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Postoperative Bleeding… in the Airway?

Authors
Richard Ramonell, MD, Charles Terry, MD, Laurence W. Busse, MD, and Alejandro Sardi-Freitez, MD
Emory University School of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine


Case

A 36-year-old male is admitted to the intensive care unit for new-onset, non-massive hemoptysis and acute hypoxemic respiratory failure one day after surgical repair of his anorectal fistula at an outside hospital. Intraoperatively, there was no report of difficult intubation, problems with sedation, or dyssynchrony with the ventilator. He was extubated to room air and discharged without supplemental oxygen but presented to our emergency department when he became acutely short of breath and developed hemoptysis. His past medical history includes mild intermittent asthma and an anal abscess complicated by an anorectal fistula. Flexible fiberoptic bronchoscopy was performed with bronchoalveolar lavage (BAL) of the right lower lobe. Sequential returns during BAL are shown below and are labelled 1, 2, and 3 based on the order they were obtained. A representative Chest CT image and bronchoscopic images are shown below.

Images

Sequential returns during BAL
CT Scan
bronchoscopic images

Question

Based on these images and the character of the BAL fluid, what is the most likely cause of the patient’s hemoptysis?

A. ARDS
B. Tuberculosis
C. Diffuse Alveolar Hemorrhage
D. Granulomatosis with polyangiitis
E. Goodpasture Syndrome

Answer