Approach to haemoptysis and pulmonary tuberculosis (incomplete PTB) Flashcards
Differential diagnoses of true haemoptysis
Respiratory
1. Infection - pneumonia, TB, abscess, bronchitis, bronchiectasis, aspergillosis
2. Neoplastic - bronchogenic, metastasis, Kaposi’s sarcoma
3. Vascular - PE, GPA, Goodpasture, HHT
Cardiac
1. Pulmonary oedema - pink frothy sputum
2. Mitral stenosis
Others
1. Bleeding disorder
2. Anticoagulation
3. Thoracic endometriosis
Differentiate from ENT or UGI bleed
1. Nasopharyngeal carcinoma
2. Oesophageal rupture
3. BGIT causes - PUD, gastric cancer
History taking framework of haemoptysis
A. Characteristics of haemoptysis
B. Associated symptoms
C. Past medical history and medications
D. Family history
E. Social history
A. Characteristics of haemoptysis
Characteristic - site, onset, duration, frequency, previous episodes, colour, quantity
- Site
- ENT bleed: epistaxis
- BGIT: vomit blood (haematemesis), nausea/vomiting/ diarrhoea, epigastic pain, melena
- Respiratory: coughing out blood from airway or lungs - Onset and duration
- Frequency and number of previous episodes
- Colour
- Fresh blood
- Pink frothy - pulmonary oedema, mitral stenosis
- Brown/rusty/mucopurulent - pneumonia, bronchiectasis
- Black - melanoptysis in pneumoconiosis - Quantity - teaspoon, cups
(volume > 200mL in a day indicates poorer prognosis)
B. Associated symptoms in haemoptysis
Associated symptoms
1. Cough and sputum production
- Acute: infection, pulmonary embolism
- Blood streak: bronchitis
- Chronic purulent: bronchiectasis
2. Dsypnoea - cardiac or respiratory
3. Pleuritic chest pain
4. Fever, rigors, night sweats
- Swinging fever: lung abscess
- Profuse night sweat: tuberculosis
5. Voice hoarseness, dysphagia - bronchogenic ca, enlarged LA in MS
6. Weight loss and anorexia - ca, TB
7. Rash, arthralgia, myalgia - GPA, SLE
8. Other sites of bleeding - GPA, HHT, pulmonary-renal syndrome
9. Leg pain, swelling, erythema - DVT, PE and risks
- Immobility, long travel, recent surgery, malignancy, OCP, prothrombic hereditary states
10. Menstrual history and menstrual pain
C. Past medical history and medications relevant to haemoptysis
D. Family history
Past medical history
1. Recurrent chest infection
- Bronchiectasis, cystic fibrosis, CVID
2. Childhood rheumatic fever - MS
3. Bleeding disorders
4. Malignancy, metastasis and VTE
5. Intracranial haemorrhage (AVM)
6. Gastrointestinal bleeding (AVM, PUD)
7. Chronic liver disease - coagulopathy
8. Immunosuppression and opportunistic infection
Medications
1. Anticoagulation and antiplatelet
2. OCP
3. Recreational drugs - cocaine causing pulmonary haemorrhage and infarct
Family history
1. Lung malignancy
2. Tuberculosis
3. HHT, bleeding disorders and thrombophilia
E. Social history in haemoptysis
- Smoking and betel nut chewing
- Occupational exposure - asbestosis, coal
- Travel history - endemic TB area
Investigations for haemoptysis
- CXR
- CT thorax
- Bronchoscopy
- Sputum - stain and culture, AFB smear culture and PCR, cytology
- FBC - anaemia for blood loss, leukocytosis for infection
- ESR, CRP
- Coagulation panel
- Liver function test
- Renal panel - pulmonary renal syndrome
- CaMgPhos
- D-dimer
- Autoantibodies - ANCA, anti-BGM, SLE panel
- UFEME - red cell cast
Population groups at high risk of tuberculosis
- Endemic regions - Africa, Asia, Eastern Europe
- Low SES - crowded living conditions, homelessness, poor healthcare
- Immunocompromised - HIV, immunosuppressants, chemotherapy
- Healthcare workers
Diagnosis of pulmonary tuberculosis
- CXR - hilar lymphadenopathy, apical consolidation, collapse, miliary TB
- AFB smear, culture and PCR
Monitoring of PTB treatment
Pre-treatment and during treatment
1. FBC, RP, LFT - dyscrasias, nephrotoxicity, hepatotoxicity
2. Visual acuity, colour vision, fundoscopy - ethambutol
3. Peripheral neuropathy - isoniazid
4. HIV, Hep B, Hep C
Management of known PTB contact
With BCG vaccination:
1. Mantoux test under 35 years old
2. CXR over 35 years old
Without BCG vaccination:
1. Mantoux test, IGRA and CXR
2. Provide BCG vaccination if negative
