RECURRENT PREGNANCY-RELATED HEMOPTYSIS IN A PATIENT WITH LADY WINDERMERE SYNDROME

Abstract

INTRODUCTION: Hemoptysis is an uncommon complication of pregnancy. We report a case of a young woman with Lady Windermere syndrome and chronic asthma with recurrent pregnancy related hemoptysis. CASE PRESENTATION: A 37 year old female (G2P1L1) in her 14th week of twin pregnancy presented with hemoptysis and shortness of breath for one week. The patient reported 1 teaspoon of bloody expectoration 2-3 times a day for the past week. There were no fever chills or cough reported prior to the episode of hemoptysis nor recent travel or sick contacts. The patient had similar episodes of non-massive hemoptysis during the last trimester of her first pregnancy, that resolved with conservative management. She has past medical history of well controlled asthma and recurrent childhood pneumonia with resultant Lady Winderemere syndrome. She has had no history of hemoptysis prior to the first pregnancy and between the pregnancies. Vital signs on admission were normal. Physical examination revealed focal coarse crepitations over the anterior right chest wall and bilateral expiratory wheezing. Cardiac and extremity examination were within normal limits. Abdominal exam was consistent with the 14th week of pregnancy. CXR showed increased markings in the region of right middle lobe.CT scans obtained after her first pregnancy revealed localized right middle lobe bronchiectasis. She was admitted for hemoptysis and asthma exacerbation. She was treated with albuterol and ipratropium nebulzations and a short course of oral corticosteroids. During the hospital stay she had few more episodes of hemoptysis that resolved with conservative treatment. The dyspnea improved and was discharged on as needed inhaled albuterol and inhaled steroids. DISCUSSIONS: Lady Windermere syndrome is a constellation of right middle lobe infiltrate in the setting of chronic Mycobacterum avium-intracellulare infection. The clinical manifestations of this syndrome consist of chronic cough, sputum production and occasional hemoptysis. The physiologic changes associated with pregnancy leads to an increase in blood volume, cardiac output and generalized vasodilatation. This has been associated with hemoptysis in patients with pulmonary vascular malformations. This is the first reported case where these changes are associated with hemoptysis in patient with Lady Windermere syndrome. We hypothesize that the recurrent episodes of hemoptysis manifesting only during pregnancy were secondary to the effect of these physiological changes on the areas of bronchiectasis. The fact that the hemoptysis occurred earlier in the second pregnancy which was the twin gestation strengthens the proposed hypothesis. CONCLUSION: Hormonal and hemodynamic changes of pregnancy can cause hemoptysis in patients with bronchiectasis.