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Massive Hemoptysis Secondary to Fibrosing Mediastinitis in a Morbidly Obese Parturient
Abstract Number: S-48
Abstract Type: Case Report/Case Series
Abstract: We present a case of massive hemoptysis in a near-term parturient necessitating urgent delivery via Cesarean section under general anesthesia with a double lumen endotracheal tube.
Case: A 32yo HIV-negative G2P1 patient presented at 29 weeks gestation with hemoptysis. She had fibrosing mediastinitis secondary to pulmonary histoplasmosis. The patient was morbidly obese (BMI 58 kg/m2) and had obstructive sleep apnea.
New onset supraventricular tachycardia, treated with adenosine and labetalol, complicated the flexible bronchoscopy. Rigid bronchoscopy then revealed a normal left lung but copious amounts of blood and mucosal swelling in the right lung. Topical epinephrine controlled the bleeding and a left-sided double lumen tube was placed to protect the left lung. The patient was successfully extubated two days later. She was transferred to the antepartum unit with telemetry and daily fetal nonstress tests for the remainder of her pregnancy. At 36 weeks gestation, the patient had 3 hemoptysis episodes (EBL 750 mL) over 2 hours. An urgent Cesarean section was performed under general anesthesia with a double-lumen tube. Intraoperatively, she received 2 units PRBCs, 1 L crystalloid and 500 mL colloid with an EBL of 1 L. A male infant weighing 3.2 kg with Apgar scores of 5 and 7 at 1 and 5 minutes was delivered. The patient was hemodynamically stable throughout the procedure and was immediately transferred intubated to the invasive radiology suite for embolization of the right inferior phrenic and right internal mammary arteries. She was extubated POD 1 to room air and was discharged home POD 6 with her infant.
To date, the patient has had no further episodes of hemoptysis. While she has a chronic cough, she does not require oxygen at rest and has stable PFTs. The infant has normal development.
This is the first case report of fibrosing mediastinitis during pregnancy. Fibrosing mediastinitis is a rare, incurable disorder characterized by the development of excessive fibrous tissue in the mediastinum1. While its etiology remains unknown, it is most commonly associated with Histoplasma capsulatum infection in North America1. Hemoptysis occurs in 20% of fibrosing mediastinitis patients. Hemoptysis treatment options include arterial embolization, pulmonary resection, and external-beam radiotherapy2.
1. Peikert T, et al. Medicine. 2011;90:412-23
2. Crossno PF, et al. South Med J 2008;101:1056-8