HEMOPTYSIS

True hemoptysis must be distinguished from epistaxis (see page 188) and hematemesis (see page 261). If the blood is bright red and alkaline (use nitrazine paper to test) and the nasal passages and posterior pharynx are clear, then it is probably hemoptysis.

Anatomy is the basic science to apply to develop a differential diagnosis of hemoptysis. Beginning at the larynx and working down the trachea, bronchi, and alveoli, one can quickly recall the major causes of hemopytysis using the cross-index of the various etiologies as in Table 36. Laryngitis is an infrequent cause of hemoptysis but laryngeal carcinoma may cause it. Tuberculosis of the larynx used to be a common cause but it is not often seen today. A foreign body such as a chicken bone lodged in the larynx or trachea should always be considered, especially in children. Additional etiologies of hemoptysis that one might encounter in the trachea are ulceration and rupture of an aortic aneurysm or a carcinoma of the esophagus with a tracheoesophageal fistula. Hereditary telangiectasia may lead to hemoptysis anywhere along the tracheobronchial tree. In the bronchi, carcinoma, tuberculosis, and bronchiectasis become prominent causes. These are probably the most common causes of chronic hemoptysis in the adult.

HEMOPTYSIS

In the alveoli the acute causes of hemoptysis—pneumonia (pneumococcal and Friedlander, especially), and pulmonary embolism or infarctions—are encountered. CHF may cause a foamy hemoptysis. Carcinoma, tuberculosis, fungi, parasites, and trauma are also important. Collagen diseases, Goodpasture syndrome, and primary hemosiderosis should be looked for in the elusive cases.

Approach to the Diagnosis

The differential diagnosis of hemoptysis can be narrowed considerably by the clinical picture. Acute hemoptysis with chest pain would suggest pulmonary embolism. A chronic cough with occasional hemoptysis suggests neoplasm, tuberculosis, or bronchiectasis. Hemoptysis with chills and fever suggests pneumonia but one should always keep pulmonary embolism in mind. Hemoptysis with dyspnea, edema, or cardiomegaly suggests mitral stenosis or CHF. The sputum is usually foamy in cases of CHF. Hemoptysis with purpura or bleeding from other sites should suggest a systemic disease or coagulation disorder.

The initial workup of hemoptysis includes a CBC, urinalysis, sedimentation rate, chemistry panel, sputum smear and culture, and a chest x-ray. If a pulmonary embolism is suspected, arterial blood gas analysis and a lung scan are ordered. Pulmonary angiography may also be necessary. If routine studies and the clinical picture suggest pneumonia, nothing more may need to be done other than a careful follow up. If CHF is suspected, a circulation time may be done but a cardiology consult and echocardiogram would be more definitive. What would you do if it was your heart?

If a bronchogenic neoplasm or bronchiectasis is suspected, a pulmonary consult and bronchoscopy would be ordered. Bronchiectasis can be identified with a CT scan of the chest also. If tuberculosis is suspected, a tuberculin test is performed, and sputum is cultured for AFB and possibly Guinea pig innoculation performed.

Other Useful Tests

1. Papanicolaou smears of sputum (neoplasm)
2. Coagulation studies (see page 83)
3. Apical lordotic views (tuberculosis)
4. Spirometry (chronic bronchitis and emphysema, CHF)
5. ECG (CHF, mitral stenosis)
6. Scalene node biopsy (carcinoma of the lung)
7. Lung biopsy (neoplasm, pneumoconiosis, collagen disease)
8. Coccidioidin skin test
9. Histoplasmin skin test
10. Blastomycin skin test

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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