Thoracic surgery for haemoptysis in the context of tuberculosis: what is the best management approach?

Sudden Death of a Young Man Due to Massive Haemoptysis Associated With Pulmonary Tuberculosis: A Rare Case

Asphyxia includes a large number of possible causes and mechanisms, such as infectious diseases of the lungs. Among these, tuberculosis (TB) is one of the main infectious causes of death worldwide. The burden of TB is very high, by virtue of antibiotic resistance and the risk of other concomitant infections, such as HIV. A major problem is related to the omitted diagnosis of TB infection which, in some cases, may remain completely unknown to the patient, with a significant increase in mortality and morbidity risk. There has been a decrease in the reported cases of sudden death due to TB, especially that associated with hemoptysis and aspiration of blood. In this report, we describe a case of sudden death that occurred in a young male in the workplace, under unclear circumstances. The autopsy detected acute asphyxia due to a massive pulmonary hemorrhage in the individual, who was apparently suffering from TB. The autopsy proved to be essential for understanding the cause of death and investigating the adequacy of the health surveillance measures carried out on the individual.

An overview on the principles of management of haemoptysis

Haemoptysis is a frequently encountered presentation in thoracic surgery practice. Most of the patients present with chronic haemoptysis while 5% of them will present with life-threatening acute haemoptysis. Emergency surgery used to be the first-line management in acute life-threatening haemoptysis which resulted in significant morbidity and mortality. With advancements in interventional procedures, most of these acute presentations are now being managed conservatively by interventionists. In a country like India with a high incidence of tuberculosis and other infectious diseases of the lungs, haemoptysis is even more common. While interventional procedures help to tide over the crisis and earn valuable time to stabilise a haemorrhaging patient, surgical resection is the definitive management most of the time. This review will endeavour to establish the definition, aetiology, emergency, and definitive management of a patient who presents with haemoptysis.

A Crucial Aftershock in Pulmonary Tuberculosis Survivors: A Case Report

Pulmonary tuberculosis is widely prevalent, and the survivors of this disease often present to healthcare facilities with long-term sequelae of the disease. Presented here is a case of a 25-year-old male who presented with concerns of fever, cough with expectoration, and blood in sputum. The patient was managed as per protocol in suspicion of necrotizing pneumonia and re-activation of tuberculosis (TB) as suggested by investigations. The hemoptysis gradually increased over time. With suspicion of a vascular aneurysm and in view of increasing hemoptysis, an early high-resolution computed tomography (HRCT) scan of the chest and a computed tomography (CT) scan of the bronchial angiography were performed. A diagnosis of Rasmussen’s aneurysm was made radiologically, and this rare and under-reported sequelae of TB in contemporary times was brought into notice. A holistic and multi-disciplinary approach involving emergency medicine physicians, internists, anesthesiologists, critical care physicians, pulmonologists, and radiologists can ensure optimal outcomes for such cases in hospital setups if timely intervened.

Surgery for hemoptysis in patients with benign lung disease

Background

Hemoptysis can be a life-threatening condition that requires urgent treatment. Surgery still plays an important role in managing this critical situation, although previous reports have reported high postoperative morbidity and mortality rates. We report our experience with surgical resection for hemoptysis caused by benign lung diseases.

Methods

We reviewed the retrospectively collected data from 94 patients undergoing pulmonary resection for various benign lung diseases with hemoptysis at a single institution from 2010 to 2016. Baseline characteristics, surgical factors, and postoperative outcomes (morbidity and mortality rates) were analyzed.

Results

The ratio of male to female patients was 1:1, and the mean age was 58.2±11.1 (range, 29-79) years. The etiology of hemoptysis included aspergilloma in 58 patients (61.7%), bronchiectasis in 10, tuberculosis in 7, necrotizing bronchiolitis in 6, and other inflammatory disease in 13. A total of 21 patients (22.3%) underwent emergency operation, and 73 (77.7%) had an elective operation. Pulmonary resection was performed by thoracotomy (n=53, 56.4%) and video-assisted thoracoscopic surgery (VATS) (n=41, 43.6%). Sublobar resection (n=50, 53.2%, segmentectomy in 19 and wedge resection in 31) was performed more often than lobectomy (n=35, 37.2%). Pneumonectomy was performed in 7 patients, and bilobectomy was performed in 2. Postoperative morbidity occurred in 23 patients (24.5%), with prolonged air leak being the most frequent complication (n=14, 14.9%). The in-hospital mortality rate was 3.2% (n=3). Complications were less frequent in patients undergoing an elective operation, VATS, and sublobar resection. Multivariate analysis showed that patients treated with VATS had a decreased risk of postoperative complications (odds ratio, 12.8; 95% confidence interval, 1.29-127.9; P=0.03).

Conclusions

Surgical resection for hemoptysis in patients with benign lung diseases is the mainstay of effective treatment with acceptable morbidity and mortality rates. If applicable, we recommend elective (planned) sublobar resection using VATS in order to improve postoperative outcomes.

Retrospective study of clinical and lesion characteristics of patients undergoing surgical treatment for Pulmonary Tuberculosis in Georgia

Objectives

Our aim was to retrospectively compare clinical data and characteristics of removed lesions of the cohort of patients undergoing therapeutical surgery for their tuberculosis.

Design and methods

Demographic and epidemiological details, clinical data, data on the surgery performed, macroscopic characteristics of the TB lesions removed, and outcome were recorded retrospectively from the 137 patients who underwent therapeutical surgery for their TB in Tbilisi, Georgia during 2014 and 2015.

Results

Men represented 70% of the included patients, presented more comorbidities and underwent operation earlier in terms of days between diagnostic and surgery. Women underwent operation at younger ages, and in MDR/XDR-TB cases, showed higher percentages of sputum conversion at >2 months and of fresh necrosis in the surgical specimens, suggesting a worse evolution. Half of cases were MDR/XDR-TB cases. In spite of being considered microbiologically cured according to WHO, a non despricable percentage of cases showed viable bacilli in the surgical specimen. Even if no causality could be statistically demonstrated, differences could be encountered according to gender and drug susceptibility of the responsible strains.

Conclusions

According to our results, host factors such as gender, type of necrosis found in the lesions, size of lesions and presence of viable bacilli in the surgical specimen, should be included in future studies on therapeutical surgery of TB. As most of studies are done in MDR/XDR-TB, more data on DS-TB operated cases are needed. Our results also highlight that, in spite of achieving the microbiologically cured status, sterilization might not occur, and thus new biomarkers and new methods to evaluate the healing process of TB patients are urgently needed and radiological assays should be taken into account.

Rasmussen's aneurysm: A forgotten scourge

Rasmussen's aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of pulmonary artery adjacent to a tuberculous cavity. Life threatening massive hemoptysis from the rupture of a Rasmussen's aneurysm is an uncommon yet life threatening complication of cavitary tuberculosis (TB). We present a case of a young woman who presented with low-grade fever and hemoptysis. Computed tomographic (CT) angiography showed biapical cavitary lesions and actively bleeding aneurysms involving pulmonary artery, which successfully underwent glue embolization.