- Email: [email protected]
Acute pulmonary hemorrhage CT evaluation
CLINICAL
IMAGING
1993;17:77-80
77
ACUTE PULMONARY HEMORRHAGE CT EVALUATION WILLIAM J. MARASCO, MD, ELLIOT K. FISHMAN, MD, JANET E. KUHLMAN, MD, AND RALPH H. HRUBAN, MD
The computed tomography (CT) scans and chest radiograph of seven patients with bronchoscopic or pathologically proven cases of pulmonary hemorrhage were reviewed to determine the appearance and value ofeach modality. CTrevealed the presence and location in all cases while chest radiographs were falsely negative in two cases. The CT pattern was always an alveolar pattern while the pattern was more variable on chest radiographs. By providing better pattern definition than the chest radiographs, CT is the study of choice in detecting the presence of a suspected pulmonary hemorrhage.
Osler Weber-Rendu syndrome, systemic lupus erythematosus) frequently give rise to APH (3, 4). The diagnosis is indicated by clinical, laboratory, and/or radiographic findings, and bronchoscopy is usually confirmatory (5). The chest radiograph is useful in diagnosis, but may appear normal during episodes of active pulmonary hemorrhage (6). Computed tomography [CT) may be more sensitive to the detection of early hemorrhage. The purpose of this study was to categorize and define the CT findings of pulmonary hemorrhage, and to determine the usefulness of CT in the evaluation of pulmonary hemorrhage.
KEY WORDS:
Pulmonary hemorrhage: infiltrates
High-resolution
CT; Alveolar
INTRODUCTION Acute pulmonary hemorrhage (APH) is characterized by diffuse filling of the pulmonary parenchyma with blood (1). The most common clinical findings are cough, hemoptysis, and respiratory distress (2). Although acute pulmonary hemorrhage is uncommon, certain etiologies, particularly anticoagulation therapy, thrombocytopenia, and autoimmune disorders (Goodpasture’s syndrome, Wegener granulomatosis,
From the Russell H. Morgan Department of Radiology and Radiological Science (W.J.M., E.K.F., J.E.K.) and the Department of Pathology (R.H.H.), The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address correspondence to: Elliot K. Fishman, MD, Department of Radiology, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205. Received April 13, 1992; accepted July 27, 1992. 0 1993 by Else&r Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010 0899.7071193/$6.00
METHODS
AND MATERIALS
Seven cases of documented pulmonary hemorrhage were examined retrospectively. In all cases patients presented with hemoptysis ranging from approximately 50 ml to 600 ml in a 24-hr period. The diagnosis was confirmed by bronchoscopy or pathological examination, and clinical, roentgenographic, and CT findings were correlated. In one case, CT findings were correlated with an autopsy specimen.
RESULTS The causes of pulmonary hemorrhage in our cases were: idiopathic (three cases), thrombocytopenia (two cases), metastatic neuroblastoma (one case), and a pulmonary varix (one case). Diagnosis was confirmed by bronchoscopy in five cases, and by gross and microscopic examination from surgical or autopsy specimens in two cases. The roentgenographic findings on standard chest radiograph included two cases with a unilateral interstitial pattern, two cases with a bilateral diffuse alveolar pattern, and one case with a unilateral lobar consolidative pattern. Two
78
MARASCO
CLINICAL
ET AL.
IMAGING
VOL. 17, NO. 1
B FIGURE 2. (A) Chest X ray shows a right upper lobe alveolar infiltrate. (B) Thoracic CT reveals a focal patchy alveolar infiltrate involving the right upper and lower lobes. Air bronchograms are well seen (patient 3). B FIGURE 1. (A) Chest X ray showing a calcified right hilar granuloma and no evidence of infiltrates. (B) Thoracic CT scan performed z days later revealing a focal patchy alveolar infiltrate in the right upper lobe [patient 4).
cases had no evidence of infiltrate (Figure 1). CT revealed a unilateral segmental or lobar patchy alveolar pattern in four cases, and a bilateral patchy alveolar pattern in three cases. The patchy alveolar pattern was similar in all cases and common to all cases (Figure 2). High resolution CT of a surgical specimen of lung revealed this patchy alveolar pattern in the same anatomic location as pathologically confirmed
gross hemorrhage. These findings are summarized in Table 1. Compared to plain radiographs, CT revealed a unilateral patchy alveolar infiltrate in two patients whose chest X rays were normal. The pattern on chest X ray varied form alveolar to interstitial, whereas on CT all the infiltrates displayed the patchy alveolar pattern, DISCUSSION
Leatherman et al. (4) have divided the etiology of APH into five main categories: idiopathic pulmonary hemosiderosis, Goodpasture’s syndrome (with anti-
JANUARY-MARCH
1993
ACUTE
PULMONARY
HEMORRHAGE
79
TABLE 1. Comparison of Findings on Chest X Ray and CT Findings on chest X ray Patient 1 2 3
4 5 6 7
Diagnosis Pulmonary varix Idiopathic Idiopathic Idiopathic Thrombocytopenia Metastatic neuroblastoma Thrombocytopenia
Age/sex
Pattern of infiltrate
Locationd
43/F
alveolar
LUL
Findings on CT
Unilateral/ bilateral
Pattern of infiltrate
unilateral
alveolar
LUL
unilateral
alveolar
RUL, RML, RLL
unilateral
RUL, RLL RUL diffuse RML, RLL
unilateral unilateral bilateral unilateral
diffuse
bilateral
77lM
negative
-
%2/M 53/F 52/F 31/M
consolidative negative alveolar interstitial
RUL
unilateral -
diffuse RUL, RML
bilateral unilateral
alveolar alveolar alveolar alveolar
38/F
alveolar
diffuse
bilateral
alveolar
Unilateral/ bilateral
Location”
” LUL = left upper lobe; RlJL = right upper lobe: RML = right midlobe; RLL = right lower lobe
basement membrane antibodies), collagen vascular diseases and systemic vasculitis, idiopathic rapidly progressive glomerulonephritis, and APH caused by exogenous agents. Bleeding diathesis (i.e., thrombocytopenia) was also cited as a cause (7). Although the etiology of acute pulmonary hemorrhage (APH) is varied, the pattern and presentation can be classified into two broad groups, depending upon where APH occurs in relation to the mucocilliary clearance mechanism of the lung. If the hemorrhage arises in the main conducting airways, proximal to the mucocilliary clearance mechanism, a peripheral infiltrative pattern is seen, and hemoptysis is the usual clinical manifestation. The most common causes of this type of hemoptysis is bronchitis and bronchiectasis. The second pattern, a localized infiltrate, is evident when the hemorrhage occurs beyond the regions of mucocilliary clearance, and the blood remains mostly in the alveoli. This type of APH most often manifests itself clinically as shortness of breath (8). In our study, all patients had APH, which originated in the lung parenchyma, and involved the main conducting system secondarily. The common radiographic findings of APH are the sudden appearance of a diffuse alveolar infiltrate that resolves in a few weeks and is often perihilar or basilar in distribution. The pattern is similar to that seen in pulmonary edema. There also may be a migratory patchy alveolar infiltrate. The importance, however, of an infiltrate in patients with APH is limited since the infiltrates seen may be caused secondarily by the hemorrhage within the alveoli, instead of being the primary cause of the hemorrhage itself. In spite of the variety of chest X-ray appearances, the differing patterns do not usually help in distinguishing the various possible underlying causes of APH (7). CT has been shown to be more sensitive than chest X ray in the evaluation of hemoptysis (9-12). Sup-
porting this finding in our study was the correlation between morbid chest X ray and morbid CT. Concomitant findings were found in five cases, however in two cases the CT revealed a unilateral lobar patchy infiltrate, whereas the chest X rays were normal. There was a uniformity in the CT pattern of APH in all our cases, whereas the pattern on chest X ray was varied. The uniform pattern seen on CT was characterized by a patchy alveolar infiltrate, either lobar or diffuse. The diffuse infiltrates were seen in patients with diffuse APH caused by thrombocytopenia. High resolution CT and pathological correlation, in one case, revealed hemosiderin-laden histiocytes, and gross hemorrhage in the alveoli in the same anatomic location as the patchy alveolar infiltrate seen on CT. Although the CT appearance of APH is nonspecific, the patchy alveolar parenchymal pattern was common and to all cases. Because CT is more sensitive and specific in detecting APH than chest X ray, in the proper clinical setting, a patchy alveolar pattern on CT may suggest the presence of APH in the face of a normal chest X ray.
REFERENCES 1. Fraser RG, Pare JA, Fraser RS, Genereux GP. Diseases of Altered Immunologic Activity. In Diagnosis of Diseases of the Chest, 2nd ed. Philadelphia: 1989; Saunders Co., pp. 1184-1186. 2. Bradely JD. The pulmonary Chest Med 1982;3:593-605.
hemorrhage
3. Albelda SM, Gefter WB, Epstein monary Hemorrhage: A review 1985:154(2):280-297.
syndromes.
Clin
DM, Miller WT. Diffuse Puland classification. Radiology
4. Leatherman JW. Davies SF, Hoidal JR. Alveolar hemorrhage syndromes: Diffuse j microvascular lung hemorrhage in immune and idiopathic disorders. Medicine 1984;63:343-361. 5. Zavala DC. 1975;68:12-19.
Diagnostic
fiberoptic
bronchoscopy.
Chest
80
MARASCO
CLINICAL
ET AL.
6. Ewan PW, Jones HA, Rhodes CG, Hughes JM. Detecrion of intrapulmonary hemorrhage with carbon monoxide uptake. NEJM 1976;295:1391-1396. 7. Bowley NB, Steiner RE. Radiological manifestations GBM disease (Goodpastures syndrome). Clin 1979;30:419-429. 8. Barrett R, Tuttle W. A study of essential Cardiovasc Surg 1960;40:468-473. 9. Haponik
EF, Fritt JE, Smith
PL, Bleecker
hemoptysis.
ER: Computed
of antiRadio1
J Thorac
chest
IMAGING
VOL. 17, NO. 1
tomography in the evaluation of hemoptysis: nosis and treatment. Chest 1987;91:80-85. 10. Heimer D, Bar Ziv J, Scharf SM. Fiberoptic patients with hemoptysis and non-localizing grams. Arch Intern Med 1985;145:1427-1428.
Impact
on diag-
bronchoscopy in chest roentgeno-
11. Fishman EK, Freeland HS, Wang KP, Siegelman Intrabronchial lesion on CT secondary to blood Assist Tomgr 1984;8(3):547-549.
S. Case report: clot. J Comput
12. Elliot DL, Barker AF, Dixon LM. Cutamenial hemoptysis: New methods of diagnosis and therapy. Chest 1985;87:687-688,
IMAGING
1993;17:77-80
77
ACUTE PULMONARY HEMORRHAGE CT EVALUATION WILLIAM J. MARASCO, MD, ELLIOT K. FISHMAN, MD, JANET E. KUHLMAN, MD, AND RALPH H. HRUBAN, MD
The computed tomography (CT) scans and chest radiograph of seven patients with bronchoscopic or pathologically proven cases of pulmonary hemorrhage were reviewed to determine the appearance and value ofeach modality. CTrevealed the presence and location in all cases while chest radiographs were falsely negative in two cases. The CT pattern was always an alveolar pattern while the pattern was more variable on chest radiographs. By providing better pattern definition than the chest radiographs, CT is the study of choice in detecting the presence of a suspected pulmonary hemorrhage.
Osler Weber-Rendu syndrome, systemic lupus erythematosus) frequently give rise to APH (3, 4). The diagnosis is indicated by clinical, laboratory, and/or radiographic findings, and bronchoscopy is usually confirmatory (5). The chest radiograph is useful in diagnosis, but may appear normal during episodes of active pulmonary hemorrhage (6). Computed tomography [CT) may be more sensitive to the detection of early hemorrhage. The purpose of this study was to categorize and define the CT findings of pulmonary hemorrhage, and to determine the usefulness of CT in the evaluation of pulmonary hemorrhage.
KEY WORDS:
Pulmonary hemorrhage: infiltrates
High-resolution
CT; Alveolar
INTRODUCTION Acute pulmonary hemorrhage (APH) is characterized by diffuse filling of the pulmonary parenchyma with blood (1). The most common clinical findings are cough, hemoptysis, and respiratory distress (2). Although acute pulmonary hemorrhage is uncommon, certain etiologies, particularly anticoagulation therapy, thrombocytopenia, and autoimmune disorders (Goodpasture’s syndrome, Wegener granulomatosis,
From the Russell H. Morgan Department of Radiology and Radiological Science (W.J.M., E.K.F., J.E.K.) and the Department of Pathology (R.H.H.), The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address correspondence to: Elliot K. Fishman, MD, Department of Radiology, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205. Received April 13, 1992; accepted July 27, 1992. 0 1993 by Else&r Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010 0899.7071193/$6.00
METHODS
AND MATERIALS
Seven cases of documented pulmonary hemorrhage were examined retrospectively. In all cases patients presented with hemoptysis ranging from approximately 50 ml to 600 ml in a 24-hr period. The diagnosis was confirmed by bronchoscopy or pathological examination, and clinical, roentgenographic, and CT findings were correlated. In one case, CT findings were correlated with an autopsy specimen.
RESULTS The causes of pulmonary hemorrhage in our cases were: idiopathic (three cases), thrombocytopenia (two cases), metastatic neuroblastoma (one case), and a pulmonary varix (one case). Diagnosis was confirmed by bronchoscopy in five cases, and by gross and microscopic examination from surgical or autopsy specimens in two cases. The roentgenographic findings on standard chest radiograph included two cases with a unilateral interstitial pattern, two cases with a bilateral diffuse alveolar pattern, and one case with a unilateral lobar consolidative pattern. Two
78
MARASCO
CLINICAL
ET AL.
IMAGING
VOL. 17, NO. 1
B FIGURE 2. (A) Chest X ray shows a right upper lobe alveolar infiltrate. (B) Thoracic CT reveals a focal patchy alveolar infiltrate involving the right upper and lower lobes. Air bronchograms are well seen (patient 3). B FIGURE 1. (A) Chest X ray showing a calcified right hilar granuloma and no evidence of infiltrates. (B) Thoracic CT scan performed z days later revealing a focal patchy alveolar infiltrate in the right upper lobe [patient 4).
cases had no evidence of infiltrate (Figure 1). CT revealed a unilateral segmental or lobar patchy alveolar pattern in four cases, and a bilateral patchy alveolar pattern in three cases. The patchy alveolar pattern was similar in all cases and common to all cases (Figure 2). High resolution CT of a surgical specimen of lung revealed this patchy alveolar pattern in the same anatomic location as pathologically confirmed
gross hemorrhage. These findings are summarized in Table 1. Compared to plain radiographs, CT revealed a unilateral patchy alveolar infiltrate in two patients whose chest X rays were normal. The pattern on chest X ray varied form alveolar to interstitial, whereas on CT all the infiltrates displayed the patchy alveolar pattern, DISCUSSION
Leatherman et al. (4) have divided the etiology of APH into five main categories: idiopathic pulmonary hemosiderosis, Goodpasture’s syndrome (with anti-
JANUARY-MARCH
1993
ACUTE
PULMONARY
HEMORRHAGE
79
TABLE 1. Comparison of Findings on Chest X Ray and CT Findings on chest X ray Patient 1 2 3
4 5 6 7
Diagnosis Pulmonary varix Idiopathic Idiopathic Idiopathic Thrombocytopenia Metastatic neuroblastoma Thrombocytopenia
Age/sex
Pattern of infiltrate
Locationd
43/F
alveolar
LUL
Findings on CT
Unilateral/ bilateral
Pattern of infiltrate
unilateral
alveolar
LUL
unilateral
alveolar
RUL, RML, RLL
unilateral
RUL, RLL RUL diffuse RML, RLL
unilateral unilateral bilateral unilateral
diffuse
bilateral
77lM
negative
-
%2/M 53/F 52/F 31/M
consolidative negative alveolar interstitial
RUL
unilateral -
diffuse RUL, RML
bilateral unilateral
alveolar alveolar alveolar alveolar
38/F
alveolar
diffuse
bilateral
alveolar
Unilateral/ bilateral
Location”
” LUL = left upper lobe; RlJL = right upper lobe: RML = right midlobe; RLL = right lower lobe
basement membrane antibodies), collagen vascular diseases and systemic vasculitis, idiopathic rapidly progressive glomerulonephritis, and APH caused by exogenous agents. Bleeding diathesis (i.e., thrombocytopenia) was also cited as a cause (7). Although the etiology of acute pulmonary hemorrhage (APH) is varied, the pattern and presentation can be classified into two broad groups, depending upon where APH occurs in relation to the mucocilliary clearance mechanism of the lung. If the hemorrhage arises in the main conducting airways, proximal to the mucocilliary clearance mechanism, a peripheral infiltrative pattern is seen, and hemoptysis is the usual clinical manifestation. The most common causes of this type of hemoptysis is bronchitis and bronchiectasis. The second pattern, a localized infiltrate, is evident when the hemorrhage occurs beyond the regions of mucocilliary clearance, and the blood remains mostly in the alveoli. This type of APH most often manifests itself clinically as shortness of breath (8). In our study, all patients had APH, which originated in the lung parenchyma, and involved the main conducting system secondarily. The common radiographic findings of APH are the sudden appearance of a diffuse alveolar infiltrate that resolves in a few weeks and is often perihilar or basilar in distribution. The pattern is similar to that seen in pulmonary edema. There also may be a migratory patchy alveolar infiltrate. The importance, however, of an infiltrate in patients with APH is limited since the infiltrates seen may be caused secondarily by the hemorrhage within the alveoli, instead of being the primary cause of the hemorrhage itself. In spite of the variety of chest X-ray appearances, the differing patterns do not usually help in distinguishing the various possible underlying causes of APH (7). CT has been shown to be more sensitive than chest X ray in the evaluation of hemoptysis (9-12). Sup-
porting this finding in our study was the correlation between morbid chest X ray and morbid CT. Concomitant findings were found in five cases, however in two cases the CT revealed a unilateral lobar patchy infiltrate, whereas the chest X rays were normal. There was a uniformity in the CT pattern of APH in all our cases, whereas the pattern on chest X ray was varied. The uniform pattern seen on CT was characterized by a patchy alveolar infiltrate, either lobar or diffuse. The diffuse infiltrates were seen in patients with diffuse APH caused by thrombocytopenia. High resolution CT and pathological correlation, in one case, revealed hemosiderin-laden histiocytes, and gross hemorrhage in the alveoli in the same anatomic location as the patchy alveolar infiltrate seen on CT. Although the CT appearance of APH is nonspecific, the patchy alveolar parenchymal pattern was common and to all cases. Because CT is more sensitive and specific in detecting APH than chest X ray, in the proper clinical setting, a patchy alveolar pattern on CT may suggest the presence of APH in the face of a normal chest X ray.
REFERENCES 1. Fraser RG, Pare JA, Fraser RS, Genereux GP. Diseases of Altered Immunologic Activity. In Diagnosis of Diseases of the Chest, 2nd ed. Philadelphia: 1989; Saunders Co., pp. 1184-1186. 2. Bradely JD. The pulmonary Chest Med 1982;3:593-605.
hemorrhage
3. Albelda SM, Gefter WB, Epstein monary Hemorrhage: A review 1985:154(2):280-297.
syndromes.
Clin
DM, Miller WT. Diffuse Puland classification. Radiology
4. Leatherman JW. Davies SF, Hoidal JR. Alveolar hemorrhage syndromes: Diffuse j microvascular lung hemorrhage in immune and idiopathic disorders. Medicine 1984;63:343-361. 5. Zavala DC. 1975;68:12-19.
Diagnostic
fiberoptic
bronchoscopy.
Chest
80
MARASCO
CLINICAL
ET AL.
6. Ewan PW, Jones HA, Rhodes CG, Hughes JM. Detecrion of intrapulmonary hemorrhage with carbon monoxide uptake. NEJM 1976;295:1391-1396. 7. Bowley NB, Steiner RE. Radiological manifestations GBM disease (Goodpastures syndrome). Clin 1979;30:419-429. 8. Barrett R, Tuttle W. A study of essential Cardiovasc Surg 1960;40:468-473. 9. Haponik
EF, Fritt JE, Smith
PL, Bleecker
hemoptysis.
ER: Computed
of antiRadio1
J Thorac
chest
IMAGING
VOL. 17, NO. 1
tomography in the evaluation of hemoptysis: nosis and treatment. Chest 1987;91:80-85. 10. Heimer D, Bar Ziv J, Scharf SM. Fiberoptic patients with hemoptysis and non-localizing grams. Arch Intern Med 1985;145:1427-1428.
Impact
on diag-
bronchoscopy in chest roentgeno-
11. Fishman EK, Freeland HS, Wang KP, Siegelman Intrabronchial lesion on CT secondary to blood Assist Tomgr 1984;8(3):547-549.
S. Case report: clot. J Comput
12. Elliot DL, Barker AF, Dixon LM. Cutamenial hemoptysis: New methods of diagnosis and therapy. Chest 1985;87:687-688,