Heart Failure Patient Coughs Up Bronchial Tree-Shaped Blood Clot

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The patient experienced an extreme bout of coughing, which led to the expectoration of an intact cast of the right bronchial tree. Image credit: The New England Journal of Medicine ©2018.
The patient experienced an extreme bout of coughing, which led to the expectoration of an intact cast of the right bronchial tree. Image credit: The New England Journal of Medicine ©2018.

A recently published case report describes the case of a 36-year-old male chronic heart failure (HF) patient who, "spontaneously expectorated an intact cast of the right bronchial tree," following an extreme bout of coughing.

The patient had presented to the hospital with an acute exacerbation of chronic HF and was admitted to the intensive care unit. His past medical history was significant for HF (EF 20%), replacement of the bioprosthetic aortic-valve for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm, and permanent pacemaker placement for complete heart block.

Following the placement of an Impella ventricular assist device and initiation of a continuous heparin infusion, the patient began experiencing episodes of hemoptysis, respiratory distress, and increasing use of supplemental oxygen. The authors reported that the patient then experienced a violent coughing fit which led to the spontaneous expectoration of a blood clot in the shape of the right bronchial tree.

Credit: The New England Journal of Medicine ©2018.

"The patient's trachea was subsequently intubated, and flexible bronchoscopy revealed a small amount of blood in the basilar branches of the right lower lobe," the study authors explained. Two days later, the patient was extubated and did not experience further episodes of hemoptysis. "One week after extubation, he died from complications of heart failure (volume overload and poor cardiac output) despite placement of the ventricular assist device," the study authors reported.

Reference

Woodard GA, Wieselthaler GM. Cast of the right bronchial tree. N Engl J Med. 2018;379(22):2151.

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