Review of Respiratory Medicine - Volumen 25, Número 2 - June 2025

Imaging In Pulmonology

Hemoptysis and Unilateral Pulmonary Ground Glass Opacity

Hemoptisis y vidrio esmerilado pulmonar unilobar

Received: 04/06/2025

Accepted: 05/01/2025

CASE REPORT

61-year-old male who works as a supervisor at a nuclear power plant. The patient is an active smoker with a 43 pack-year history, overweight, and currently going through the immediate postoperative period after umbilical hernioplasty.

Medical history: more than 6 episodes of hemoptysis with bright red blood and clots of approximately 200 ml each, with acute onset. The patient denies other symptoms. He reports recurrent epistaxis during childhood and ado­lescence.

Hemodynamically stable, with basal crackles on the right side. Mucocutaneous telangiectases observed on the bridge of the nose, cheeks, fore­head, lips, tongue, and hands. Laboratory results: Hb (hemoglobin): 15g/dl, Hto (hematocrit): 44.5%, C-reactive protein: 0.26mg/dl, D-dimer: 1.15ugr/ ml, normal coagulogram.

Initialchest HRCT without contrast showed ground-glass infiltrates (GGI) and a right basal cobblestone pattern (Image 1). Two hours later, a chest HRCT with contrast revealed progressive GGI extension (Image 2).

Bronchoalveolar lavage was performed (BAL), revealing the presence of hemosiderophages, and confirming pulmonary hemorrhage. Re­sults from molecular biology, microbiology, and anatomic pathology ruled out other diagnoses.

ADMISSION DIAGNOSIS

Focal alveolar hemorrhage, suspected pulmonary arteriovenous malformation (PAVM)

CLINICAL DISCUSSION

In cases of focal alveolar hemorrhage, it is impor­tant to rule out localized lesions such as bronchiec­tasis, chronic bronchitis, infections, tumors, trau­ma-related causes, vasculitis, and PAVM, among others.¹ In this patient, with alveolar hemorrhage confirmed by BAL, along with physical examina­tion findings, recurrent epistaxis, and a paternal history of Rendu-Osler-Weber Syndrome, the primary diagnostic suspicion is PAVM. A selective bronchial arteriography was performed (Image 3).

PAVM secondary to Hereditary Hemorrhagic Telangiectasia (HHT) is confirmed. The patho­logical artery is embolized, and stops the bleeding.

HHT or Rendu-Osler-Weber Syndrome: is an autosomal dominant disorder with a global prevalence of 1/5,000-8,000. It is characterized by cutaneous and mucosal telangiectases, recur­rent epistaxis, and arteriovenous malformations (AVMs) in the brain, liver, gastrointestinal tract, and lungs.^2-4

PAVMs occur in 20-50% of patients with HHT, creating systemic-to-pulmonary arteriovenous shunts. They are typically unilateral and located in the lower lobes. They can cause hypoxemia, para­doxical emboli, pulmonary hemorrhage, hemopty­sis, and hemothorax. Selective embolization is the treatment of choice, with a 15% recanalization rate. CT follow-up is recommended. Diagnosis through contrast-enhanced high-resolution computed axial tomography (HRCAT) requires visualization of a feeding artery and a draining vein. PAVMs with fo­cal pulmonary hemorrhage are observed with GGO and areas of consolidation, due to the presence of alveolar blood, along with superimposed interlobu­lar septal lines that can form a “crazy paving pat­tern.”^1,5 Also notable is the “dark bronchus sign”, caused by filling and prominence of segmental and subsegmental bronchi. Hemoptysis is always a diag­nostic challenge. In this case, we want to highlight the importance of CT findings as the first step in the diagnostic evaluation, along with the BAL to confirm focal pulmonary hemorrhage.

Conflict of interest

Authorshave no conflict of interest to declare that are relevant to the content of this article.

REFERENCES

1. Weerakkody Y, Baba Y, Kang O, et al. Hemorragia pulmonar localizada. Artículo de referencia. Radiopaedia.org DOI: 10.53347/rID-24805

2. Dunphy L, Talwar A, Patel N, Evans A. Hereditary Haemor­rhagic Telangiectasia and pulmonary arteriovenous mal­formations. BMJ Case Reports. 2021;14(1). DOI: 10.1136/bcr-2020-238385

3. Faughnan ME, Mager JJ, Hetts SW, et al. Segunda Guía Internacional para el Diagnóstico y Manejo de la Tel­angiectasia Hemorrágica Hereditaria. Ann Intern Med 2020;173:989. DOI: 10.7326/M20-1443

4 Kühnel T, Wirsching K, Wohlgemuth W, Chavan A, Evert K, Vielsmeier V. Hereditary hemorrhagic telangiectasia. Oto­laryngol Clin North Am. 2018;51:237-54. DOI: 10.1016/j.otc.2017.09.017

5. Raptis DA, Short R, Robb C, et al. CT appearance of pul­monary arteriovenous malformations and mimics. Radio­Graphics. 2022;42:56–68. DOI: 10.1148/rg.210076