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Case In Point: Massive, fatal hemoptysis in a patientwith AIDS and B-cell lymphoma

Case In Point: Massive, fatal hemoptysis in a patientwith AIDS and B-cell lymphoma

The authors describe an immunocompromised patient who had massive hemopty- sis caused by pseudomonal pneumonia in the community setting.

The case

A 49-year-old man presented to the emergency department (ED) and complained of fever and cough that produced bloody sputum for 1 day. He had AIDS and recently received a diagnosis of large B-cell lymphoma. His most recent CD4+ cell count was 24/µL. He had opted against receiving highly active antiretroviral therapy and prophylaxis for opportunistic infection.

He had received chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisone 1 week before presentation. At the time of presentation, he was neutropenic (white blood cell count, 90/µL) and thrombocytopenic (platelet count, 13,000/µL).

Shortly after arrival to the ED, the patient started to expectorate large amounts of bright red blood. Hypoxic respiratory failure and hypotension subsequently developed, requiring endotracheal intubation; mechanical ventilation; and aggressive resuscitation with crystalloids, blood products, and platelets.

His chest radiograph showed a new confluent opacity in the left mid-lung zone and the retrocar-diac area (Figure 1). Broad-spectrum antibiotic coverage with meropenem and vancomycin was immediately started.

Emergent bronchoscopy revealed pulsatile bleeding from the left lower lobe without a visible endobronchial source. Endobronchial tamponade of the massive bleeding from the left lower lobe was ineffective. However, contralateral single-lung ventilation resulted in acceptable oxygenation.

The patient underwent urgent bronchial arteriography with the goal to selectively embolize a possible feeding vessel(s) to the left lower lobe. The angiogram demonstrated a dilated descending branch of the left bronchial artery, which was successfully embolized. However, on return from this intervention, the patient had recurrent massive bleeding from the left lower lobe and worsening coagulopathy despite replacement with fresh frozen plasma and cryoprecipitate.

Repeated attempts to bronchoscopically control the bleeding and to clear the contralateral airway remained unsuccessful. The family, honoring the patient's directives, did not want to consider surgical resection and approached the medical staff to discontinue further resuscitative efforts. The patient expired 5 hours after presentation.

An autopsy revealed severe diffuse pulmonary hemorrhage in the left lower lobe. Microscopic examination showed widespread destruction of the entire lobe with invasion and obliteration of the large and small arteries by Gram-negative rods without associated inflammation (Figure 2). His blood cultures grew Pseudomonas aeruginosa.

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