Radiology

A six month old girl presented with history of fever since 10 days and cough and breathlessness since two days . The patient had history of left axillary abscess following insect bite one month ago which was treated by incision and drainage .On examination ,there was decreased air entry on right side in lower zone and scattered crepetation in both lungs. A chest radiograph obtained on admission showed right lower zone consolidation and left lower zone cavitatory changes(Fig.1).

Fig 1

She had 50 cc of hemoptysis on 10^th day of admission to hospital . A repeat chest radiograph revealed a mass in right lower zone(fig 2).Ultrasonography revealed a loculated collection in right pleural cavity .Ultrasound guided tap was attempted which was dry.

Fig 2

Following this, the patient again had second episode of hemoptysis (40cc) on the 16^th day of admission. A CT SCAN of the chest revealed a large right lower lung collection with a high attenuation areas in the cavity (Fig 3).A contrast enhanced CT scan of the chest showed a intensely enhancing partially thrombosed aneurysm along the anterior aspect of the collection(Fig.4).

Fig 3	Fig 4

 

Pulmonary angiography confirmed the diagnosis of pseudoaneurysm from anterior basal segmental artery arising from middle lobe branch of right pulmonary artery (Fig 5).

Fig 5

 

Selective coil embolisation of pseudoaneurysm was done successfully using four 35-5-5 mm steel coils (Cook) and one 300-6 mm coil (Balt- spirales) (Fig 6).There was no hemoptysis following embolisation .

 

Fig 6

 

Discussion:

Massive hemoptysis almost always arises in the systemic circulation from causes such as bronchiectasis ,tuberculosis ,tumour and infection. Bleeding from aneurysm of pulmonary artery is very rare .

Etiologically , pulmonary artery aneurysms can be due to specific etiology such as tuberculosis (Rasmussen’s aneurysm),syphilis, traumatic or of nonspecific etiology such as Mycotic aneurysms seen in septicemia, bronchiectasis, lung abscess, and other acute or chronic inflammatory conditions; or may seen in association with pulmonary hypertension, congenital or arteriosclerotic. Aneurysms involving the lobar or segmental branches of the pulmonary arteries occur in Behcets and Hughes–Stovin syndromes. Aneurysms associated with necrotic pulmonary neoplasms, post embolic and iatrogenic aneurysms represent other less common causes of pulmonary aneurysms.

A destructive lung process, irrespective of its pathogenesis, can destroy adjacent lung ,weaken the arterial wall, or erode any vessel in its vicinity. A cavitary lesion in the close proximity to a central pulmonary artery is a potential source of bleeding. Contrast enhanced CT and pulmonary angiography is indicated for hemoptysis associated with necrotic cavity whatever its origin to study all vessels supplying the cavity.

Aneurysmal rupture resulting in massive hemoptysis is potentially fatal, with death caused by aspiration of blood and consequent asphyxiation or less commonly ,by exsanguination.

Endovascular treatment is successful alternative to surgical resection in the form of lobectomy or aneurysmectomy for treatment of pulmonary arterial aneurysm. Embolisation is done selectively of involved branch by steel coil or silicon balloon so as to preserve any residual pulmonary function distal to aneurysm as it also blocks the perfusion to the aerated lung beyond the embolisation site .

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