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 Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 65-66

A rare cause of massive hemoptysis in pulmonary tuberculosis – Rasmussen's aneurysm: A forgotten scourge


1 Department of Pulmonary Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
2 Department of Pathology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India

Date of Submission01-Jan-2019
Date of Decision17-Jan-2019
Date of Acceptance19-Jan-2019
Date of Web Publication13-Mar-2019

Correspondence Address:
Dr. Swetabh Purohit
Department of Pulmonary Medicine, Room No. 3308, OPD Block, Adesh Institute of Medical Sciences and Research, NH-7, Barnala Road, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_6_19

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How to cite this article:
Purohit S, Joshee V. A rare cause of massive hemoptysis in pulmonary tuberculosis – Rasmussen's aneurysm: A forgotten scourge. Biomed Biotechnol Res J 2019;3:65-6

How to cite this URL:
Purohit S, Joshee V. A rare cause of massive hemoptysis in pulmonary tuberculosis – Rasmussen's aneurysm: A forgotten scourge. Biomed Biotechnol Res J [serial online] 2019 [cited 2019 Jul 22];3:65-6. Available from: http://www.bmbtrj.org/text.asp?2019/3/1/65/254104



Sir,

Hemoptysis is a known complication of active or old burnt-out pulmonary tuberculosis (PTB).[1] The common causes of hemoptysis in PTB patients include tubercular reactivation, bronchiectasis, aspergilloma,[2] and vascular complications such as hypervascularity from bronchial arteries, arteriovenous fistula formation, and pseudoaneurysms. Massive hemoptysis in PTB patients is often secondary to a vascular complication and usually originates from the bronchial circulation (95%) rather than pulmonary circulation.[3] Being rare, Rasmussen's aneurysm (pseudoaneurysm arising from pulmonary arteries) which is a potentially treatable cause for hemoptysis is not looked for and is often missed. Here, we report a case of 70-year-old male PTB patient with massive hemoptysis where the cause of bleeding was a rare Rasmussen's aneurysm.

A 70-year-old male patient presented to the emergency room with a 1-day history of coughing up 10 cups filled with blood. He was a k/c/o PTB (sputum smear 1 +positive for acid-fast bacilli, cartridge-based nucleic acid amplification test-rifampicin-sensitive Mycobacterium tuberculosis detected). On clinical examination, the patient was diaphoretic and distressed. His chest auscultation revealed crepitations in the right axillary and infrascapular area. Examination of other systems was unremarkable. He was anemic with a hemoglobin of 6 g/dL and hypotensive with a blood pressure of 96/50 mmHg. The patient was resuscitated and was transfused with 4 units of packed red blood cells to a hemoglobin level of 10 g/dL. A contrast-enhanced computed tomography (CT) of the thorax was done to find the cause of hemoptysis which revealed dumbbell-shaped bilobulated aneurysm arising from the right posterior basal artery branch of the right pulmonary artery. Larger content of the aneurysm was in the form of noncontrast-enhancing subtotal thrombus [Figure 1]. The bilobed lesion was collectively measured 84 mm × 74 mm. The lateral half lobe seen in the right basal region was measured 55 mm × 45 mm with patent-enhancing artery branch in it. The medial half lobe was measured 48 mm × 34 mm and seen in the left paraesophageal region inferior to the carina causing displacement of the carina [Figure 2]. The bronchial arteries were not enlarged, and no active contrast extravasation was detected from them. After resuscitation, the patient was referred to cardiothoracic vascular surgeon, and selective endovascular coil placement was done with occlusion of the pulmonary aneurysm. The patient's hemoptysis was resolved over the next 12 h. The patient was treated with a full course of antitubercular therapy. The patient is stable and under regular follow-up at our chest outpatient department.
Figure 1: Contrast-enhanced computed tomography thorax showing dumbbell-shaped right pulmonary artery aneurysm

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Figure 2: Contrast-enhanced computed tomography thorax coronal section showing bilobulated Rasmussen's aneurysm

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Fritz Waldemar Rasmussen, a Danish physician, first described 11 cases of pulmonary aneurysms in patients with tuberculosis in 1868. Although it is reported in 5% of autopsy series[3] of patients with tubercular cavities, only a few clinical case reports exist in literature.[4],[5],[6],[7] In pulmonary TB patients after ruling out active infective etiology, the cause of hemoptysis is generally looked for in the bronchial arteries, especially in cases with massive hemoptysis. Bronchial arteries in such patients get hypertrophied and enlarged and show rich bronchopulmonary communications, which are the usual source of bleed. Bronchial artery embolization using various substances such as gel foam, pva-poly vinyl alcohol (PVA) embolization particles, and coils, has been used to control massive hemoptysis. If no abnormal bronchial arteries are found, then surgical lobectomy is considered for the control of life-threatening bleed. Rasmussen's aneurysm, though rare, if present, can be another treatable cause of hemoptysis in such patients. CT pulmonary angiography is the best investigation to confirm their existence and should be done in all PTB patients presenting with hemoptysis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhalla A, Pannu AK, Suri V. Etiology and outcome of moderate-to-massive hemoptysis: Experience from a tertiary care center of North India. Int J Mycobacteriol 2017;6:307-10.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ofori A, Steinmetz AR, Akaasi J, Asafu Adjaye Frimpong GA, Norman BR, Obeng-Baah J, et al. Pulmonary aspergilloma: An evasive disease. Int J Mycobacteriol 2016;5:235-9.  Back to cited text no. 2
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3.
Santelli ED, Katz DS, Goldschmidt AM, Thomas HA. Embolization of multiple rasmussen aneurysms as a treatment of hemoptysis. Radiology 1994;193:396-8.  Back to cited text no. 3
    
4.
Corr P. Pulmonary artery aneurysm as a cause of massive hemoptysis: Diagnosis and management. Case Rep Radiol 2011;2011:141563.  Back to cited text no. 4
    
5.
Syed M, Irby J. Airway management of ruptured pulmonary artery “Rasmussen” aneurysm and massive hemoptysis. BMC Res Notes 2015;8:346.  Back to cited text no. 5
    
6.
Shih SY, Tsai IC, Chang YT, Tsan YT, Hu SY. Fatal haemoptysis caused by a ruptured rasmussen's aneurysm. Thorax 2011;66:553-4.  Back to cited text no. 6
    
7.
Idor G, Idor C, Serra CA. Rasmussen aneurysm and paragonimiasis presented as massive hemoptysis. Chest 2014;143:112A.  Back to cited text no. 7
    


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