BRONCHIAL ARTERY EMBOLIZATION FOR MASSIVE HEMOPTYSIS IN CAVITARY SARCOIDOSIS

Abstract

INTRODUCTION: Cavitary lesions are an uncommon presentation of sarcoidosis. While rare, massive hemoptysis can occur and represents a potentially fatal consequence of cavitary sarcoidosis. Bronchial artery embolization for control of massive hemoptysis has been described for patients who are poor surgical candidates. We present a case of chronic cavitary sarcoidosis presenting with massive hemoptysis despite serial wedge resections which responded to bilateral bronchial artery embolization. CASE PRESENTATION: A 48 year old non-smoking male with a long-standing diagnosis of pulmonary cavitary sarcoidosis presented with acute onset of massive hemoptysis. He experienced several prior episodes of hemoptysis requiring bilateral upper lobe wedge resections. A chest computed tomography (CT) identified bilateral upper lobe cavitary lesions with extravasation of contrast from the large right upper lobe cavity. The patient subsequently underwent angiography which revealed active extravasation of contrast from a left sided intercostal bronchial trunk, as well as abnormal appearing parenchyma in the right midlung, correlating to location of extravasation of contrast on the CT. Successful embolization of the left bronchial artery and three right bronchial arteries was performed. After three weeks a chest CT performed revealed a significant decrease in the size of the cavitary lesions. Approximately 4 weeks following the embolization, he experienced recurrent hemoptysis. Repeat angiography of the left bronchial artery revealed that the prior embolization was successful. Two weeks later a CT chest identified further improvements in the size of the cavitary lesion. He was started on methotrexate for refractory sarcoidosis and has returned to his exercise regimen. He continues to taper his prednisone. After four months the patient denied further episodes of hemoptysis and reports improvement in his exercise tolerance. DISCUSSIONS: Sarcoidosis is an idiopathic granulomatous disease typified by hilar lymphadenopathy, interstitial pulmonary fibrosis, and noncaseating granulomas. Although uncommon, cavitary lesions may occur and can result in massive hemoptysis. This results from erosion of a cavitary lesion into a bronchial vessel, typically resulting from ongoing inflammation due to disease progression or secondary infection. Hemoptysis is typically conservatively managed with serial bronchoscopy and supportive care. Alternatively, surgical resections of the cavitary lesions identified via angiography have been performed when conservative therapy fails. Both modalities have a high mortality rate. Bronchial artery embolization is safe and minimally invasive, and can be utilized as an alternative approach, especially for patients who are poor surgical candidates. CONCLUSION: Cavitary sarcoidosis with resultant massive hemoptysis is a rare manifestation of sarcoidosis. The successful use of bronchial artery embolization to control hemoptysis in this population has not been reported. We present the first reported case of cavitary sarcoidosis presenting with hemoptysis successfully treated with bronchial artery embolization.