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Fatal Hemoptysis Caused by Ruptured Giant Rasmussen's Aneurysm

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.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —50-year-old man with hemoptysis. A, Anteroposterior radiograph of chest shows large round opacity (arrow) in right lung.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —50-year-old man with hemoptysis. B, CT scan of chest at lung window reveals large mass (arrow) in superior segment of right lower lobe. Multiple small nodules are seen in both lungs.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   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.

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.

References

1. Ravi R, Bandekar VG, Gandhi MS, Aulakh BG, Deshmukh HL. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology 1996;200:691-694[Abstract/Free Full Text]
2. Remy J, Lemaitre L, Lafitte JJ, Vilain MO, Saint Michel J, Steenhouwer F. Massive hemoptysis of pulmonary arterial origin: diagnosis and treatment. AJR 1984;143:963-969[Abstract/Free Full Text]
3. Ungaro R, Saab S, Almond CH, Kumar S. Solitary peripheral pulmonary artery aneurysm: pathogenesis and surgical treatment. J Thorac Cardiovasc Surg 1976;71:566-571[Abstract]
4. Souders CR, Smith AT. The clinical significance of hemoptysis. N Engl J Med 1952;20:790-793
5. Davidoff AB, Udoff EJ, Schonfeld SA. Intraaneurysmal embolization of a pulmonary artery aneurysm for control of hemoptysis. AJR 1984;142:1019-1020[Free Full Text]

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This Article Figures Only Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Patankar, T. Articles by Mukherji, S. K. Search for Related Content PubMed PubMed Citation Articles by Patankar, T. Articles by Mukherji, S. K. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?