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ORIGINAL ARTICLE
Year : 2022 | Volume
: 11
| Issue : 4 | Page : 394-399
A prospective study of the clinical profile of hemoptysis and its correlation with radiological and microbiological findings
Harveen Kaur, Naveen Pandhi, NC Kajal
Department of Pulmonary Medicine, Government Medical College, Amritsar, Punjab, India
Correspondence Address:
Harveen Kaur
Department of Pulmonary Medicine, Government Medical College, Amritsar, Punjab
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmy.ijmy_137_22
Background: The etiological pattern of hemoptysis has evolved, with pulmonary tuberculosis (PTB) becoming less prevalent as a cause. There is a paucity of literature regarding the spectrum of diseases that present as hemoptysis and the data related to detailed clinical profile are lacking. Hence, this study is taken up to determine the clinical profile of hemoptysis and its correlation with radiological and microbiological findings. Methods: This was a 3-year observational prospective study of a total of 50 patients who presented with active hemoptysis. Data were recorded from these patients for assessing the clinical characteristics, radiological, and microbiological correlation. Results: The most common etiologies of hemoptysis identified in this study were PTB in 60% of the patients, aspergilloma in 14%, followed by bronchiectasis in 8%, pneumonia in 8%, carcinoma lung in 4%, and lung abscess in 1 (2%). Mild hemoptysis was present in 8% of patients, whereas 42% had moderate hemoptysis, 18% of patients had severe, and 32% had massive hemoptysis. Sixty percent of patients had recurrent hemoptysis, and the majority of the patients, i.e., 68% tested negative on sputum smear examination for acid-fast bacillus. In 60% of patients, no growth was obtained in the sputum cultures. The most common organisms isolated from sputum cultures of the rest of the patients were Pseudomonas in 14%, Klebsiella in 10%, Escherichia coli in 4%, Staphylococci in 4%, and Streptococcus pneumoniae in 4% of the cases. The majority of the patients were having consolidation and cavitary disease. A highly significant correlation was noted between the radiological findings of consolidation, mycetoma, cystic shadows, lung mass, and lung abscess and the etiology of hemoptysis (P = 0.000). Conclusion: Hemoptysis of any volume implies a life-threatening process, which mandates immediate evaluation and treatment. It is evident that the etiological spectrum of hemoptysis is continuously changing, and more sophisticated investigations, better imaging techniques, bronchoscopic tools, availability of newer techniques in the developing world, and changing patterns of diseases, all contribute to these changes. Identification of the etiology, and localization of the bleeding site, is essential for the efficient management of hemoptysis.
Keywords: Bronchiectasis, computed tomography chest, culture sensitivity, hemoptysis, lung cancer, pulmonary tuberculosis, sputum for acid-fast bacillus
Hemoptysis is defined as the expectoration of blood, either alone or mixed with mucus, from the lower respiratory tract.[1] It can be caused by a variety of etiologies, including parenchymal disorders, airway diseases, and vascular diseases. Infections such as tuberculosis (TB), pneumonia, aspergillosis, or lung abscess are the common causes within the pulmonary parenchyma.
The etiological pattern of hemoptysis has evolved in developed countries, with pulmonary TB (PTB) becoming less prevalent as a cause.[2] In developing countries, TB is still the principal cause of hemoptysis,[3] but in developed economies, bronchogenic carcinoma and bronchiectasis are more common. Hemoptysis in TB can be caused by bronchiectasis, aspergilloma, TB reactivation, chronic bronchitis, scar carcinoma, microbiological colonization within a cavity, or vascular complications including pseudoaneurysms.[4]
The amount of blood expectorated in 24 h is a standard means of determining the severity of hemoptysis: mild (<30 mL), moderate (31–100 mL), severe (100–600 mL), and massive (more than 600 mL).[5] A significant volume of expectorated blood solely should not be used to define massive hemoptysis, rather a quantity of blood sufficient to cause a life-threatening condition for the patient is a more accurate and relevant definition.[6]
The major goals of the diagnostic workup in hemoptysis, after the initial examination, are to identify the location and the cause of bleeding, as well as to detect any danger to the patient's life. Sputum should be sent for microbiological investigations, including staining and culture for mycobacteria, and cytological examination if the patient is a smoker and over 40 years of age. Chest radiography is the only diagnostic imaging modality indicated when the case history and clinical picture are clear, and the hemoptysis is mild. A contrast-enhanced multislice computed tomography (CT) with angiography should be performed in cases of massive hemoptysis and whenever the findings of chest radiography are equivocal or uncertain.
Hemoptysis is a distressing and common presenting symptom in chest clinics worldwide and requires a complete evaluation to determine the cause, localization of bleed, and subsequent management. This study was conducted with the aim to determine the clinical profile of hemoptysis and its correlation with radiological and microbiological findings.
MethodsEthics
This study was approved by institutional ethics committee (Memo number: 14457 and D-26, dated- June 21, 2021). Informed consent was obtained from the participants of this study.
Study design and patient population
This observational prospective study was carried out in the Department of Pulmonary Medicine, Government Medical College, Amritsar. A total of 50 patients who presented with active hemoptysis to the outpatient department or were admitted to the wards were included in the study.
Patient selection
Inclusion criteria
All patients aged 18 years and above presenting with active hemoptysis to the Department of Pulmonary Medicine, Government Medical College, Amritsar.Exclusion criteria
Patients <18 years of ageKnown coagulopathiesBleeding from nonrespiratory sources such as hematemesis, oral mucosal bleed, and otorhinolaryngological bleeding.A detailed history was sought, inquiring about any blood dyscrasia, smoking history, drug history (including use of anticoagulants), and occupational history. Significant past medical histories included prior hemoptysis, lung diseases such PTB, lung cancer, bleeding disorders, the use of anticoagulant medications for any clinical condition, and any associated vasculitis. A complete clinical examination was performed in all cases, including a general examination, examination of the respiratory system in detail, and other systems. Investigations were done to arrive at a diagnosis and to detect any associated conditions or comorbidities. Results of sputum microbiology, and radiological investigations such as chest radiography and CT chest, were also noted.
Statistical analysis
Data have been documented, tabulated, and analyzed using appropriate statistical methods wherever applicable. Statistical analyses were conducted using StatMate V (ATMS Co., Ltd., Tokyo, Japan). P < 0.05 was considered statistically significant. Descriptive statistics were also used.
ResultsPatient characteristics
This prospective study included 50 patients who presented with active hemoptysis to the outpatient department or were admitted to the wards. After obtaining written informed consent, the clinical profile of these patients was evaluated, along with the radiological and microbiological correlation in each case. Maximum patients were in the older age group. The age of the patients was in the range of 19–75 years, but the majority of the patients (22%) belonged to the age group of 51–60 years. The mean age recorded was 42.44 years [Figure 1]. There was an overall male preponderance in the study with 84% of patients being males and 16% females [Figure 2]. Most of the patients (56%) were from urban areas. Most of the patients were laborers (34%), students (14%), and farmers (12%). Twelve percent of the patients were unemployed.
Clinical profile
Cough with expectoration (98%), fever (70%), and breathlessness (54%) were the three most common associated complaints of these hemoptysis patients. The most common comorbidities reported in this study were hypertension in 18% of patients, followed by diabetes mellitus in 10%. Other comorbidities were HIV infection in 8%, chronic obstructive pulmonary disease in 6%, ischemic heart disease in 4%, chronic liver disease in 4%, and chronic kidney disease in 2% of the patients. Fourteen patients were alcoholics, 12 were smokers, and four were intravenous drug addicts, whereas 18 patients were not having any history of addiction. Mild hemoptysis was present in 8% of patients, whereas 42% had moderate hemoptysis, 18% of patients had severe, and 32% had massive hemoptysis [Table 1]. Out of these, 62% of patients had recurrent hemoptysis, whereas 38% of cases experienced hemoptysis only once. Fifty-four percent of patients were having a previous history of Anti-tuberculosis therapy (ATT) intake. The majority of the patients were having pallor (84%), followed by clubbing (26%) and lymphadenopathy (20%).
Etiology
The most common etiologies of hemoptysis identified in this study were TB in 60% of the patients, aspergilloma in 14%, followed by bronchiectasis in 8%, pneumonia in 8% of the patients, carcinoma lung in 4%, and lung abscess in 1 (2%) of the study participants. Oral anticoagulants were reported to be the underlying cause of hemoptysis in 1 (2%) of the patients. The cause remained unknown in 1 (2%) of the patients [Figure 3].
Microbiological profile
The majority of the patients, i.e., 68% tested negative on sputum smear examination for acid-fast bacillus (AFB), whereas 32% had positive smear results. In CBNAAT testing of sputum samples, “R” sensitive mycobacterium TB (MTB) was detected in 28 (56%) patients, whereas MTB was not detected in the remaining 22 (44%) patients. In the majority of patients (60%), no growth was obtained in the sputum cultures. The most common organisms isolated from sputum cultures of the rest of the patients were Pseudomonas in 14%, Klebsiella in 10%, Escherichia More Details coli in 4%, Staphylococci in 4%, and Streptococcus pneumoniae in 4% of the cases. Among the fungal pathogens, Candida albicans was isolated in 2% and Aspergillus niger in another 2% of patients [Table 2]. A significant correlation has been noted between the sputum culture findings and the etiology of hemoptysis (P = 0.001).
Radiological characteristics
Out of the total patients, 58% were having bilateral disease (statistically significant, P = 0.030), whereas 38% of patients had unilateral disease (statistically significant, P = 0.045). No radiographic abnormalities were detected in 2 (4%) of the study participants. The majority of the patients were having consolidation and cavitary disease. Consolidation, cavitation, and fibrosis were reported in 42 (84%), 26 (52%), and 13 (26%) patients, respectively. Other radiological findings were mycetoma in 7 (14%), cystic shadows in 4 (8%), lung mass in 2 (4%), lung abscess in 1 (2%), and pleural effusion in 2 (4%) of the patients [Table 3]. A highly significant correlation was noted between the radiological findings of consolidation, mycetoma, cystic shadows, lung mass, and lung abscess and the etiology of hemoptysis (P = 0.000). The radiological findings of cavitation (P = 0.017) and fibrosis (P = 0.035) also had a significant etiological correlation. Owing to the low prevalence of malignant pleural effusion and tuberculous pleuritis in our study sample, no significant correlation could be established between the chest X-ray (CXR) findings of pleural effusion and the etiology of hemoptysis (P = 0.107).
DiscussionHemoptysis is one of the common symptoms and a potentially serious condition in all parts of the world, including India. It is usually considered an indication of PTB, but it can be associated with various other etiologies. As it is a symptom of a wide range of pulmonary diseases, determining its cause might be difficult for the treating physician. This study was conducted to find out the etiological diagnosis, radiological, and microbiological findings in patients presenting with hemoptysis.
Out of the 50 patients taken in the study, as shown in [Figure 1], the maximum number of patients belonged to the age group of 51–60 years, i.e., 22%, followed by 20% in the age groups of 21–30 years and 41–50 years each. Minimum patients were in the age group of <20 years, i.e., 10%. The mean age was 42.44 years. This is in agreement with the study done by Abal et al., where the mean age of presentation among hemoptysis patients was 42.2 (16–86) years.[7]
In our study, the maximum number of patients were males, i.e., 84%, whereas females constituted 16% of the total patients. The Abal et al., in their study, also found hemoptysis to be 4.2 times more common in males than in females.[7] Fidan et al. found similar findings in their study with a male:Female ratio of 2.72:1.[8]
Most of the patients were laborers, i.e., 17 (34%), followed by students 7 (14%), 6 (12%) patients were unemployed, 6 (12%) patients were farmers, 5 (10%) patients were homemakers, 3 (6%) patients were truck drivers, and 3 (6%) were shopkeepers. Poverty could be a significant predisposing factor, ranging from poor overall hygiene, poor living conditions, poor nutrition, and immune status. Furthermore, treatment interruptions are more common among poor families.
The most common symptom recorded in our study was cough with expectoration, which was present in 49 (98%) of cases followed by fever, which was present in 35 (70%) cases. Breathlessness was present in 27 (54%) of cases, chest pain in 8 (16%) of cases, weight loss was present in 14 (28%) of cases, and loss of appetite in 16 (32%) of cases.
This is in accordance with a study conducted by Korvadiya et al. to study the clinical profile of hemoptysis, which included 100 patients who presented with active hemoptysis. In this study, coughing (98%) was the most commonly associated symptom in 98 patients. Other associated symptoms reported were dyspnea, fever, chest pain, malaise, night sweat, and weight loss.[9]
The severity of hemoptysis in this study is classified as mild (<30 mL), moderate (31–100 mL), severe (101–600 mL), and massive hemoptysis (>600 mL or any amount of bleeding with hemodynamic and respiratory compromise) over 24 h. Out of the 50 cases, 4 (8%) patients had mild hemoptysis, 21 (42%) patients had moderate hemoptysis, 9 (18%) patients had severe, and 16 (32%) had massive hemoptysis. Of these, 31 (62%) patients had recurrent hemoptysis, whereas 19 (38%) cases included in this study experienced hemoptysis only once. In a retrospective study done by Shankar et al. out of 254 patients who presented with varying severity of hemoptysis, 34.25% of patients were having mild, and 18.89% of patients moderate (31–100 mL) bleeding. Severe (101–600 mL) and massive (>600 mL) hemoptysis were found in only 8.26% and 5.11%, respectively.[10] The recurrence rate of hemoptysis in our study is in accordance with that observed by Tunçözgür et al. in their study, where 60% of all 249 patients had a previous episode of hemoptysis.[11]
PTB was the most common cause of hemoptysis four decades ago as shown by Rao in his study in 1960,[12] and it is still the leading cause of hemoptysis, as is evident from the present study, in which TB was found to be the leading cause of hemoptysis in 60% of patients. The second-most common cause of hemoptysis noted in our study was aspergilloma (n = 7, 14%), followed by bronchiectasis (n = 4, 8%), pneumonia (n = 4, 8%), and carcinoma lung (n = 2, 4%), whereas 1 (2%) of the patients had lung abscess as the underlying cause of hemoptysis. The etiology was found to be oral anticoagulants in 1 (2%) of the patients. The cause remained unknown in 1 (2%) of the patients.
However, the etiological pattern of hemoptysis differs in developed countries. Abal et al.[7] found bronchiectasis as the most common cause in 20% of patients. Hirshberg et al.[13] also found similar findings. McGuinness et al. recorded hemoptysis in 25% of bronchiectasis and 16% of TB cases.[14] Fidan et al. recorded lung cancer (34.3%) as the most common cause of hemoptysis, followed by bronchiectasis (25.0%).[8] The high rate of hemoptysis due to TB in the present study was probably due to the high prevalence of TB in our country.
The recurrence of TB is still a major problem in high-burden countries. The rate of recurrence is highly variable and has been estimated to range from 4.9% to 47%. The widely recognized host factors independent of treatment programs that predispose to TB recurrence include gender differences, malnutrition, and comorbidities such as diabetes, renal failure, and systemic diseases, especially immunosuppressive states such as human immunodeficiency virus, substance abuse, and environmental exposures such as silicosis.[15]
Similarly, in a prospective study done by Bhalla et al. to evaluate the etiology of hemoptysis in a tertiary care center of North India, PTB (active/sequel) was the most common etiology (65%), followed by community-acquired pneumonia (10.93%), bronchiectasis (9.3%), carcinoma lung (7.18%), and miscellaneous causes (8.6%).[16]
The majority of the patients taken in the study, i.e., 34 (68%) tested negative on sputum smear examination for AFB, whereas the remaining 16 (32%) patients tested positive. In CBNAAT testing of sputum samples of study participants, “R” sensitive MTB was detected in 28 (56%) patients, whereas MTB was not detected in the remaining 22 (44%) patients.
Secondary bacterial and fungal infections as a cause of active hemoptysis were diagnosed in 20 patients. The most common organism isolated from sputum was Pseudomonas in 7 (14%) cases, followed by Klebsiella in 5 (10%), E. coli in 2 (4%), Staphylococci in 2 (4%), S. pneumoniae in 2 (4%), A. niger in 1 (2%), and C. albicans in 1 (2%) of the patients. No growth was obtained in sputum cultures of 30 (60%) patients. The sputum culture findings had a significant correlation with the etiology of hemoptysis (P = 0.001), as is evident from [Table 2].
The majority of the etiological diagnoses were established on the basis of chest radiography and CT chest findings. As is seen in [Table 3], the unilateral disease was present in 19 (38%) patients (statistically significant, P = 0.045), whereas the bilateral disease was present in 29 (58%) patients (statistically significant, P = 0.030). The CXR of most patients taken in the study demonstrated more than one finding. Consolidation was present in 42 (84%) patients, cavitation in 26 (52%), and fibrosis in 13 (26%) of the study participants. Secondary fungal infections can also occur and are often difficult to diagnose in resource-constraint countries due to similar presentation to tuberculosis and may require CT thorax, serum precipitating antibodies to Aspergillus species, respiratory cultures, and even lung biopsy or videothoracoscopy in some cases.[17] In our study, mycetoma was present in 7 (14%), cystic shadows in 4 (8%), lung mass in 2 (4%), and lung abscess in 1 (2%) of the patients. While 2 (4%) patients were having pulmonary as well as extrapulmonary involvement, i.e., pleural effusion was present, and no radiographic abnormalities were detected in 2 (4%) of the study participants. Owing to the high prevalence of PTB and post-TB sequelae, and the changing epidemiological trends of lung cancer among Indian patients, a highly significant correlation was noted between the radiological findings of consolidation, mycetoma, cystic shadows, lung mass, and the etiology of hemoptysis (P = 0.000). The radiological findings of cavitation (P = 0.017) and fibrosis (P = 0.035) also had a significant etiological correlation. Similarly, in a study done by Bondade et al. out of 60 patients who presented with hemoptysis, CXR was normal in 12 (20%) patients. Among 48 patients with abnormal CXR, 16 (26.7%) had bronchiectasis, fibrocavitations were present in 10 (16.6%), mass lesion in 8 (13.3%), unresolved pneumonia in 6 (10%), hilar adenopathy 4 (6.7%), and collapse in 2 (3.3%) patients.[18]
Our study is believed to contribute to identifying the clinical and etiological profile of hemoptysis based on socio-economic, demographic, and behavioral parameters. This study was taken up to determine the potential risk factors and etiology of hemoptysis, so that the management of patients will also be strengthened through preventing these factors, alongside patient treatment, which will have a positive impact on successful treatment outcomes and may decrease mortality.
ConclusionHemoptysis can be caused by a wide range of disorders, and the etiologic diagnosis must be made as soon as possible since prompt treatment can save patients' lives. This study provides a detailed analysis of the clinical profile of hemoptysis, along with the etiological correlation of radiological and microbiological findings. There are very few studies available from developing countries, analyzing the causes and outcomes of hemoptysis in the Indian population. Hence, studies will need to define the detailed clinical profile based on socio-economic, demographic, and behavioral parameters to determine the etiology, and thus optimal management for patients with hemoptysis.
Limitation of the study
The spectrum of diseases that present as hemoptysis, in developing parts of the world has not been studied extensively. Data related to the detailed clinical profile of hemoptysis are lacking. This is a single-center study with limited sample size, so the observations cannot be generalized.
Ethical statement
This study was approved by the Institutional Ethics Committee, Government Medical College, Amritsar, with the Approval Number14457/D-26/2019.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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