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Haemoptysis

Medicine > Infection

Differential Diagnosis Schema 🧠

Respiratory Causes

  • Bronchitis: Common cause of haemoptysis, often associated with a recent upper respiratory infection; sputum may be blood-streaked.
  • Bronchiectasis: Chronic productive cough with large volumes of sputum; often associated with cystic fibrosis or previous infections.
  • Tuberculosis: Chronic cough, weight loss, night sweats, and haemoptysis; important to consider in at-risk populations or those with a history of exposure.
  • Lung Cancer: Persistent cough, weight loss, and haemoptysis in older adults or smokers; may present with a mass on imaging.
  • Pneumonia: Acute onset with fever, productive cough, and sometimes haemoptysis; crackles and consolidation may be found on examination.
  • Pulmonary Embolism: Sudden onset of pleuritic chest pain, dyspnoea, and haemoptysis; risk factors include recent surgery, immobility, or malignancy.
  • Pulmonary AV Malformation: Rare cause of haemoptysis, often associated with hereditary hemorrhagic telangiectasia.
  • Lung Abscess: Foul-smelling sputum, fever, and haemoptysis; may be seen in individuals with a history of aspiration or immunosuppression.
  • Goodpasture’s Syndrome: Autoimmune condition with haemoptysis and glomerulonephritis; may present with haematuria and renal impairment.
  • Idiopathic Pulmonary Haemosiderosis: Recurrent haemoptysis with iron deficiency anemia, more common in children.

Cardiovascular Causes

  • Mitral Stenosis: Haemoptysis may occur due to increased pulmonary venous pressure; often associated with dyspnoea, orthopnoea, and a mid-diastolic murmur.
  • Pulmonary Hypertension: May cause haemoptysis due to rupture of bronchial veins under increased pressure; often presents with dyspnoea and signs of right heart failure.
  • Left Ventricular Failure: Can lead to pulmonary congestion and haemoptysis, especially in acute decompensation.
  • Aortic Dissection: Can cause haemoptysis if the dissection ruptures into the pulmonary vasculature; presents with sudden tearing chest pain radiating to the back.
  • Pulmonary Embolism: As noted, a common cardiovascular cause of haemoptysis; associated with chest pain, dyspnoea, and tachycardia.
  • Vasculitis: Systemic vasculitides like granulomatosis with polyangiitis can involve the lungs and cause haemoptysis.
  • Congestive Heart Failure: Haemoptysis can occur due to pulmonary congestion; associated with peripheral oedema, orthopnoea, and paroxysmal nocturnal dyspnoea.

Other Causes

  • Coagulopathy: Anticoagulant or antiplatelet therapy, or underlying bleeding disorders, can cause haemoptysis.
  • Trauma: Chest trauma or recent invasive procedures such as bronchoscopy can lead to haemoptysis.
  • Foreign Body: Aspiration of a foreign body, especially in children, can cause haemoptysis.
  • Iatrogenic: Procedures such as lung biopsy, bronchoscopy, or even severe coughing can lead to haemoptysis.
  • Drugs: Certain drugs, like cocaine, can cause haemoptysis, especially when smoked.
  • Fungal Infections: Particularly in immunocompromised patients, fungal infections like aspergillosis can cause haemoptysis.
  • Malignancies Outside the Lung: Metastases to the lung, particularly from breast or renal cell carcinoma, can present with haemoptysis.
  • Endobronchial Lesions: Benign or malignant growths within the bronchi can cause haemoptysis.

Key Points in History 🥼

Symptom Onset and Characteristics

  • Onset: Acute onset may suggest pulmonary embolism, trauma, or infection; chronic or recurrent haemoptysis suggests malignancy or bronchiectasis.
  • Amount of Blood: Large volume haemoptysis is concerning for major pathology such as malignancy or bronchiectasis; small amounts may be seen in bronchitis or minor trauma.
  • Associated Symptoms: Fever, weight loss, night sweats, and chronic cough suggest tuberculosis or malignancy.
  • Pain: Pleuritic chest pain may indicate pulmonary embolism or infection, while central chest pain could suggest a cardiovascular cause.
  • Previous Episodes: Recurrent episodes may suggest bronchiectasis, mitral stenosis, or an underlying coagulopathy.
  • Travel History: Recent travel, particularly to areas endemic with tuberculosis or certain parasitic infections, may be relevant.
  • Exposure History: Smoking history, occupational exposures (e.g., asbestos), and environmental factors can increase risk for lung cancer and other pathologies.
  • Medication History: Review for anticoagulants, antiplatelets, and drugs known to cause pulmonary toxicity.
  • Systemic Symptoms: Signs like haematuria, joint pain, or skin rashes may indicate a systemic vasculitis or autoimmune condition.
  • Risk Factors: Consider risk factors for venous thromboembolism, such as recent surgery, immobility, or malignancy.

Background

  • Past Medical History: Document any history of chronic lung disease (e.g., COPD, asthma), cardiovascular disease, or previous episodes of haemoptysis.
  • Drug History: Detailed review of current and past medications, particularly anticoagulants, antiplatelets, and any recent changes in medication.
  • Family History: Consider family history of bleeding disorders, lung cancer, or hereditary conditions like cystic fibrosis or hereditary hemorrhagic telangiectasia.
  • Social History: Smoking status, alcohol use, and illicit drug use (e.g., cocaine) are important to assess.
  • Occupational History: Exposure to asbestos, silica, or other inhaled irritants may increase the risk of malignancy or lung disease.
  • Recent Procedures: Any recent thoracic procedures or surgeries, such as bronchoscopy, thoracentesis, or lung biopsy, should be noted.
  • Immunosuppression: Consider HIV status, use of immunosuppressive medications, or recent organ transplantation, which may predispose to infections like tuberculosis or fungal diseases.
  • Travel History: Relevant for assessing exposure to endemic infections, particularly tuberculosis, or parasitic infections.
  • Occupational Exposure: Ask about exposure to industrial dust, chemicals, or smoke, which could contribute to lung pathology.

Possible Investigations 🌡️

Initial Investigations

  • Chest X-Ray: First-line imaging to assess for infections, masses, and other structural abnormalities.
  • Full Blood Count (FBC): To assess for anaemia, leukocytosis, or thrombocytopenia, which may suggest infection, malignancy, or a bleeding disorder.
  • Coagulation Profile: To assess for coagulopathies, especially in patients on anticoagulants or with a bleeding diathesis.
  • Arterial Blood Gas (ABG): Particularly in cases of significant haemoptysis or respiratory distress to assess oxygenation and acid-base status.
  • Renal Function Tests: To assess for renal impairment, especially if a vasculitis or Goodpasture’s syndrome is suspected.
  • Sputum Culture and Sensitivity: To identify infectious pathogens, especially in patients with signs of pneumonia or bronchiectasis.
  • ECG: To assess for signs of pulmonary embolism or other cardiovascular causes.
  • D-Dimer: Used in the assessment of pulmonary embolism, particularly in low to intermediate risk cases.
  • Sputum Cytology: Consider in patients with a history of smoking or suspicion of lung cancer.
  • Tuberculosis Testing: Including tuberculin skin test (TST) or interferon-gamma release assays (IGRAs) in patients with risk factors.
  • Autoimmune Screen: ANA, ANCA, and anti-GBM antibodies if vasculitis or Goodpasture’s syndrome is suspected.

Advanced Investigations

  • CT Pulmonary Angiography (CTPA): Gold standard for diagnosing pulmonary embolism, also useful for identifying other vascular causes of haemoptysis.
  • Bronchoscopy: Allows direct visualisation of the airways, biopsy of suspicious lesions, and control of active bleeding.
  • High-Resolution CT (HRCT) Chest: Provides detailed images of the lung parenchyma, useful in diagnosing interstitial lung disease, bronchiectasis, or malignancy.
  • Echocardiography: To assess for mitral stenosis, left ventricular failure, or pulmonary hypertension.
  • Ventilation-Perfusion (V/Q) Scan: An alternative to CTPA for diagnosing pulmonary embolism, particularly in patients with contraindications to CT contrast.
  • Pulmonary Function Tests (PFTs): Useful in chronic lung disease to assess the extent of airflow limitation or restriction.
  • Positron Emission Tomography (PET) Scan: Useful in staging lung cancer or evaluating suspicious lesions detected on CT.
  • Renal Biopsy: Considered if there is suspicion of glomerulonephritis or Goodpasture’s syndrome.
  • Lung Biopsy: Indicated if bronchoscopy and imaging are inconclusive, especially if there is suspicion of malignancy or interstitial lung disease.

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Infection