Unexplained Hemoptysis: Causes and Next Steps

Abnormal vomiting of blood, known as hematemesis, can be caused by various medical conditions. Some common causes include: 1. Gastrointestinal bleeding: This can occur due to ulcers, gastritis, or esophageal varices. 2?

A family member, a 23-year-old male currently abroad, has a history of tuberculosis that has been resolved for a long time.
Around the end of March this year, he experienced severe coughing symptoms without hemoptysis, which was diagnosed as simple nasal and ocular allergies.
After continuing to take allergy medications, the cough symptoms resolved, and he felt well until recently when he began to experience hemoptysis.
The bleeding occurs in larger amounts in the early morning or at night, with the most recent episode being approximately 300cc, followed by intermittent smaller amounts of blood for the past week.
He has undergone two chest X-rays at the hospital, both of which were reported as normal, with the doctors stating that hemoptysis can be normal.

Aside from the hemoptysis, he had no prior physical discomfort or other obvious symptoms until the day before yesterday when he felt somewhat fatigued.
I am concerned whether there might be an issue with his blood vessels that is not detectable by X-ray.
Since the end of March, he has been using Aeromax budesonide nasal spray, a steroid nasal spray from France, for his nasal allergies.
After stopping the medication for a week, he began to experience severe hemoptysis, prompting him to resume use.
However, he continues to cough up small amounts of dark-colored blood daily.
Additionally, he started experiencing knee pain and headaches yesterday, and his overall condition has begun to deteriorate.

Which specialty should he consult? Is this a drug reaction or indicative of another disease? Thank you for your guidance on how to proceed.

Jiaqi, 20~29 year old female. Ask Date: 2020/06/05

Dr. Liao Yaopan reply Family Medicine

Hello, the text mentions "hemoptysis." Gastrointestinal issues must be evaluated; online consultations are not equivalent to in-person medical visits and cannot provide diagnoses or treatment recommendations.
Changhua Hospital cares about you.

Reply Date: 2020/06/05

More Info

Unexplained hemoptysis, or coughing up blood, can be a concerning symptom and warrants thorough investigation, especially given your family member's medical history and recent symptoms. In this case, the patient is a 23-year-old male with a past history of tuberculosis (TB), which can have long-term effects on lung health, even after successful treatment. The recent onset of hemoptysis, particularly after a period of allergy-related coughing, raises several potential concerns.

Possible Causes of Hemoptysis
1. Residual Effects of Tuberculosis: Even after treatment, TB can leave scarring or cavitary lesions in the lungs, which may become inflamed or infected, leading to bleeding.
2. Bronchial Irritation or Inflammation: The use of nasal corticosteroids, such as budesonide, can sometimes lead to irritation of the respiratory tract, especially if there is an underlying condition like bronchitis or if the patient has been coughing excessively.

3. Pulmonary Vascular Issues: Conditions affecting the blood vessels in the lungs, such as pulmonary embolism or arteriovenous malformations, could also lead to hemoptysis. These conditions may not always be visible on a standard chest X-ray.

4. Infections: Aside from TB, other infections such as pneumonia or bronchitis can cause hemoptysis.
5. Malignancy: Although less likely in a young person, lung cancer or other malignancies can present with hemoptysis, especially if there is a history of smoking or other risk factors.

6. Coagulation Disorders: If the patient has any underlying blood clotting disorders, this could lead to bleeding in the lungs.

Next Steps
Given the severity of the hemoptysis (300cc is a significant amount), it is crucial to seek immediate medical attention. Here are some recommended steps:
1. Consult a Pulmonologist: The patient should see a specialist in pulmonary medicine. A pulmonologist can perform a more detailed evaluation, including a thorough history, physical examination, and possibly more advanced imaging studies like a CT scan of the chest, which can provide better visualization of lung structures and blood vessels than a standard X-ray.

2. Consider Bronchoscopy: This procedure allows direct visualization of the airways and can help identify the source of bleeding. It can also facilitate biopsies if any suspicious lesions are found.

3. Review Medications: Discuss the use of budesonide and any other medications with a healthcare provider. It’s essential to determine if the medication could be contributing to the symptoms or if an alternative treatment plan is necessary.

4. Monitor Symptoms: Keep track of any additional symptoms, such as fever, weight loss, or changes in cough, as these can provide important clues to the underlying cause.

5. Blood Tests: A complete blood count (CBC) and coagulation profile may be warranted to assess for any underlying blood disorders or infections.

Conclusion
In summary, unexplained hemoptysis, especially in a young individual with a history of TB, should not be taken lightly. The combination of recent symptoms, including fatigue, knee pain, and headaches, alongside the hemoptysis, suggests that a comprehensive evaluation is necessary. The patient should seek care from a pulmonologist as soon as possible to determine the cause of the bleeding and initiate appropriate treatment. Early intervention is crucial in managing potential complications and ensuring the best possible outcome.

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