Working Paper of Public Health Volume 2012 - Azienda Ospedaliera ...

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Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 20/2012A 57 year old woman, non smoker, non atopic, was sent to us so we could study aneoformant lesion at the beginning of the superior right bronchus (Figure 1). She had beenadmitted to another hospital in February 2012 after suffering from seven episodes of massivehemoptysis. At the bronchoscopy there was no blood in the bronchial tree, but a little lesionwith normal mucosa was present in the superior bronchus. The biopsy was followed by amassive hemoptysis episode that stopped only after 4 doses of tranxamic acid 5ml/500mg.During the emergency the patient had a hypotensive crisis, so only after the bleeding ceasedshe was transferred to the intensive care unit for monitoring of the hemodynamic functions.Finally, one hour later, a bronchoscopy was performed confirming the bleeding hadstopped. In March a CT/PET was practiced and proved negative for hypercaptations. Thehistological evidence of the biopsy was normal bronchial mucosa with conserved structure,so this report was considered negative for neoplastic lesion. When she arrived at our hospitalat the end of March, her doctors suggested a biopsy to be carried out with a rigidbronchoscope, which is safer in case of bleeding. However, after taking view of thehistological description and visual image of the previous bronchoscopy we decided to use aflexible bronchoscopy in the presence of an MD anaesthesiologist. We found a lesion at thebeginning of the medium bronchus (Figure 2); it was about 1-2 mm, raised from the surfacewith a white cap and covered form, apparently normal mucosa, but no lesion in the rightupper bronchus, probably because this lesion had disappeared after the previous biopsy.Suspecting Dieulafoy’s disease, we didn’t carry out a biopsy of the lesion and proceeded toan x-ray study. The arteriography showed convoluted and ectatic bronchial vascularstructures, particularly around and behind the trachea and around the right bronchus. (Figure3). An embolization of the right bronchial artery and in particular of the common tract of theintercostal bronchial trunk was then performed using three 5mm spirals (Figure 4).Figure 1: lesion at the beginningof superior right bronchusFigure 2: lesion at the beginningof medium bronchus2
Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 20/2012Figure 3: ArteriographyABFigure 4Spiral in the right bronchial artery, [A: X-ray B: CT]DiscussionDieulafoy’s disease is an extremely rare vascular anomaly, characterized by the presence ofa dysplastic artery in the sub-mucosa. At present, there are few proven cases reported inliterature [2-3-4]. The pathogenesis of Dieulafoy disease remains unclear. It was first reportedin the gastrointestinal tract [5]; more recently it has also been described in the respiratorytract [6-7]. While in the gastrointestinal tract the bleeding is often spontaneous but also fatal,3
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