Pediatr Pulmonol. 2016 Sep;51(9):E31-3. doi: 10.1002/ppul.23424.
Hemoptysis from an aorto-pulmonary collateral vessel in a four month old resolved by embolization.
Zaidi SJ, Javois AJ, Akhter J.
Advocate Children’s Hospital, Oak Lawn, Illinois.
Hemoptysis in the children is a rare but serious diagnosis and is even more uncommon in infancy. Mortality is reported and depends on associated illnesses, underlying etiology, and amount of bleeding. A 4-month-old patient presented with significant hemoptysis. Flexible bronchoscopy with differential lavage confirmed the presence and site of origin of hemoptysis. She was managed with cardiac catheterization for embolization of an aorto-pulmonary collateral vessel with immediate complete resolution and no further recurrences. This highlights the importance of cardiac catheterization to detect collateral vessels as a cause for hemoptysis at this age and its successful resolution following embolization. Pediatr Pulmonol. 2016; 51:E31-E33. © 2016 Wiley Periodicals, Inc.
aorto-pulmonary collateral; cardiac catheterization; embolization; hemoptysis; pediatric
Hemoptysis in children is a rare occurrence but causes significant anxiety to the patients, their families and their providers. Even though, it is a rare symptom, it can be potentially fatal. The amount of bleeding, etiology and associated illnesses dictate the severity of presentation. The most common causes in children include infections, foreign body aspiration, tracheostomies, congenital heart disease and other systemic illnesses.
Aorto-pulmonary collateral vessels (APCs) are a source of bronchial bleeding commonly seen in association with congenital heart disease and are often intervened upon in the cardiac catheterization laboratory. APCs are systemic vessels that are connected to and supply the pulmonary circulation. They are not often implicated or tested for in children with hemoptysis without congenital heart disease.
We hypothesized that APCs may be implicated in the causation of hemoptysis in our 4-month old patient since other important causes were ruled out with a thorough standardized workup. Infectious, rheumatologic, immunologic and hematologic causes were ruled out prior to cardiac catheterization. Chest X ray and CT scan were non-specific and did not assist with localization or potential etiology differentiation, though bronchoscopy did show active bleeding from the right lung. A pediatric cardiology consultation was obtained and the patient was prepared for a cardiac catheterization. This showed a large APC to her right lung which was coil embolized. She remained stable in the intensive care unit overnight and had no recurrences.
Figure 1 shows the large APC to the right lung on cardiac catheterization.
Figure 2 shows decreased flow in this collateral vessel after coil embolization.
The importance of this study is to recognize APCs as possible causes of hemoptysis in infants in whom other common causes have been ruled out. In addition, a chest CT scan was not helpful in our patient. An early diagnosis with pediatric cardiology may be helpful in such cases. Cardiac catheterization would also have the ability for intervention which other modalities of imaging lack.
- Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000 May;28(5):1642-7.
- Turcios NL, Vega M. The child with hemoptysis. Hosp Pract 1987; 22: 217-218.