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Hemoptysis, expectoration of blood from the respiratory tract, must be differentiated from expectorated blood originating from the nasopharynx or GI tract. Hemoptysis can result from infections, malignancies, or vascular disease. Acute bronchitis is the most common cause of hemoptysis in the United States; tuberculosis is the leading cause worldwide.
Hemoptysis originating from the alveoli is known as diffuse alveolar hemorrhage (DAH). DAH can be caused by inflammatory diseases including granulomatosis with polyangiitis, systemic lupus erythematosus, and anti-glomerular basement membrane disease. Within the first 100 days after bone marrow transplant, inflammatory DAH can cause severe hypoxemia. Noninflammatory DAH usually results from inhalational injuries from toxic exposures, such as smoke inhalation or cocaine.
Hemoptysis most commonly originates from small- to medium-sized bronchi. Because the bleeding source is usually bronchial arteries, there is potential for rapid blood loss. Airway hemoptysis is often caused by viral or bacterial bronchitis. Pts with bronchiectasis have increased risk of hemoptysis. Cavitary lung disease with hemoptysis can result from infections with endemic fungi, Nocardia, Aspergillus, and atypical mycobacteria. Pneumonia can cause hemoptysis, especially if cavitation (e.g., tuberculosis) and/or necrotizing pneumonia (e.g., Klebsiella pneumoniae and Staphylococcus aureus) develop. Paragonimiasis, a helminthic infection common in pts from Southeast Asia and China, can cause hemoptysis and must be differentiated from tuberculosis. Cancers developing in central airways (e.g., squamous cell carcinoma, small-cell carcinoma, and carcinoid tumors) often cause hemoptysis. Cancers that metastasize to the lungs cause hemoptysis less commonly.
Pulmonary vascular sources of hemoptysis include congestive heart failure with pulmonary edema, which usually causes pink, frothy sputum. Pulmonary embolism with infarction and pulmonary arteriovenous malformations are additional pulmonary vascular etiologies to consider.