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Weekly Chest CasesArchive of Old Cases

Case No : 1115 Date 2019-03-12

  • Courtesy of Yoon Joo Shin, Kyung Won Lee / Seoul National University Bundang Hospital
  • Age/Sex 58 / M
  • Chief Complaintrecurrent hemoptysis, dyspnea after strenuous exercise
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Exercise-induced pulmonary hemorrhage
Radiologic Findings
Among 8 years, patient was visited hospital several times complaining of recurrent blood-tinged sputum, hemoptysis and dyspnea after strenuous exercise. In fact, the patient was amateur marathoner who runs about 100 km a week. First CT scan demonstrated patchy consolidation and GGO in the LLL posterior basal segment. Bronchoscopy showed focal bleeding at the LB 10 (posterior basal segmental bronchus) at that time. Five years later, the patient underwent additional CT scan for evaluating his hemoptysis, CT demonstrated new, ill-defined geographic GGO in BULs. These lesions were disappeared on the last CT image which was took three years later, and another geographic GGO newly demonstrated in BUL, especially RUL. Considering the image findings and clinical aspects together, it was possible to assume that the patient's symptoms and images were caused by severe exercise.
Brief Review
Exercise-induced pulmonary hemorrhage (EIPH) or exercise-induced pulmonary edema (EIPE) have frequently been documented in racehorses, however, EIPH/EIPE have also been often described with hard aerobic exercise in humans including marathon runners, triathletes, cyclists, and swimmers. EIPH may presented with a variety of clinical symptoms, including asymptomatic patients, cough, dyspnea, blood-tinged sputum, hemoptysis, or epistaxis after extreme exercise.
Capillary wall tearing was one of the pathogenesis explaining the disease. Exercise elevates pulmonary capillary pressures and can affect the integrity of the blood-gas barrier. With extreme exertion, these changes result in increased permeability and cause bleeding into the lung.
Recent histological studies identified extensive remodeling of small pulmonary veins in EIPH/EIPE-affected horse lungs. Strenuous exercise results in high pulmonary vascular pressure and high vascular pressure results in pulmonary vein wall remodeling. Those lesions lead to diminished vein lumen diameter and during hard exercise, venous occlusion induces regionally increased pulmonary capillary pressure, capillary rupture and bleeding.
Imaging findings are non-specific and may appear in the form of pulmonary hemorrhage or pulmonary edema. The bronchoscopic evaluation, including the bronchoalveolar lavage can help with diagnosis.
References
1. Andrew J. Ghio, Christine G., Maryann B. Exercise-induced pulmonary hemorrhage after running a marathon, Lung, 2006;184:331–333
2. DS Kim, MH Lee, et al., A 45-Year-Old Man With Recurrent Dyspnea and Hemoptysis during Exercise: Exercise-Induced Pulmonary Hemorrhage/Edema, Tuberc Respir Dis 2015;78:375–379
Keywords
lung, Pulmonary hemorrhage,

No. of Applicants : 81

▶ Correct Answer : 36/81,  44.4%
  • - The University of Kyoto Hospital , Japan TOMOAKI OTANI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - Chonbuk National University Medical School , Korea (South) HYEJIN YANG
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - Chonbuk National University Hospital , Korea (South) EUN HA JUNG
  • - Gyeongsang National University Hospital , Korea (South) HWANGHEE JO
  • - Asan Medical Center , Korea (South) EUNJI CHOI
  • - Ajou University Hospital , Korea (South) KYUNGMIN LEE
  • - Other , Korea (South) SEONGSU KANG
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Chungbuk National University Hospital , Korea (South) CHANGHOON OH
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Myongji Hospital , Korea (South) KI EON KWON
  • - Other , Korea (South) JIYEON HAN
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - Medicheck health care , Korea (South) Chae hun Lim
  • - Ajou University Hospital , Korea (South) DAYOUNG KIM
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - , Japan NAOMI YUASA
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - Korea University Guro Hospital , Korea (South) KYU-CHONG LEE
  • - Chonbuk National University Hospital , Korea (South) SOL KI KIM
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - Ajou University Hospital , Korea (South) SUBIN HEO
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - Japanese Red Cross Wakayama Medical Center , Japan AKIHIKO SAKATA
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - Seoul Veterans Hospital , Korea (South) HYUN JUNG YOON
  • - Ajou University Hospital , Korea (South) YOO YOUNGJIN
▶ Correct Answer as Differential Diagnosis : 3/81,  3.7%
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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