Ann Thorac Surg 2004;77:336-338
© 2004 The Society of Thoracic Surgeons
Case report
Life-threatening hemoptysis in a child: the only symptom
Alper Toker, MDa,
Serhan Tanju, MD*a,
Yusuf Bayrak, MDa,
Emre Cenesiz, MDb,
Nermin Guler, MDb,
Sukru Dilege, MDa,
Goksel Kalayci, MDa
a Department of Thoracic Surgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey
b Department of Pediatrics, Istanbul Medical School, Istanbul University, Istanbul, Turkey
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Shiraishi, Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan 602-8566.
e-mail: isao{at}koto.kpu-m.ac.jp
 |
Abstract
|
|---|
An 8-year-old girl was evaluated for hemoptysis, 50 mL/day, which lasted for 3 days. Computed thoracic tomography detected a mass lesion in the right lower lobe. During rigid bronchoscopic examination, exanguinating hemoptysis occurred, and a Fogarty balloon catheter was placed in the right intermediate bronchus. Thoracotomy revealed a 2 x 2-cm mass in the right lower lobe. Common basal segmentectomy was performed. Pathological frozen-section analysis confirmed the diagnosis of perforated hydatid cyst.
|
Introduction
|
|---|
In the pediatric population, life-threatening hemoptysis is seldom a reason for pulmonary resection. Here we present the case of a pediatric patient who had an undiagnosed mass with life-threatening hemoptysis. We report this case to discuss hemoptysis in pediatric hydatid disease and to emphasize that life-threatening hemoptysis can be the only symptom in pediatric patients with complicated hydatid disease.
An 8-year-old girl was hospitalized because of expectoration of approximately 50 mL of blood per day. She experienced loss of the same amount of blood during a 3-day stay in the department of pediatric pulmonology and allergy while studies were done. Chest roentgenogram revealed a pneumonic infiltration, and computed tomography showed a mass lesion in the right lower lobe (Fig 1). Bronchoscopic examination was performed with a Storz rigid bronchoscope (size 5). During bronchoscopic examination, no endobronchial lesion was noticed, and no biopsy was done. Also during the examination, exsanguinating hemoptysis from the orifice of the right lower lobe occurred. More than 200 mL blood was aspirated. A No. 6 Fogarty balloon catheter was placed and inflated in the intermediate bronchus. The patient was intubated, and an exploratory thoracotomy was performed. A centrally located mass lesion was palpated in the right lower lobe. To obtain a biopsy specimen, an anatomical common basal segmentectomy was done with open bronchus technique, and retrograde exploration of the intermediate bronchus was performed. Pathological frozen-section analysis revealed perforated and infected hydatid disease of the lung.
The patient was discharged on postoperative day 4 but was readmitted at week 1 after operation because of postoperative pneumothorax. There was chest tube drainage for 5 days. In the second postoperative month, the patient was free from symptoms and had a completely expanded right lung (Fig 2).
|
Comment
|
|---|
Pediatric hemoptysis is most likely to be secondary to infection, tracheostomy-related problems, or foreign-body aspiration. Other causes include congenital heart disease, pulmonary hemosiderosis, cystic fibrosis, trauma, or factitious hemoptysis [1]. However, a parasitic cause, such as Echinococcus granulosus, has not been implicated in most series concerning hemoptysis in children. This could be due to the fact that most of these series are from geographical areas where cystic hydatid disease is not endemic [2]. A study [3] of 110 children with pulmonary hydatid disease from an area of Turkey where this disease is common found that hemoptysis was the preponderant symptom (36/110 patients), but it was not reported to be an alarming symptom. When diagnosed with a cystic mass in the lung, hemoptysis is not a dangerous condition, as the cause is attributed to hydatid disease, and the disease can be treated surgically. However, complicated hydatid cysts can mimic lung masses and can create problems during diagnosis. We believe complicated hydatid disease is one disease that should be considered in the differential diagnosis of life-threatening hemoptysis in the pediatric population. Complicated hydatid cysts are hard to diagnose in the preoperative period if defined radiologic findings are not noticed. The diagnosis usually is reached during operation.
In patients with hemoptysis, bronchoscopic examination, treatment, and bronchial arterial embolization should be the first line of treatment [4]. After a definitive diagnosis has been made, resection should be performed in elective situations [4]. If massive hemorrhage had not occurred during bronchoscopy in the operating room, we would have chosen bronchial arterial embolization and an elective surgical procedure.
The surgical approach in our patient emphasizes the importance of Fogarty balloon catheter occlusion of the origin of the hemoptysis and diagnosis by exploratory thoracotomy with minimal resection. The aim of occluding the intermediate bronchus is to prevent aspiration from the other lung and to arrest the blood. Thoracotomy can be safely performed without fear of asphyxia. Minor resections can be carried out in patients with hemoptysis without a definitive diagnosis. Selective endobronchial ventilation may be useful during the resection.
The most important predictors of death after pediatric hemoptysis have been identified as age, amount of hemoptysis, use of blood products, and presence of fever [5]. The amount of hemoptysis was reported to be a significant predictor of death only for patients with congenital heart disease. Two other studies [6, 7] demonstrated higher mortality in patients with cystic fibrosis when the amount of hemoptysis increased. Knott-Craig and colleagues [8] reported an overall mortality rate of 13% in a study of 120 adult patients with massive hemoptysis, defined as more than 200 mL/day. In a pediatric series [5], hemoptysis was categorized as mild (<150 mL/day), large (150 to 400 mL/day), or massive (>400 mL/day). We believe that the amount of hemoptysis should be defined according to the body size index or weight of the pediatric patient. In our study, we considered 3 consecutive days of hemoptysis of 50 mL for a girl weighing 30 kg to be an indication for endobronchial evaluation. This could be accepted as a sign of life-threatening hemoptysis, which could be considered to be 200 mL in a single episode.
In pediatric patients with life-threatening hemoptysis and an undiagnosed pulmonary mass that does not resemble hydatid disease of the lung, complicated hydatid cysts should be considered in the differential diagnosis. If a diagnosis is not established, the preferred approach is a minor resection with frozen section examination.
|
References
|
|---|
- Batra P.S., Holinger L.D. Etiology and management of pediatric hemoptysis. Arch Otolaryngol Head Neck Surg 2001;127:377-382.[Abstract/Free Full Text]
- Bharti S., Bharti B. Hydatid disease of lungs unusual cause of hemoptysis. Indian Pediatr 2002;39:1062-1063.[Medline]
- Solak H., Yeniterzi M., Yuksek T., Anil N., Goktogan T., Ceran S. The hydatid cyst of the lung in children and results of surgical treatment. Thorac Cardiovasc Surg 1990;38:45-47.[Medline]
- Guimaraes C.A. Massive hemoptysis. In: Pearson F.G., Cooper J.D., Deslauriers J., eds. Thoracic surgery. Philadelphia: Churchill Livingstone, 2002:717-736.
- Coss-Bu J.A., Sachdeva R.C., Bricker J.T., Harrison G.M., Jefferson L.S. Hemoptysis: a 10-year retrospective study. Pediatrics 1997;100:E7.
- Holsclaw D.S., Grand R.J., Shwachman H. Massive hemoptysis in cystic fibrosis. J Pediatr 1970;76:829-838.[Medline]
- Stern R.C., Wood R.E., Boat T.F., Matthews L.W., Tucker A.S., Doershuk C.F. Treatment and prognosis of massive hemoptysis in cystic fibrosis. Am Rev Respir Dis 1978;117:825-828.[Medline]
- Knott-Craig C.J., Oostuizen J.G., Rossouw G., Joubert J.R., Barnard P.M. Management and prognosis of massive hemoptysis. Recent experience with 120 patients. J Thorac Cardiovasc Surg 1993;105:394-397.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
S. I. Sersar, H. E. AbdelMooty, M. M. Hafez, and M. F. Ismail
Hemoptysis
Ann. Thorac. Surg.,
April 1, 2005;
79(4):
1464 - 1464.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
