Hemoptysis

Differential Overview

❑ Bronchitis

❑ Pneumonia

❑ Pulmonary edema

❑ Pulmonary infarction

❑ Tuberculosis

❑ Bronchogenic carcinoma

❑ Chest trauma

❑ Bronchiectasis

❑ Bronchial adenoma

❑ A-V malformation

❑ Aspergilloma

❑ Vasculitis

❑ Lung abscess

❑ Mitral stenosis

❑ Hereditary hemorrhagic telangiectasia

❑ Parasitic

Diagnostic Approach

In primary care practice, neoplasm is the cause of less than 2% of cases of hemoptysis. A chest radiograph is nonetheless an essential component of the evaluation of every case of hemoptysis.

Differentiate hemoptysis from hematemesis. Hemoptysis is frothy, blood-tinged sputum that the patient can usually distinguish as coming from the lungs. Hematemesis is associated with nausea and vomiting, and it may be darker. Nasal or pharyngeal bleeding with posterior pharyngeal drainage could also be a source.

Clubbing indicates a chronic disorder and may be found in association with neoplasm, bronchiectasis, and lung abscess. Massive hemoptysis is usually due to lung cancer, tuberculosis, or aortic aneurysm.

Differential Diagnosis

Bronchitis  Hemoptysis occurring in the setting of an acute vigorous productive cough suggests bronchitis, and is associated with typical upper respiratory symptoms.

Pneumonia  Fever, cough tinged with blood, pleuritic chest pain, and focal rales with consolidative findings may occur in any combination. Pneumococcus classically produces rust-colored sputum. Klebsiella may produce a tenacious “currant jelly” sputum.

Pulmonary edema  In acute left heart failure, frothy pink sputum occurs with dependent rales, S₃ gallop, and dyspnea.

Pulmonary infarction  In acute pulmonary embolism, sudden onset of pleuritic chest pain and dyspnea with a pleural rub will occur. A source may be found in a unilateral swollen leg.

Tuberculosis  The classic presentation is blood-tinged sputum. Epidemiologic exposure/risk factors (e.g., being a health care worker, an Asian immigrant, or at risk for HIV) or upper lung field consolidative findings provide additional clues.

Bronchogenic carcinoma  When presenting with hemoptysis, the lung cancer is usually primary because metastatic cancer is rarely endobronchial. Environmental exposure to tobacco or asbestos or a family history of this disease increases the risk. A firm, palpable supraclavicular node is sometimes found.

Chest trauma  Rib fracture may cause a lung laceration. There will be exquisite tenderness over the rib segment, and the fragment will “float.”

Bronchiectasis  It is recognized clinically by recurrent episodes of grossly bloody sputum (due to necrosis of bronchial mucosa) in a patient with chronic copious purulent sputum.

Bronchial adenoma  Being quite vascular, these often present with episodes of self-limited hemoptysis recurrent over years.

A-V malformation  There may be an audible bruit on auscultation of the lung.

Aspergilloma  Suspect in an immunosuppressed host with prior cavitary lung disease or bullous disease with wheezing.

Vasculitis  Goodpasture syndrome and Wegener granulomatosis are characterized by hemoptysis in association with hematuria. Wegener granulomatosis will be associated with a nasal septal ulcer or perforation.

Lung abscess  Unmistakably fetid sputum will be intermittently mixed with blood.

Mitral stenosis  Hemoptysis is a diagnostic pearl in a patient with a soft, low-pitched apical diastolic murmur and an opening snap. This condition is often not considered because of its rarity and the orientation toward considering pulmonary causes of hemoptysis.

Hereditary hemorrhagic telangiectasia  Telangiectasias are evident on the lips and skin, and there is usually a history of bleeding from other sites.

Parasitic  Schistosomiasis, paragonomiasis, or echinococcus should be considered in international travelers or immigrants.

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Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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