weight loss, failure to thrive and contact with visitors from endemic area. Due to her digital clubbing and persistent findings on chest x-rays, bronchiectasis (with or without cystic fibrosis), pulmonary sequestration and pulmonary arterio-venous malformations should be a high probability. Regarding the previous diagnosis of asthma, Allergic Bronchopulmonary Aspergillosis (ABPA) should be kept in mind. Wegener's granulomatosis, idiopathic pulmonary hemosiderosis are less likely and usually present with diffuse, bilateral densities on the chest x-ray.
A history of frequent coughing during eating should be considered as a possibility of aspiration. A diagnosis asthma is doubtful due to the presence of chronic cough despite proper asthmatic treatment. Gastroesophageal reflux disease and chronic aspiration should be kept in the back of our minds.
What is your initial management?
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