Hemoptysis

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Causes

There are many underlying disorders that can cause hemoptysis (coughing up blood), ranging from heart problems to trauma to infections to lung disease. Worldwide, tuberculosis is the most common cause of hemoptysis. In industrialized countries, the most common causes are bronchitis, bronchiectasis, and bronchogenic carcinoma.

In patients with AIDS, the most common cause of hemoptysis is pneumonia. In about 15% to 30% of cases, the underlying problem is never found—undiagnosed hemoptysis is commonly referred to as idiopathic hemoptysis.

Other causes include pulmonary infarction or embolism, various heart problems, vascular disorders, pulmonary AVM , and trauma.

Tuberculosis and other mycobacterial infections
A mycobacterium is a type of bacteria that causes a variety of infections, including tuberculosis. A mycobacterial infection can destroy pulmonary tissue, usually by forming cavities in the airway walls.

The hemoptysis that results is usually mild to moderate and may be associated with other symptoms, including unexplained weight loss, cough, purulent sputum (thick, opaque, yellowish white discharge), and a history of mycobacterial exposure. A chest x-ray usually shows signs of infection, including a visible cavity, and the mycobacterium should be microscopically visible in the patient's sputum.

Bronchitis
Bronchitis is an inflammation and swelling of the bronchi that can be acute or chronic. It is a very common cause of hemoptysis that results from recurrent coughing that irritates and eventually breaks down the mucosal lining of the airways.

The hemoptysis is usually mild and often associated with a purulent sputum (thick, opaque, yellowish-white discharge), low-grade fever and occasionally, wheezing. Usually the sputum is examined under the microscope to look for the pathogenic culprit. A chest x-ray is usually normal. The patient is usually prescribed cough suppressants and antibiotics.

Bronchiectasis
Bronchiectasis is a chronic dilation and consequent infection of the bronchioles and bronchi that results from obstruction in the bronchi. The dilation results from damage to the surrounding supportive tissue and is usually a result of infection or fibrosis (the abnormal formation of scar tissue).

Cystic fibrosis is an example of a disease that leads to bronchiectasis. In addition to hemoptysis, patients with bronchiectasis often have a severe cough and chronic purulent sputum (thick, opaque, yellowish white discharge).

Lung Cancer
Bronchogenic carcinoma is cancer that originates in the lining of the bronchi. About 90% of lung cancers are bronchogenic. The other 10% begin in the bronchioles, alveoli, or trachea. Bronchogenic carcinoma is a less common cause of hemoptysis than bronchitis or bronchiectasis, but is an important one.

Most cases of bronchogenic carcinoma occur in smokers. If the disease is advanced, patients may experience unaccountable weight loss and various other common symptoms of lung cancer.

A chest x-ray can reveal the location of the neoplasm (tumor), and cancerous cells can often be detected in microscopic examination of the patient's sputum. The diagnosis sometimes cannot be confirmed until the tissue is biopsied.

About 7% of patients with bronchogenic cancer are initially diagnosed because of hemoptysis. About 20% of patients with bronchogenic cancer experience hemoptysis at some point. The bleeding results from necrosis of the tumor (death of the cells that make up the tumor), the rupture of small blood vessels in the area, or the tumor invading one of the pulmonary blood vessels. Massive bleeding can occur if the tumor erodes into one of the large pulmonary vessels.

Hemoptysis can also result from metastatic cancer to the lungs (especially breast, kidney, colon, and esophageal metastases). The cancer causes bleeding in much the same way that bronchogenic carcinoma causes bleeding.

Pneumonia
Pneumonia is a lung infection caused by a number of different microorganisms. When a healthy person inhales one of these microbes, the immune system responds and prevents the microbe from reproducing and causing infection. But, in people with weakened immune systems (e.g., patients with AIDS), the microbes settle in the lungs, where they grow and multiply.

As the lung tissue tries to protect itself, the lungs fill with liquid and pus. In addition to hemoptysis, other symptoms include a high fever, cough, and chest pain.

Pulmonary infarction or embolism
A pulmonary embolism is the sudden closure of a pulmonary artery due to a blood clot or presence of foreign material. Pulmonary infarction is the death of lung tissue due to the lack of oxygen resulting from a single embolism or several recurrent embolisms. Pulmonary embolism can be massive, resulting in death or severe shock; or it can be relatively mild.

Infarction is a relatively uncommon cause of hemoptysis. Associated symptoms include chest pain (pleuritic chest pain in particular, meaning the pain is felt as the patient breathes in and out), cough, low-grade fever, tachypnea (rapid breathing), tachycardia (rapid heartbeat), and dyspnea (shortness of breath, even without exertion).

The chest x-ray of a patient with a pulmonary infarction or embolism is usually normal, but there may be a couple of distinguishing features.

Heart problems
Mitral stenosis (a narrowing of the mitral valve that leads into the left ventricle) can lead to very mild hemoptysis—pink, frothy sputum with mild traces of blood. Other symptoms associated with left ventricular failure include orthopnea (difficulty breathing when lying down), paroxysmal nocturnal dyspnea (PND; a shortness of breath that appears suddenly at night, usually waking a person from sleep), and shortness of breath while exercising.

Coagulopathy
A coagulopathy (also known as a hypercoagulable state) is any disease that affects coagulability—the ability to of the blood to clot. In a patient with coagulopathy, clots cannot form after even mild trauma to the mucosal lining of the respiratory airways, leading to mild hemoptysis.

Other signs of coagulopathy include epistaxis (nosebleed), purpura (appearance of lesions, or bruises, on the skin due to broken blood vessels), menorrhagia (excessively long or heavy periods), and hematuria (blood in the urine).

Anticoagulants
Anticoagulants are drugs commonly prescribed to prevent the formation of blood clots. They are often used to treat thromboembolic disorders (blood clot disorders; a thrombus is a clot and an embolism is the sudden closure of an artery due to a clot). Hemoptysis sometimes develops in people who take anticoagulant medication.

Drug use
In addition to anticoagulants, a variety of other drugs including aspirin, cocaine, and penicillamine (a drug used to treat lead poisoning and other disorders) are known to cause hemoptysis.

Catamenial hemoptysis
Catamenial hemoptysis is menstrual-related hemoptysis. It is also known as pulmonary endometriosis. Endometriosis is the development of cells outside of the uterus that normally grow only inside the uterus—the same cells that are shed monthly during menstruation. Researchers do not know how or why endometriosis occurs.

Usually the abnormal cell growth occurs in other areas of the reproductive tract, but sometimes it occurs in the liver, lung, and even the brain. Endometriosis in the lungs results in catamenial hemoptysis. It is very rare and usually treated using hormones.

Cryptogenic hemoptysis
About 15% to 30% of hemoptysis cases go undiagnosed and the underlying cause is never determined. This is true even after extensive diagnostic tests, including a bronchoscopy. Usually the hemoptysis is mild and attributed to bronchial inflammation, and the prognosis (final outcome) for most patients is good.

Iatrogenic hemoptysis
An iatrogenic condition occurs as a result of the activity of a physician or surgeon. Iatrogenic hemoptysis can occur following a biopsy of lung tissue taken during a bronchoscopy. Usually the bleeding stops on its own, but sometimes it can be severe.

Aspergillosis
Aspergillosis is a lung infection caused by the fungus Aspergillus fumigatus. It is rare, except in patients with compromised immune systems. The fungus usually grows to form a ball (known as an aspergilloma) that can invade the blood vessels in the area, causing massive hemoptysis and major damage. A chest x-ray is usually diagnostic, and treatment usually involves surgically removing the lesion.

Lung abscess
A lung abscess is an accumulation of pus (a fluid product of inflammation and infection) in the lungs that can cause hemoptysis.

Arteriovenous malformation (AVM)
AVM is a congenital (present at birth) childhood disease characterized by the presence of abnormal arteries and veins throughout the lungs. The abnormalities cause internal damage to the lungs and eventually cause loss of function.

Idiopathic pulmonary hemosiderosis
Idiopathic pulmonary hemosiderosis is a rare childhood disease that leads to the deposition of hemosiderin (an iron byproduct of hemoglobin) in the lungs. It is believed to be an autoimmune disease, meaning that the body mistakenly attacks its own healthy tissue, causing damage. Patients suffer repeated sudden attacks of hemoptysis and dyspnea (difficult breathing).

Goodpasture's syndrome
Goodpasture's syndrome also involves an accumulation of iron in the lungs. Goodpasture's also involves the kidneys, and most patients die from kidney failure several months after being diagnosed.

Trauma
Trauma to the chest, such as from a car accident or other injury, can cause hemoptysis immediately following the incident or later.

Wegener's granulomatosis
Wegener's granulomatosis is an autoimmune disease, meaning that the body attacks its own healthy, normal tissue, causing damage. Wegener's is very rare and is characterized by inflammation.

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