Massive Hemoptysis as a Presentation of Bronchial Mucosal Hemangioma - A Rare Presentation of a Rare Disease

Abstract

INTRODUCTION: Mucosal hemangiomas limited to tracheo-bronchial tree is extremely uncommon and has not been well described in current literature. We present a case of hemoptysis due to histologically proven bronchial mucosal hemangioma. CASE PRESENTATION: A 81 year old man presented to the emergency department with six episodes of hemoptysis described as tablespoon sized blood clots over a 24 hour period. No other symptoms were noted. His history was significant for hypertension, Idiopathic Pulmonary Fibrosis and coronary artery disease. No evidence of bleeding or coagulation disorders was noted. CT revealed bullous emphysematous changes and lower lung field fibrosis. On bronchoscopy, a large blood clot and a small non-obstructing polypoid vascular lesion with stigmata of a recent bleed was seen in the posterior segment of the right upper lobe. Endobronchial biopsy of the lesion was performed. Argon plasma coagulation was used to control the bleeding. Pathology was negative for malignant cells and revealed benign bronchial mucosa with dilated capillary spaces compatible with mucosal hemangioma. No further hemoptysis occurred on follow-up over the next year. No other skin or mucosal hemangiomas were noted. DISCUSSION: Mucosal hemangiomas are benign lesions of the mucosal surface rarely found in the trachea or bronchi. Various morphologies such as lobular capillary, sclerosing, epithelial, large cavernous and solitary capillary hemangiomas have been reported to be the etiology of hemoptysis. However, very few cases of frank hemoptysis from bronchial mucosal hemangiomas have been reported. Their origin is unknown, but appears benign. Pathology includes capillary dilatation with little supporting stromal matrix and lack of ulceration. Our patientaTMs lesion was covered with benign bronchial mucosa and exhibited dilated capillary spaces, typical of a mucosal hemangioma. Epistaxis and hemoptysis are the two most common presenting symptoms for airway mucosal hemangiomas. Massive hemoptysis is a rare manifestation. Imaging studies are not helpful due to their small size and bronchoscopy is the diagnostic modality of choice. The treatment of symptomatic bronchial hemangiomas may include cryotherapy, argon plasma coagulation, embolization of large lesions and surgical resection if uncontrollable hemoptysis occurs. The natural history of these lesions is unknown. CONCLUSIONS: Bronchial mucosal hemangiomas are a rare entity and should be considered in the differential diagnosis of hemoptysis. Pathology reveals dilated capillary spaces with little supporting stromal matrix. Radiographic studies are usually unhelpful and bronchoscopy is the diagnostic and therapeutic modality of choice.