A RARE CAUSE OF RECURRENT HEMOPTYSIS

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Hemoptysis is defined as expectoration of blood from tracheobronchial tree. It is an alarming symptom and matter of concern for both the patient and treating physician. Hemoptysis can be caused by a variety of conditions, including tracheobronchial diseases, pulmonary parenchymal lesions, primary vascular anomalies, and systemic coagulopathies. We report a case of descending aorto-pulmonary fistula (DAPVF) as the cause of recurrent hemoptysis in a 33 year old female. To the best of our knowledge only very few cases of DAPVF as a cause of hemoptysis in adults has been reported in literature. CASE PRESENTATION: A 33 year old female presented with chief complaints of recurrent mild hemoptysis, for two years which increased to 3-5 episodes in a month since last 2 months. She was a non-smoker and menstruation had no effect on episodes of hemoptysis. There was no other significant history and general physical examination was unremarkable. There was nothing significant on respiratory system examination however, on cardiovascular system examination a continuous murmur was heard over the 4th intercostal space with a normal pulmonary valve closure sound along the left sternal border. All routine blood examinations were normal. Chest x-ray and echocardiography was within normal limits. Contrast enhanced computed tomography (CECT) revealed serpiginous structures consistent with enlarged vessels in left lower lobe of lung. CT pulmonary angiography was done, which showed an anomalous systemic artery arising from the descending aorta which was connected to the left inferior pulmonary vein representing structure of DAPVF (Figure 1 A & B). Figure 2 A & B shows the course of DAPVF in saggital section and the 3D reconstruction of the same. Patient was referred to department of cardiothoracic surgery for ligation of the fistula. DISCUSSION: Arterio-venous (AV) malformations have three essential structural elements in the form of arterial supply, a draining vein and the intervening aneurysmal sac. They are classified into venous-systemic fistulas and arterial-systemic fistulas. Congenital anomalous systemic artery to pulmonary venous arterio-venous fistulas are left to left shunt without lung sequestration. These are very rare congenital anomalies and can induce hemoptysis and heart failure. Very few cases of DAPVF as a cause of hemoptysis in adults has been reported. The persistently elevated venous pressure, at different venous segments lead to lobar or segmental pulmonary arterial hypertension and rupture of proliferating and dilated vessels of the basal segments may result in hemoptysis. This case highlights the importance of imaging in diagnosis of such rare anomalies when echocardiography fails to identify the cause of murmur. CONCLUSIONS: In conclusion, DAPVF is a rare, congenital anomaly which can induce hemoptysis. CECT and CT angiography helps in the correct diagnosis of this rare anomaly. Reference #1: Corey R. Hemoptysis. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations [Internet]. 3rd ed. Boston: Butterworths; 1990. Available from: http://www.ncbi.nlm.nih.gov/books/NBK360/ Reference #2: Hu Y, Zhong Q, Li Z, Chen J, Shen C, Song Y. An Occult Congenital Fistula Between the Descending Aorta and the Left Pulmonary Vein in an Adult Presenting With Recurrent Episodes of Hemoptysis. Chest. 2013 Feb;143(2):549–53. Reference #3: Lawler LP, Fishman EK. Arteriovenous malformations and systemic lung supply: evaluation by multidetector CT and three-dimensional volume rendering. AJR Am J Roentgenol. 2002 Feb;178(2):493–5. DISCLOSURES: No relevant relationships by Amitesh Gupta, source=Web Response No relevant relationships by Lovika Lakhtakia, source=Web Response No relevant relationships by Balakrishnan Menon, source=Web Response No relevant relationships by PARUL MRIGPURI, source=Web Response No relevant relationships by Mani Tiwari, source=Web Response