Hemoptysis during Sexual Intercourse* - CHEST Publications ...

FIGURE 1. Intraoperative AP chest x-ray film showing central venous
catheter in superior vena cava. The catheter tip was slightly curled
cemia, arrhythmia, air embolism, and catheter embolism.
Literature review shows the complication rate ranges from
0.4 to 11 percent. 12 Routine postinsertion chest x-ray examination
can help diagnosis some of these complications in
addition to providing information on the position of the
catheter. A malpositioned catheter can result in faulty central
FIGURE 2. Lateral chest x-ray film, nine days later, revealing the
catheter tip impinging on the posterior wall of the superior vena
cava, in addition to a right hydrothorax.
Downloaded From: http://chestioumal.chestpubs.org/ on 07/03/2013
venous pressure readings; it can also lead to thrombosis or
perforation of the central vein. An analysis of 13,800 subclavian
catheterizations showed incorrect position of the
catheter was found in 15 percent of the cases, verified with xray
examination. 3 Therefore, it is important to obtain a
routine postcatheter insertion chest x-ray film, even if blood
can be aspirated freely from the catheter, as in this case. A
coiled catheter tip on an AP chest x-ray film means that the
catheter tip is impinging on the vein and additional information
can be obtained from a lateral chest roentgenogram. A
review by Conces and Holden 4 showed that only 1.2 percent
of subclavian venous catheter placements were followed by
standard AP and lateral chest roentgenogram. It should be
emphasized that a malpositioned catheter tip is a harbinger
of complications, and x-ray confirmation of the catheter
position is mandatory following central venous catheterization.
REFERENCES
1 Borja AR, Masri Z, Shruck L, Pejo S. Unusual and lethal
complications of infraclavicular subclavian vein catheterization.
Int Surg 1972; 57:p42-45
2 Herbst CA. Indications, management, and complications of percutaneous
subclavian catheters. Arch Surg 1978; 113:1421-25
3 Eerola R, Kaukinen L, Kaukinen S. Analysis of 13,800 subclavian
vein catheterizations. Act Anaesthesiol Scand 1985; 29:193-97
4 Conces DJ, Holden RW. Aberrant locations and complications in
initial placement of subclavian vein catheters. Arch Surg 1984;
119:293-95
Hemoptysis during Sexual
Intercourse*
Unusual Manifestation of Coronary
Artery Disease
Sudhir Bansal, M.D.,t John A. Day, Jr, M.D.;t
and Sidney S. Braman, M.D.I
Sexual activity increases physiologic demands on the car­
diovascular system. A patient with stable angina pectoris
experienced recurrent bouts of hemoptysis caused by left
ventricular failure that occurred only during sexual activity.
Severe atherosclerothic coronary vascular disease was con­
firmed by cardiac catheterization. The patient underwent
successful coronary artery bypass grafting; nine months
after surgery, he is sexually active and symptom-free.
Several studies have shown that sexual activity places
increased demands on the cardiovascular system. 1,2 The
demands are usually modest during sexual intercourse and
are less for middle-aged patients with coronary artery disease
compared to young healthy laboratory volunteers. 35 These
*From the Departments of Medicine, Veterans Administration
Medical Center, Rhode Island Hospital and Brown University,
Providence.
Supported by a grant from the VA Medical Research Service.
tStaff Physician and Assistant Professor of Medicine.
^Pulmonary Fellow
IClinical Associate Professor of Medicine.
Reprint requests: Dr. Bansal, VA Medical Center, Davis Park,
Providence, RI 02908
CHEST / 93 / 4 / APRIL, 1988 891

observations led Masters and Johnson to conclude that most
middle-aged men with atherosclerotic heart disease who are
not in congestive heart failure can safely engage in this
activity. 6 We report the case of a middle-aged man with
known stable angina pectoris who developed hemoptysis due
to left ventricular dysfunction during sexual intercourse.
Failure to recognize this unusual association caused some
delay in appropriate diagnostic work-up and therapy.
CASE REPORT
A 65-year-old man with a six-year history of stable angina pectoris
presented to the emergency room several times over a four-month
period, complaining of "coughing up blood." He estimated the
quantity to be a tablespoon each episode, this was always followed by
blood streaking of the sputum which persisted for several hours.
During his first few visits, he was quite vague about the circumstances
of his illness, though all of his visits were in the early hours of
the morning. Repeated chest roentgenograms and cytologic examinations
of the sputum done during clinic follow-up visits were
negative. On one of these visits, he reluctantly admitted that all of
these episodes had been precipitated by sexual activity (intercourse
or masturbation). The patient had had the same sexual partner for the
past 50 years and had sex once a week. He suffered a total of six
episodes. Each episode was accompanied by "coughing, hard
breathing, and chest tightness." Relief came with no specific therapy.
Despite these symptoms, the patient did not complain of decreased
exercise tolerance, orthopnea, or an increased frequency of his usual
angina, which was normally manifested by chest pain after physical
exertion. The chest pain was normally relieved by one sublingual
nitroglycerin tablet. He had no symptoms of chronic bronchitis
despite a cigarette smoking history of two packs per day for 30 years
until three years previously. His past medical history was significant
for a schizoaffective disorder, osteoarthritis, and peptic ulcer
disease.
The patient was admitted to the hospital for an evaluation. At this
time, his medications were propranolol, isosorbide dinitrite,
cimetidine, chlordiazepoxide, and nitroglycerin. His physical examination
was unremarkable. A resting ECG, echocardiogram, and
chest roentgenogram were normal, as were a complete blood count,
chemistry screen, and coagulation studies. After 314 minutes of a
treadmill stress test, the patient developed chest tightness accompanied
by global 3 mm ST segment depression at a heart rate of 134
beats per minute. There were no blood pressure changes and no
hemoptysis. His symptoms resolved five minutes after the administration
of sublingual nitroglycerin. The ECG changes resolved after
16 minutes. Cardiac catheterization revealed an ejection fraction of
70 percent and a left ventricular end-diastolic pressure of 16 to 20
mm Hg. Coronary angiography showed a 75 percent obstruction of
the proximal left anterior descending with 99 percent obstructions of
the first diagonal and obtuse marginal branches, and also a 99
percent lesion of the right coronary artery.
The patient underwent a saphenous vein bypass graft of these
lesions with good results. Five months postoperatively, while managed
on cimetidine and digoxin, the patient is completely
asymptomatic with excellent exercise tolerance. He is currently
having sex twice a week without any symptoms.
DISCUSSION
While lung diseases are the most common cause of
hemoptysis, cardiovascular diseases must be considered in
the appropriate clinical setting. We believe that our patient
developed cardiac ischemia during sexual activity due to
increased cardiovascular demands in the face of limited
coronary blood supply. Transient left ventricular compromise
and resultant acute pulmonary congestion led to recurrent
hemoptysis. We feel this is strongly supported by the
absence of pulmonary disease, the fact that the hemoptysis
was episodic and temporally related to sexual activity, and
the fact that the patient returned to normal physical and
sexual activity, without hemoptysis, following successful
bypass surgery.
Hemoptysis was a common symptom of mitral stenosis in
the precardiac surgery era; it can result from acute pulmo­
nary congestion precipitated by sexual intercourse, physical
exercise, and marked excitement. 7 Pulmonary congestion
without the signs and symptoms of pulmonary edema is felt
to cause blood streaking of sputum, as a result of rupture of
pulmonary capillaries. 7 Our patient had repeatedly normal
chest roentgenograms that were taken from two hours to
three days after the episode of hemoptysis; presumably, the
pulmonary congestion was quite transient and thus, missed
by roentgenogram. Mitral stenosis was ruled out by both
echocardiogram and catheterization.
In our patient, ischemia-mediated ventricular dysfunction
was believed to be the mechanism of acute pulmonary
congestion. While this most often occurs in patients with
impaired baseline ventricular function, patients with normal
ventricular function are also subject to this complication." It
has also been reported that sexual activity can precipitate
dangerous arrhythmias in patients with ischemic heart dis­
ease; we doubt, however, that this was a factor in our case. 3
In patients with recurrent hemoptysis associated with
physical exertion, occult left ventricular dysfunction with
resultant pulmonary congestion must be considered in the
differential diagnosis. Our patient demonstrated that this
may occur during the exertion of sexual intercourse in
patients with ischemic heart disease.
REFERENCES
1 Bohlen JG, Held JP, Sandorson O, Patterson RE Heart rate, ratepressure
product, and oxygen uptake during four sexual activities.
Arch Intern Med 1984;114:1745-48
2 Mann S, Craig Millar MW, Gould BA, Melville DI, Raferty EB.
Coital blood pressure in hypertensives Gepalgia, syncope and the
effects of beta-blockade. Br Heart J 1982; 47:84-89
3 Nemec ED, Mansfield L, Kennedy JW. Heart rate and blood
pressure responses during sexual activity in normal males. Am
Heart J 1976; 92:274-77
4 McNaughton M W. Heart rate and blood pressure response to stair
cliimbing and sexual activity. Circulation 1978; 57:215
5 Hellerstien HK, Friedman EH. Sexual activity and the post
coronary patient. Arch Intern Med 1970; 125:987-99
fi Masters WH, Johnson VE. Human sexual inadequacy. London:
Churchill, 1970:998
7 Hurst WB. The heart, 6th ed. New York: McGraw-Hill, 1986:
118-19
8 Clark LT, Garfien OB, Dwyer EM Jr. Acute pulmonary edema due
to ischaemic heart disease without accompanying myocardial
infarction: natural history and clinical profile. Am J Med 1983; 75:
332-36
9 Fletcher GF, Johnston BL, Cantwell JD. Dynamic electrocardiographic
monitoring during coitus in patients post myocardial
infarction and revascularization. Circulation 1978; 7:204
892 Hemoptysis during Sexual Intercourse (Bansal, Day, Braman)
Downloaded From: http://chestioumal.chestpubs.org/ on 07/03/2013

Delivers 40-140 more actuations
than other oral steroid inhalers.
Built-in barrel eliminates need
and cost of spacers.
Large barrel slows spray to
a fine mist, not a jet spray that
requires precise breathing
coordination. Easily inhaled mist makes over
90% of dose potentially available
to airways.
Inhalation made easy.
(Plus low cost and portability)
I Azmacort"
^ (triamcinolone
acetonide) a
costs
i
less than other
oral steroid
inhalers.
Downloaded From: http://chestioumal.chestpubs.org/ on 07/03/2013
• •
Very low
incidence
of oral
candidiasis.
Breathable, economical, portable—the
unbeatable choice
for asthma patients who must
have steroid therapy.
Azmacort
(triamcinolone acetonide)
From the makers of Slo-bid
(THEOPHYLLINE ANHYDROUSL
RORER PHARMACEUTICALS
i n l a division of
\mM RORER PHARMACEUTICAL CORPORATION
\mM\ FORT WASHINGTON PA 19034
PLEASE SEE NEXT PAGE FOR BRIEF SUMMARY OF PRESCRIBING INFORMATION.
Inhaler telescopes into a
compact unit that fits pocket
or purse.
FC#76
892-A

892-B
AzmaCOrt (triamcinolone acetonide) inhaler
Brief Summary For Oral Inhalation Only
INDICATIONS: Azmacort itriamcinolone acetoniclei inhaler is indicated only for patients
who require chronic treatment with corticosteroids tor the control ol the symptoms
ot bionchial asthma Such patients would include those already receiving systemic
codicosleroids and selected patients who are inadequately controlled on a non-steroid
regimen and in whom steroid therapy has been withheld because ot concern over
potential adverse effects
Azmacort" inhaler Is WO/" indicated: 1 For relief of asthma which can be controlled Oy
bronchodilators and other non-steroid medications 2 In patients who require systemic
corticosteroid treatment infrequently 3 In the treatment of non-asthmatic bronchitis
CONTRAINDICATIONS: Azmacort inhaler is contraindicated in the pnmary treatment
ol status asthmaticus or olher acute episodes of asthma where intensive measures
are required
Hypersensitivity to any ol the ingredients of this preparation contramrticates its use
WARNINGS:
Particular caie is needed in patients who are transferred from systemically active
corticosteroids to Azmacort " inhaler because deaths due to adrenal insufficiency
have occurred in asthmatic patients during and after Iransfer Irom systemic
corticosteroids to aerosolized steroids in recommended doses After withdrawal
Irom systemic corticosteroids, a number of months is usually required for recovery
ol hypothalamic piimtaiy adicuai iHPA; function For some patients who have
iccmvcd l.iii|i: dose:; of (u.il M-muds 1 nr lung pounds nl tuns; liiilcit' Ihi'iapy v.-111
Azmacort inhaler is initiated recovery may be delayed for one year or longer
During this period ol HPA suppression patients may exhibit signs and symptoms
of adrenal insufficiency when exposed to trauma surgery or infections particularly
gastroenteritis or other conditions with acute electrolyte loss Although Azmacort
inhaler may provide control ol asthmatic symptoms during these episodes, in
'ecommended doses n supplies only normal physiological amounts of corticosteroid
systemically and does NOT provide the increased systemic steroid which is
necessary for coping with these emergencies.
During periods of stress or a severe asthmatic attach patients who have been
recently withdiawrt from systemic coiticosteioids should be instructed lo resume
systemic steroids (in large doses> immediately and to contact their physician
lor further instruction These patients should also be instructed to carry
a warning card indicating that they may need supplementary systemic steroids
during periods of stress or a severe asthma attack
Localized infections with Candida albicans have occurred infrequently in the mouth
and pharynx these areas should be examined by the treating physician at each
patient visit T he percentage ol positive mouih and thioat cultures for Candida
albicans did not change dunng a yeai ol continuous therapy The incidence ol
clinically apparent infection is low |2 5%!. These infections may disappear spontaneously
oi may require treatment with appropriate antifungal therapy or discontinuance of
treatment with Azmacort inhaler
Azmacort inhaler is not to be regarded as a bronchodilator and is not mdicalec
lot rapid relief of bronchospasm
Patients should be instructed to contact then physician immediately when episodes of
asthma which aie not responsive to bronchodilators occur during the course of tieatment
with Azmacort inhaler Dunng such episodes patients may require therapy with
systemic corticosteroids.
There is no evidence that control of asthma can De achieved by the administration
of Azmacort"'' inhaler in amounts greater than the recommended doses which appear lo
be the therapeutic equivalent ol approximately 10 mg/day of oral prednisone
Theoretically, the use of inhaled corticosteroids with alternate day prednisone oral
therapy should be accompanied by more HPA suppression than a therapeutically
equivalent regimen of either alone
Transfer of patients from systemic steroid therapy to Azmacort inhaler may unmask
allergic conditions previously suppressed by the systemic steroid therapy, e.g.. rhinitis
conjunctivitis and eczema
PRECAUTIONS: During withdiawal from oral steroids some patients may experience
symptoms of systemically active steroid withdrawal eg joint and or muscular pain
lassitude and depression, despite maintenance or even improvement of respiratory
(unction (See DOSAGE AND ADMINISTRATION lor delailsi Although steroid withdrawal
effects are usually transient and not severe, severe and even fatal exacerbation
of asthma can occui if Ihe previous daily oral conirostcmid requirement had significantly
exceeded 10 mg day ol prednisone or equivalent
In responsive patients inhaled corticosteroids will often permit control of asthmatic
symptoms wiin less suppression of HPA function than therapeutically equivalent oral
doses of prednisone Since triamcinolone acetonide is absorbed into the circulation aim
can be systemically active, the beneficial effects of Azmacort inhaler in minimizing
or preventing HPA dysfunction may be expected only when recommended dosages
are not exceeded
Suppression ol HPA function has been reported in volunteers who received 4000 meg
daily ot triamcinolone acetonide In addition suppression ol HPA function has been
reported in some patients who have leceived recommended doses lor as little as
6-12 weeks Since the response ol HPA function to inhaled corticosteroids is highly
individualized the physician should consider this information when treating patients
Because of the possibility of systemic absorption of inhaled corticosteroids patients
healed with these drugs should be observed carefully for any evidence of systemic
corticosteroid elfects including suppression of growth in children Particular care
should be taken in observing patients postoperatively oi during periods of stress lor
evidence ol a decrease in adrenal lunciion
The long-term effects of triamcinolone acetonide inhaler in human subjects are not
completely known although patients have received Azmacort inhaler on a continuous
basis for periods of two years or longer While there has been no cluneal evidence
ol adverse experiences the local elfects of the agent on developmental or immunologic
processes in the mouth, pharynx, trachea and lung are also unknown
The potential elfects of Azmacort inhaler on acute recurrent or chronic pulmonary
nfections including active or quiescent tubercu osi! an nol km ivn For this reason
since systemic administration of corticosteroids may mask some signs of lungal
bacterial or viral infection, the same caution should be observed when treating patients
with Azmacort ' inhaler. The potential effects of long-term administration of Azmacort
inhaler on lung or other tissues are unknown However pulmonary infiltrates with
eosinophils have occurred in patients receiving olher inhaled corticosteroid's
Pregnancy: Pregnancy Category D Azmacort triamcinolone acetonide' has been
•• :• v/iitngc'iic n rats ;ind •abb ts .'.I'-en in doses aimpa'a:] e tc no
highest dose recommended foi humanuse approximately 0 032 mg kq day Administration
of aeiosol inhalation to pregnant rats and rabbits produced emoryotoxic and
fetotoxic effects which were comparable lo those produced by administration by
other routes.
Teratogenic elfects in both species included a low incidence of cleft palate and/or
internal hydrocephaly and axial skeletal defects These findings lepiesenl known
effects of glucocorticoids in laboratory animals
There aie no well-controlled studies in pregnant women Experience with other dosage
forms of triamcinolone acetonide does not include any positive evidence of adverse
elfects on the fetus However, since such experience cannot exclude possibility of
fetal damage, Azmacort"'' inhaler should be used during pregnancy only if the benefit
clearly justifies the potential risk to Ihe fetus Infants born to mothers who have
received substantial doses of corticosteroids during pregnancy should be carefully
observed lor hypoartrenahsm
Nursing mothers: It is not known whether this drug is excreted in human milk
Because of the potential for tumorigenicity shown for triamcinolone acetonide in animal
studies, a decision should be made whether to discontinue nursing or to discontinue
the drug, taking info account Ihe importance of the drug to the mother
ADVERSE REACTIONS: A few cases of oral candidiasis have been reported isee
1 WARNINGS In addition, some patients receiving Azmacort inhaler have experienced
hoarseness dry thioat irritated throal and dry mouth Increased wheezing and cough
have been reported infrequently as has facial edema These adverse elfects have
generally been mild and transient.
RORER PHARMACEUTICALS
KB RORERPHARMACEUTICAL CORPORATION
HSI FORT WASHINGTON PA 19034
Downloaded From: http://chestioumal.chestpubs.org/ on 07/03/2013
AMERICAN
COLLEGE OF
CHEST
PHYSICIANS
Postgraduate Courses
54th ANNUAL
SCIENTIFIC ASSEMBLY
POSTGRADUATE COURSES
Date:
October 3,1988
Location:
Anaheim, California
This year's Annual Scientific Assembly,
to be held October 3-7, will feature a
"track" focusing on "New/High
Technology in Chest Medicine and
Surgery". The following postgraduate
courses will be held at the Meeting.
• Perioperative Management of the
Cardiothoracie Patient
• Invasive and Noninvasive Diagnosis in
Lung Cancer
• The Pleural Space
• Cardiac Disease in the ICU (Non-MI)
• Chest Imaging
• Overview of Pulmonary Infections
Sponsor:
American College of Chest Physicians
For further information contact:
Division of Education, ACCP
911 Busse Highway
Park Ridge, IL 60068-2375
(312) 698-2200

m Tidal Volume, Air Flow
• Paradoxical Breathing
• Apnea Alarms—
Obstructive/Central
• Diaphragm Fatigue
• Neonate—Pediatric—Adult
• Ambulatory Capability
The
of all these patients are
being monitored by
®
'"For complete information, fill out coupon
and mail to:
AMBULATORY MONITORING, INC.
731 SAW MILL RIVER RD., ARDSLEY, NEW YORK 10502
TELEPHONE: (914) 693-9240 TELEX: CALIB ARLY 131 423
Name. Title
Hospital/Institution
Address
City State Zip
My need is urgent, please call at
Downloaded From: http://chestioumal.chestpubs.org/ on 07/03/2013
The non-invasive, long term pulmonary
monitoring system jfe,'
A Respiratory Inductive Plethysmograph (Respitrace®)
offers quantitative tidal volumes and flow measurements
while simultaneously describing diaphragm and chest
wall muscle contributions breath by breath.. .eliminates
measurement errors introduced by mouthpiece or mask.
With calibration to ± 10% of spirometry, Respitrace can
be worn comfortably for hours without losing accuracy.
Compatible with existing DC recorders and computer
systems for data storage.
n SYSTEMS
. J AN ESTABLISHED METHOD IN PULMONARY MEDICINE
892-C