Kausar Rehana, Syed Asif Hussain Jafri.
Massive Hemoptysis from Pulmonary Arteriovenous Malformation.
J Coll Physicians Surg Pak Jan ;11(5):332-4.

Pulmonary arteriovenous malformation, a relatively rare entity, was first diagnosed during life in 1939. Although, it usually follows a benign course, yet, can present with life-threatening hemoptysis. A case of recurrent hemoptysis for 27 years, presented as massive hemoptysis, is reported in which no obvious cause of hemoptysis was found on routine work up i.e., chest radiography, computerized tomography of the chest and bronchoscopy. During emergency surgery an abnormal vessel found around the left lower lobe bronchus was excised and left lower lobe was resected which stopped the hemoptysis with no evidence of recurrence at 2 years follow-up.

Case Report: A 50 years old gentleman was referred from DHQ Hospital Bhakkar, with 2 days history of massive hemoptysis to the emergency department of Pakistan Institute of Medical Sciences, Islamabad. There was history of recurrent hemoptysis following dry irritating cough for the last 27 years, not associated with any expectoration, fever, weight loss, epistaxis, maleena and skin rash. His previous episodes were mild to moderate in severity, occurring at interval of 2-3 months, and investigations including complete blood picture, sputum for acid-fast bacilli, Mantoux test, bleeding, coagulation profile and liver functions tests were normal. In the past he had received antituberculous treatment as well. There was no history of exposure to chemicals or use of herbal medications. Specifically, there was no history of any trauma to the chest.

On examination he was pale, anxious, tachypoenic, tachycardiac and his blood pressure was 90/60 mmHg. Breathing sounds were decreased in the left lower chest posteriorly. Rest of the physical and systemic examination was unremarkable. After giving emergency treatment with oxygen, whole blood and tranexamic acid intravenously, he underwent bronchoscopy which showed a long fibrinous clot arising from left lower lobe basal segmental bronchus. It was left undisturbed. Investigations revealed hemoglobin of 9.0gm/dl and arterial blood gas analysis showed hypoxemia. Chest radiograph showed a nonhomogenous shadowing in the left lower zone. In view of long hemoptysis history a clinical impression of dry bronchiectasis or bronchial adenoma possibly at segmental level was made. Computerized scan of chest showed a soft tissue density in the left lower lobe along the left paravertebral region posteriorly. Pulmonary angiography was requested at a tertiary centre but due to the worsening condition of the patient, this was abandoned. Emergency thoracotomy was performed and peroperatively an abnormal, tortuous and dilated vessel was found around the left lower lobe bronchus. Diagnosis of pulmonary arteriovenous malformation was made. Abnormal vessel was excised and left lower lobectomy was done. Histopathological examination of specimen showed lung tissue containing numerous congested vessels and dilated bronchi containing blood. Blood vessels at places were tortuous and the walls were not uniform in thickness. Some of the blood vessels were hybrid of arteries and veins

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