Case Report

Pediatric hemoptysis with Pulmonary hemorrhage and respiratory failure

Abstract

Hemoptysis is a rare complaint in the pediatric popula- tion. It is most commonly of infectious etiology and is rarely life threatening. However, there are rare Life-threatening causes of pediatric hemoptysis, which should be included in the differential diagnoses of children presenting to the emergency department (ED) with this complaint.

This study aims to present a case of pediatric hemoptysis, briefly discuss the differential diagnosis, and present a review of the causes, manifestations, and treatment for hemoptysis secondary to diffuse alveolar hemorrhage (DAH).

We present a case of a child with a history of anemia who was brought to the ED with a cough productive of slightly Blood-tinged sputum and who rapidly developed respiratory failure requiring intubation secondary to DAH.

Although pediatric hemoptysis is generally a Benign condition, emergency physicians should include DAH in the differential diagnosis, especially in patients with a history of unexplained anemia.

Hemoptysis is an uncommon chief complaint in children. It is rarely life threatening and most commonly caused by acute lower respiratory tract infections. Other less common causes include bronchiectasis, foreign body aspiration, Pulmonary arteriovenous malformations, trauma, tumors, and alveolar hemorrhage syndromes [1]. We present a case of a child who came to the ED with scant hemoptysis and rapidly developed respiratory failure secondary to DAH. We discuss the etiology and symptoms of alveolar hemorrhage syndromes and their acute and chronic treatment as emergency physicians should include these conditions in the differential diagnosis of children presenting with a complaint of blood-tinged sputum.

A 7-year-old girl presented to the ED with a chief complaint of racing heart and productive cough with blood- tinged sputum. The mother reported that the cough had been present intermittently for several months but became more frequent and was productive of blood-tinged sputum on the day of presentation. The patient was slightly short of breath but denied fever, chills, or sick contacts. The mother denied

any other bleeding, including melena or hematuria, but did note that in the past, the patient bruised easily.

Past medical history was significant for recurrent anemia and several episodes of pneumonia. Two weeks before this visit, the patient had been seen for acute right ankle swelling. blood work at that time showed elevated erythrocyte sedimentation rate and C-reactive protein and negative rheumatod factor and antinuclear antibody. Paternal family history was significant for anemia and childhood “lung disease,” requiring a partial lung resection.

On physical examination, the patient was well nourished, slightly pale, and in no acute distress. She was afebrile, with a normal respiratory rate, blood pressure, and oxygen saturation on room air but was tachycardic to 145. Head, ears, nose, and throat examination revealed pale conjunctiva, moist mucous membranes without exudates or petecchia. Her neck was supple and without lymphadenopathy. Cardiac examination revealed tachycardia but no murmurs, rubs, or gallops. The lungs were clear. Abdominal examination was benign. Extremities were without edema or ecchymosis or joint swelling or tenderness. Neurological examination was unremarkable.

The patient was placed on oxygen, and an intravenous fluid bolus was given. An electrocardiogram showed sinus tachycardia. A bedside echocardiogram was performed out of concern for an effusion, but given the tachycardia and recent positive rheumatological laboratory results, it was negative. Chest x-ray (posterior anterior and lateral views shown in Fig. 1A and B) showed large patchy alveolar infiltrates. Complete blood count revealed significant microcytic anemia, with a hemoglobin level of 5.7 g/dL and a hematocrit of 21.5%, but no leukocytosis or thrombycotopenia. Electrolytes and renal function were normal, and coags were normal. The ESR and CRP were elevated.

Although the patient was initially well-appearing, she rapidly decompensated, becoming tachypneic and hypoxic. She had several episodes of a few milliliters of hemoptysis, became hypoxic with 100% oxygen, and was emergently intubated. The patient was transfused, and antibiotics were given for a possible infection. She was transferred to local pediatric hospital for bronchoncospy, which revealed numer- ous punctuate, petechial lesions on the bronchial mucosa. Lung biopsy showed florid intra-alveolar hemosiderosis secondary to diffuse vascular damage. The Pulmonary findings and rheumatologic markers (positive P-ANCA) led

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prednisone and cyclophosphamide, was subsequently extu- bated, and made an uneventful recovery.

Diffuse alveolar hemorrhage is a rare but life-threatening cause of pediatric hemoptysis and should be considered in patients presenting with recurrent “pneumonias” or anemia. It can be caused by a number of vascular, immunologic, and coagulation disorders, all of which lead to damage to the alveolar microcirculation [3-5].

The classic presentation of DAH includes an acute onset of hemoptysis, alveolar infiltrates on chest radiograph, and anemia. However, initial presentations may be subtle, as in our patient, with Recurrent episodes of pneumonia with or without small volume hemoptysis and recurrent, unex- plained anemia [4]. The initial physical examination may be benign. Cardiopulmonary examination findings, if present, include inspiratory crackles, systolic murmur related to mitral stenosis, or pulmonary hypertension. If the diagnosis of hemoptysis vs hematemesis is not clear, the sample’s pH will reveal the source [3]. Sputum is generally alkaline, and gastric samples are acidotic. Initial chest x- rays may be normal or show bilateral diffuse alveolar infiltrates–leading to a diagnosis of pneumonia, as was seen in our patient.

Cough with blood-tinged sputum is generally related to benign lower respiratory tract infections. However, close observation of the vital signs and good initial history and physical examination and reexamination are key in identify- ing potentially life-threatening causes and identifying the need for immediate intervention. A broad differential, including DAH, should be considered in patients presenting to the ED with hemoptysis–especially in patients with Abnormal vital signs, history of recurrent pneumonias, and unexplained anemia.

Adam P. Dine DO, MSHA Sandra L. Werner MD, FACEP Department of Emergency Medicine MetroHealth Medical Center Cleveland, OH, USA

E-mail address: swerner@metrohealth.org doi:10.1016/j.ajem.2007.10.035

References

Fig. 1 A and B, PA and lateral chest x-ray showing diffuse alveolar infiltrates.

to the diagnosis of DAH secondary to microscopic poly- angiitis, one of a group of rare vasculidities that can cause pulmonary hemorrhage. Treatment for this condition includes immunosuppressive therapy [2]. Our patient was treated with

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