Ann Thorac Surg 2011;91:921-922. doi:10.1016/j.athoracsur.2010.08.025
© 2011 The Society of Thoracic Surgeons
Case Reports
Massive Hemoptysis After Aspiration of a Toothpick
Rajeev P. Misra, DOa,
Charles A. Dietl, MDb,*
a Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
b Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
Accepted for publication August 16, 2010.
* Address correspondence to Dr Dietl, Division of Cardiothoracic Surgery, Department of Surgery, 2-ACC, MSC 10 5610, 1 University of New Mexico, Albuquerque, NM 87131-0001 (Email: cdietl{at}salud.unm.edu).
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Abstract
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A 42-year-old man presented with massive hemoptysis. His past medical history was significant for a bayonet injury to the left chest several years ago. A chest computed tomographic scan showed a radio-opaque foreign body in the left lower lobe. A left thoracotomy was performed because of unrelenting hemoptysis in association with a foreign body that could not be retrieved by bronchoscopy. At surgery, a toothpick covered with blood was retrieved from the left lower lobe bronchus. A left lower lobectomy was performed because a lung abscess was present. Postoperatively, the patient confirmed that 1 year prior he had fallen asleep with a toothpick in his mouth while intoxicated.
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Introduction
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Massive hemoptysis is usually defined as expectoration of blood exceeding 100 to 600 mL in a 24-hour time period [1]. Massive hemoptysis is a life-threatening condition associated with mortality rates ranging from 23% to 85%. Appropriate therapy includes immediate intubation to maintain airway patency to prevent death from asphyxiation. Emergency pulmonary resection is usually necessary for uncontrollable hemoptysis [2]. History of foreign body aspiration is a rare cause of massive hemoptysis [3]. We believe that late onset massive hemoptysis after aspiration of a toothpick has not been previously reported.
A 42-year-old man presented to the emergency room with a chief complaint of sudden onset hemoptysis. He denied any prior history of hemoptysis or exposure to tuberculosis. He also denied any fever, chills, night sweats, productive cough, or weight loss. He reported no recent trauma, although his past medical history was significant for a bayonet injury to the left chest several years ago. There was no personal or family history of heart disease or lung cancer. The patient had a 20-pack-year history of smoking, as well as alcohol and drug abuse, but none in the recent past. The work-up for tuberculosis proved to be negative. At the time of presentation, the patient was clinically stable and his initial hematocrit was 45%. A chest roentgenogram revealed a focal opacity in the left lower lung field. A contrasted computed tomographic scan of the chest showed a linear, high attenuation foreign body measuring approximately 6 cm in length, located within a subsegmental bronchus of the lateral segment of the left lower lobe, associated with parenchymal hemorrhage (Fig 1).
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Fig 1. Detail of coronal view of computed tomographic scan of the chest showing a dense radio-opaque foreign body measuring approximately 6 cm in length (arrow), lodged within a subsegmental bronchus of the left lower lobe, associated with focal air and parenchymal hemorrhage.
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The patient was admitted to the internal medicine service and a pulmonary medicine consult was obtained. The patient continued to have several episodes of hemoptysis with volumes in excess of 600 mL during a 3-day span. Fiberoptic bronchoscopy was performed, but visualization was limited secondary to active bleeding. Cardiothoracic surgery consultation was obtained. The decision was made to take him to the operating room for an exploratory thoracotomy because of persistent hemoptysis in association with a foreign body that could not be retrieved by bronchoscopy. At surgery, a rigid foreign body was palpated within the left lower lobe. When the left lower lobe bronchus was incised, a wooden toothpick covered with blood clots was retrieved (Fig 2). A left lower lobectomy was performed because there was necrotic tissue and an abscess in the surrounding lung parenchyma.
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Fig 2. Wooden toothpick covered with blood clots retrieved from the left lower lobe bronchus during the operation.
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The specimen was submitted to surgical pathology, which revealed that the toothpick had eroded through the wall of a basal segmental bronchus into an adjacent vessel. Histologic changes in the lung tissue were consistent with acute and chronic bronchitis with focal bronchial mucosal necrosis. There was also peribronchial fibrosis noted, with bronchiolization of the airways, lipid macrophage accumulation, and focal pneumonia.
After the operation, the patient confirmed that approximately 1 year earlier, he had fallen asleep with a toothpick in his mouth while intoxicated with alcohol, and that he was unable to find it when he woke up. The patient had an uneventful recovery and was discharged on postoperative day 6.
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Comment
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Despite the fact that tuberculosis and bronchiectasis have become less prevalent, the most common causes of massive hemoptysis include lung cancer, lung abscess, and aspergilloma, as well as tuberculosis, bronchiectasis, and broncholith [1]. Less common causes include bronchial adenoma, pulmonary embolism, mitral stenosis, congenital heart disease, aortic aneurysms, coagulation disorders, and pulmonary parenchymal diseases. Massive hemoptysis involves disruption of high-pressure bronchial vessels that proliferate with various pulmonary diseases [1]. The prognosis of massive hemoptysis is poor, and mortality of operable patients treated nonsurgically has ranged from 23% to 85%, whereas the mortality of surgically treated patients ranges from 15% to 25% [1]. Thus, most investigators recommend immediate surgery. Conservative methods have also been used successfully in some cases, including bronchoscopic balloon tamponade [4] and selective bronchial artery embolization [5]. In the case of our patient, operative management was chosen because of the presence of a foreign body on preoperative computerized tomographic scan that could not be retrieved by bronchoscopy.
This case illustrates an unusual presentation of massive hemoptysis. Retained foreign bodies in the bronchial tree seldom present with hemoptysis, and may be difficult to remove endoscopically. According to the literature, a more common complication of undiagnosed and retained foreign bodies in the tracheobronchial tree is bronchiectasis that may require pulmonary resection [6]. Correct diagnosis is usually obtained with contrast computed tomographic scan after bronchoscopy [7]. We conclude that early thoracotomy is recommended in cases presenting with massive hemoptysis, unless the foreign body can be retrieved endoscopically and the bleeding can be controlled effectively.
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References
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- Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation, and therapy for massive hemoptysis Clin Chest Med 1992;13:69-82.[Medline]
- Metin M, Sayar A, Turna A, et al. Emergency surgery for massive haemoptysis Acta Chir Belg 2005;105:639-643.[Medline]
- Clark JG, Shaw RC. Pulmonary cavitation and massive hemoptysis caused by an unsuspected intraparenchymal foreign body Chest 1980;78:776-777.[Medline]
- Kato R, Sawafuji M, Kawamura M, Kikuchi K, Kobayashi K. Massive hemoptysis successfully treated by modified bronchoscopic balloon tamponade technique Chest 1996;109:842-843.[Medline]
- Poyanli A, Acunas B, Rozanes I, et al. Endovascular therapy in the management of moderate and massive haemoptysis Br J Radiol 2007;80:331-336.[Abstract/Free Full Text]
- Cataneo AJ, Reibscheid SM, Ruiz Junior RL, Ferrari GF. Foreign body in the tracheobronchial tree Clin Pediatr (Phila) 1997;36:701-706.[Abstract/Free Full Text]
- Shin SM, Kim WS, Cheon JE, et al. CT in children with suspected residual foreign body in airway after bronchoscopy Am J Roentgenol 2009;192:1744-1751.[Abstract/Free Full Text]
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Abstract
Introduction
