key: cord-0784162-3tttl1eo
authors: Ogunleye, Olushola; Ajibola, Oluwafemi; Chukwu, Nneka; Suseelan, Hary
title: A COMPARISON OF TWO CASES PRESENTING WITH HEMOPTYSIS ATTRIBUTABLE TO COVID-19 PNEUMONIA
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.329
sha: 667eb99dca2b880ba10624123452cab5b7d55bd0
doc_id: 784162
cord_uid: 3tttl1eo

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 virus, has emerged as a leading cause of death globally. The most reported initial symptoms are cough, fever, dyspnea, and fatigue. Hemoptysis is atypical in COVID-19. We report cases of COVID-19 pneumonia presenting with hemoptysis in two unrelated men. CASE PRESENTATION: Patient-I was a 60-year-old nonsmoker with no known comorbidities that tested positive for COVID-19 three days earlier. He presented with 10-day history of fever and cough with blood-streaked sputum that progressed to coughing frank blood. He was febrile (103.0°F) and saturating at 95% inspiring ambient air. Chest examination revealed crackles at the right lower lung field. Laboratory evaluation noted normal platelet count, elevated D-dimer (445 ng/mL) and elevated C-reactive protein (17.2 mg/dL). Chest x-ray showed patchy opacification at the right mid and lower lung zones. He was treated conservatively. The hemoptysis resolved by day 2 and he was discharged on day 5.Patient-II, a 56-year-old former smoker with hypertension and diabetes, was diagnosed with COVID-19 twelve days earlier and developed acute hypoxic respiratory failure requiring a 5-day hospitalization at a different hospital. He presented with 2-day history of worsening shortness of breath and cough with bloody sputum. He was afebrile (98.9°F) and saturating at 67% inspiring ambient air. Chest examination revealed bilateral crackles. Laboratory evaluation noted normal platelet count, elevated D-dimer (5,876 ng/mL) and elevated C-reactive protein (21.7 mg/dL). Chest x-ray showed patchy opacification in the mid and lower lung zones bilaterally. He was treated with high-flow oxygen, Tocilizumab, Remdesivir and Dexamethasone. The hemoptysis resolved by day 2. On day 14, he was discharged on 3 L/min of supplemental oxygen.In both patients, chest CT angiography showed no evidence of acute pulmonary embolism. DISCUSSION: The pathogenesis of hemoptysis in COVID-19 is attributed to pulmonary embolism and/or alveolar destruction – the former being more common. Only 1–5 % of COVID-19 patients on hospital admission develop hemoptysis, with incidence as high as 13% in COVID-19 patients with concurrent pulmonary emboli. SARS-CoV-2 induces a pro-inflammatory and hypercoagulable state, thus increasing risk of thromboembolic events. Both of our patients had elevated D-dimer levels, but imaging showed no evidence of pulmonary emboli, thus suggesting alveolar destruction as the more likely cause of hemoptysis. Studies indicate that presentation with hemoptysis in COVID-19 patients increases the odds of severe illness 1.8-4.0 times. Host factors, such as presence and absence of comorbidities, likely played a significant role in determining disease severity/outcome for these patients. CONCLUSIONS: These cases highlight the relevance of recognizing hemoptysis as part of the clinical symptomology of COVID-19 pneumonia. REFERENCE #1: Peys E, Stevens D, Weygaerde YV, et al. Haemoptysis as the first presentation of COVID-19: a case report. BMC Pulm Med. 2020;20(275):1-4. https://doi.org/10.1186/s12890-020-01312-6 REFERENCE #2: Ozaras R, Uraz S. Hemoptysis in COVID-19: pulmonary emboli should be ruled out. Korean J Radiol. 2020;21(7):931-933. https://doi.org/10.3348/kjr.2020.0477 REFERENCE #3: Jiang F, Deng L, Zhang L, Cai Y, Cheung CW, Xia Z. Review of the clinical characteristics of coronavirus disease 2019 (COVID-19). J Gen Intern Med. 2020;35(5):1545-1549. doi:10.1007/s11606-020-05762-w DISCLOSURES: No relevant relationships by Oluwafemi Ajibola, source=Web Response No relevant relationships by Nneka Chukwu, source=Web Response No relevant relationships by Olushola Ogunleye, source=Web Response No relevant relationships by Hary Suseelan, source=Web Response

, caused by SARS-CoV-2 virus, has emerged as a leading cause of death globally. The most reported initial symptoms are cough, fever, dyspnea, and fatigue. Hemoptysis is atypical in COVID-19. We report cases of COVID-19 pneumonia presenting with hemoptysis in two unrelated men.

CASE PRESENTATION: Patient-I was a 60-year-old nonsmoker with no known comorbidities that tested positive for COVID-19 three days earlier. He presented with 10-day history of fever and cough with blood-streaked sputum that progressed to coughing frank blood. He was febrile (103.0 F) and saturating at 95% inspiring ambient air. Chest examination revealed crackles at the right lower lung field. Laboratory evaluation noted normal platelet count, elevated D-dimer (445 ng/mL) and elevated Creactive protein (17.2 mg/dL). Chest x-ray showed patchy opacification at the right mid and lower lung zones. He was treated conservatively. The hemoptysis resolved by day 2 and he was discharged on day 5.Patient-II, a 56-year-old former smoker with hypertension and diabetes, was diagnosed with COVID-19 twelve days earlier and developed acute hypoxic respiratory failure requiring a 5-day hospitalization at a different hospital. He presented with 2-day history of worsening shortness of breath and cough with bloody sputum. He was afebrile (98.9 F) and saturating at 67% inspiring ambient air. Chest examination revealed bilateral crackles. Laboratory evaluation noted normal platelet count, elevated D-dimer (5,876 ng/mL) and elevated C-reactive protein (21.7 mg/dL). Chest x-ray showed patchy opacification in the mid and lower lung zones bilaterally. He was treated with high-flow oxygen, Tocilizumab, Remdesivir and Dexamethasone. The hemoptysis resolved by day 2. On day 14, he was discharged on 3 L/min of supplemental oxygen.In both patients, chest CT angiography showed no evidence of acute pulmonary embolism.

The pathogenesis of hemoptysis in COVID-19 is attributed to pulmonary embolism and/or alveolar destructionthe former being more common. Only 1-5 % of COVID-19 patients on hospital admission develop hemoptysis, with incidence as high as 13% in COVID-19 patients with concurrent pulmonary emboli. SARS-CoV-2 induces a pro-inflammatory and hypercoagulable state, thus increasing risk of thromboembolic events. Both of our patients had elevated D-dimer levels, but imaging showed no evidence of pulmonary emboli, thus suggesting alveolar destruction as the more likely cause of hemoptysis. Studies indicate that presentation with hemoptysis in COVID-19 patients increases the odds of severe illness 1.8-4.0 times. Host factors, such as presence and absence of comorbidities, likely played a significant role in determining disease severity/outcome for these patients.

CONCLUSIONS: These cases highlight the relevance of recognizing hemoptysis as part of the clinical symptomology of COVID-19 pneumonia.

Haemoptysis as the first presentation of COVID-19: a case report

Hemoptysis in COVID-19: pulmonary emboli should be ruled out

Review of the clinical characteristics of coronavirus disease 2019 (COVID-19)