Hemoptysis & Bronchiectasis

Today we learned about a patient who presented with hemoptysis in the setting of latent TB that was diagnosed as TB Bronchiectasis. We discussed the framework for hemoptysis:

Hemoptysis

We then reviewed the CT and determined it was bronchiectasis:

  • Bronchioectasis is defined as “Irreversible dilation and destruction of larger bronchi caused by chronic infection and inflammation”
  • Development of bronchiectasis always requires two factors
    • An infectious insult
    • Impaired drainage, airway obstruction or a defect in host defense
  • Etiologies
    • Any pulmonary Infections
      • Childhood infections (bacterial, viral or mycoplasma PNA)
      • Mycobacterial infections
    • Cystic Fibrosis
      • up to 7 percent of patients with cystic fibrosis (CF) are diagnosed at age 18 years or older
      • Sinusitis and bronchiectasis are the major respiratory manifestations of CF in adults
    • Airway obstruction
      • FBA or any other intraluminar obstructing lesion (such as a carcinoid tumor) or extraluminal compression
    • Tracheobronchomalacia/tracheobronchomegaly
    • Defective host defenses
      • Local: Ciliary dyskinesia
      • Systemic: hypogammaglobulinemia/prolonged immunosuppression
    • Young Syndrome
      • Bronchiectasis, sinusitis and obstructive azoospermia who have no evidence of cystic fibrosis
    • Rheumatic/Systemic Disease
      • RA/Sjogrens
    • Primary Ciliary Dysfunction
    • Allergic bronchopulmonary aspergillosis
      • should be suspected in patients with a long history of asthma that is resistant to bronchodilator therapy and associated with a cough often productive of sputum that is mucopurulent or contains mucous plugs.
    • Alpha-1 antitrypsin deficiencies
  • Signs and Symptoms
    • cough, mucopurulent sputum production, dyspnea, rhinosinusitis, hemoptysis (27%) and recurrent pleurisy
    • on exam crackles and wheezing are common
  • Radiographic Findings
    • The internal diameter of the bronchus is larger than that of its accompanying vessel
    • the bronchus fails to taper in the periphery of the chest
  • Treatment of Acute Exacerbation
    • Deciding when a patient has an acute exacerbation requires clinical judgement as there is no laboratory features specific for an exacerbation
    • Antibiotics decrease the existing bacterial burden and can decrease systemic inflammatory mediators
    • 10-14 day treatment course is appropriate (though the ERS 2017 guidelines suggest 14)

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