Introduction: TB remains a major global cause of hemoptysis. Coinfection with aspergillosis is rare and may be underdiagnosed, especially outside endemic regions. When combined, TB and invasive fungal infection can cause massive hemoptysis, which may be fatal without timely intervention. Identifying the bleeding source is often difficult, even with CT angiography and bronchoscopy, requiring close monitoring and conservative management. We report a case of massive hemoptysis due to TB and aspergillosis, complicated by anticoagulation started for initial presentation of embolism. Description: A 29-year-old male presented with 1 month of dyspnea, hemoptysis, fever, and weight loss, CT chest revealed RUL segmental PE, b/l ground-glass opacities and bronchiectasis. He was started on heparin and antibiotics. In 24 hours, he developed acute respiratory failure with massive hemoptysis, endotracheal tube obstruction by blood, a significant hemoglobin drop with hypotension requiring vasopressors, transfusion and emergent bronchoscopy. Clots were seen bilaterally, predominantly from the right, though no clear source was identified. Clots were later shifted to the right to continue ventilate the left lung. Repeat bronchoscopy cleared the clots and re-expanded the right lung. Microbiologic workup was positive for TB PCR, fungitell, and galactomannan EIA, confirming TB and invasive fungal infection with bleeding likely worsened by anticoagulation. Initiation of voriconazole, RIPE therapy, and stress-dose steroids led to clinical improvement, along with iv and inhalational trenexemic acid. Patient improved, extubated and was followed up with public health for continuation of TB treatment. Discussion: TB-Aspergillosis co-infection is rare without immune compromise, but should be considered in patients with massive hemoptysis, fever, and weight loss. 90% cases of massive hemoptysis originate from bronchial artery, but literature suggests pulmonary arterial source is also important in patients with fungal infection. CT and fiberoptic bronchoscopy have similar yields, but in life-threatening massive hemoptysis, FOB is the first-line management. Shock, contralateral lung aspiration and blood transfusion needs increase mortality, highlighting the need for prompt source control and treatment with antibiotics and steroids.
Trivedi et al. (Sun,) studied this question.