Hemoptysis during Sexual Intercourse* - CHEST Publications ...

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.
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892 Hemoptysis during Sexual Intercourse (Bansal, Day, Braman)
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