Management of Massive Hemoptysis Post Endobronchial Ultrasound and Computed Tomographic-Guided Lung Biopsy in Lung Transplant Patient with Pulmonary Venous Obstruction

S. Cullivan1, H. K. Moriarty2, J. J. Egan1, C. A. Ridge2, K. Redmond1, O. O'Connell1;

Author address: 

1National Heart and Lung Transplant Center, Mater Misericordiae University Hospital, Dublin, Ireland, 2Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.

Abstract: 

Introduction
A 21-year-old patient post double lung transplant for cystic fibrosis was found to have a right hilar mass compressing the right pulmonary veins and right lung nodules. Endobronchial ultrasound (EBUS) and computed tomographic (CT) guided lung biopsy of these lesions, both resulted in massive hemoptysis >200mls after the first needle pass. This case highlights the clinical and radiological features that should alert the interventionist to pulmonary hypertension to adequately prepare for biopsy-related bleeding complications.
Case
The patient presented with fatigue, dyspnea and pyrexia on a background history of a double lung transplant for cystic fibrosis 1 year previously. Pre-transplant, the patient had chronic superior vena cava obstruction due to an implanted central venous line. Physical examination revealed anterior chest wall venous engorgement, upper extremity swelling and bibasal inspiratory crackles. CT of the chest demonstrated a 2.6 cm right hilar mass (Figure 1), which invaded and compressed the right superior and inferior pulmonary veins. Contrast-enhanced CT demonstrated interlobular septal thickening suggesting pulmonary venous hypertension and solid pulmonary nodules with ground glass halos, suggesting angioinvasive aspergillosis.
An EBUS and a subsequent CT-guided biopsy were performed to make the critical distinction between suspected pulmonary and mediastinal aspergillus infection versus post-transplant lymphoproliferative disorder. EBUS transbronchial needle aspiration of the infrahilar mass was complicated by massive hemoptysis, greater than 200mls, which was successfully managed with a therapeutic bronchoscopy. CT biopsy of the parenchymal lesions was also complicated by hemoptysis, which was managed conservatively with suction.
Serum beta-D-glucan was strongly positive on two occasions and the patient improved with systemic antifungal therapy and subsequent oral posaconazole for angioinvasive aspergillosis.
Discussion
This case presentation highlights several important learning opportunities for the interventionist. Firstly, it illustrates the CT findings and relevance of pulmonary venous hypertension due to a mass compressing the pulmonary veins. CT demonstrated interlobular septal thickening and extrinsic compression of the right pulmonary veins. Secondly, the radiological and hematological tests suggestive of aspergillosis include lung nodules with a perilesional ground glass halo, mediastinal mass and positive beta-D-glucan. Thirdly the management of massive hemoptysis during both EBUS and CT guided lung biopsy in the context of pulmonary hypertension. Pulmonary hypertension is a serious risk factor to be considered in patients undergoing interventional procedures. Preparation prior to interventional procedures is critical, including the need for therapeutic bronchoscope access as in this case, tamponade therapies, topical coagulation therapies and oxygenation strategies including intubation facilities should the need arise.

Tables: 

2018

abstract No: 

A3156 / P751

Full conference title: 

The American Thoracic Society Conference 2018
    • ATS 2018