AJR 2000; 174:262-263
© American Roentgen Ray Society
Fatal Hemoptysis Caused by Ruptured Giant Rasmussen's Aneurysm
Tufail Patankar,
Srinivasa Prasad,
Hemant Deshmukh and
Suresh K. Mukherji
King Edward Memorial Hospital Mumbai 400 012,
India
University of North Carolina School of Medicine Chapel
Hill, NC 27599-7510
The source of hemoptysis in cavitary pulmonary tuberculosis is usually from
bronchial arteries. Pseudoaneurysm of bronchial arteries, although an
important source of hemoptysis, is seen infrequently
[1]. Pulmonary artery
pseudoaneurysms are occasionally encountered in patients with hemoptysis due
to pulmonary tuberculosis. Although clinically occult cases do occur,
pulmonary pseudoaneurysms are usually symptomatic. Hemoptysis is the chief
complaint and is frequently fatal.
A 50-year-old male farmer presented with 400 ml of hemoptysis. Two days
earlier, he had a bout of 300 ml of hemoptysis. The patient had a history of
partially treated pulmonary tuberculosis. A chest radiograph obtained 2 months
before presentation showed multiple bilateral nodular shadows with a large
cavity in the right mid zone with an air-fluid level. A chest radiograph
obtained at admission showed a large mass in the right lung
(Fig. 2A). A bronchial
angiogram showed normal findings. CT of the chest revealed a large mass in the
right lung overlying multiple small lung nodules
(Fig. 2B). A contrast-enhanced
CT scan of the chest showed a large partially thrombosed aneurysm involving
the right descending pulmonary artery in the wall of the cavity
(Fig. 2C). Diagnostic catheter
pulmonary angiography confirmed the diagnosis of pseudoaneurysm of the
pulmonary artery. The patient had a bout of massive hemoptysis during the
angiographic procedure and underwent emergency right pneumonectomy. The
resected lung specimen showed a large partially thrombosed Rasmussen's
aneurysm in the wall of the cavity, which was filled with blood. Bilateral
diffusely scattered foci of tuberculous lesions were also found. The patient
died on the third postoperative day as a result of pulmonary edema.

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Fig. 2. 50-year-old man with hemoptysis.
C, Contrast-enhanced CT scan of chest obtained after administration
of IV contrast material shows that large partially thrombosed aneurysm
(arrow) that arose from right descending pulmonary artery.
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A destructive lung process, irrespective of its pathogenesis, can destroy
adjacent lung, weaken the arterial wall, or erode any vessel in its vicinity
[2]. A cavitary lesion in close
proximity to a central pulmonary artery is a potential source of bleeding
[2]. Rasmussen's aneurysm
refers to an aneurysm of the small to medium pulmonary artery branches that
develops in the vicinity of a tuberculous cavity. Other causes of mycotic
aneurysms are septicemia, bronchiectasis, lung abscess, and other acute or
chronic inflammatory conditions. Although syphilitic pulmonary aneurysms are
centrally located, Rasmussen's aneurysms are usually distributed peripherally
and beyond the branches of main pulmonary arteries
[3]. Aneurysms involving the
lobar or segmental branches of the pulmonary arteries occur in
Behçet's and Hughes-Stovin syndromes.
Posttraumatic aneurysms, dissecting aneurysms, aneurysms associated with
necrotic pulmonary neoplasms, and postembolic and iatrogenic aneurysms
represent other less common causes of pulmonary aneurysms
[3].
Aneurysmal rupture resulting in massive hemoptysis is potentially fatal,
with death caused by aspiration of blood and consequent asphyxiation or, less
commonly, by exsanguination
[4]. Bleeding associated with
acute tuberculosis from the pulmonary vessels is small in volume and caused by
necrosis of a small pulmonary artery branch or vein
[4,
5]. Massive hemoptysis
associated with chronic cavitary tuberculosis usually results from the rupture
of Rasmussen's aneurysm through the wall of the cavity
[4], as was seen in our
patient.
There is the potential risk of aneurysmal rupture during diagnostic
catheter angiography. Endovascular treatment is a successful alternative for
the treatment of Rasmussen's aneurysm. We were unable to occlude the aneurysm
because of the extent of hemoptysis present during pulmonary angiography.
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