Abstract Introduction Hemoptysis is the expectoration of blood from the lower respiratory tract, while pseudohemoptysis-bleeding from the upper airway, nasopharynx, or GI tract-may mimic it. Accurate localization is key to guiding diagnosis and treatment. Case Presentation 18-year-old male with exercise-induced asthma, repaired cleft palate and anxiety presented to the ED with recurrent hemoptysis. ED staff and parents observed repeated hemoptysis with clots. CTA chest, echocardiogram, autoimmune-vasculitis panel, TB QuantiFERON GOLD, and fungal serologies were negative. Bronchoscopy (FB) showed no lower respiratory bleeding. He was discharged but returned a month later after recurrent hemoptysis and epistaxis, including a large-volume episode at school. Repeat FB showed no active bleeding and minimal hemosiderin-laden macrophages on bronchoalveolar lavage. Laryngoscope did show evidence of possible nasopharyngeal reflux (NPR) secondary to velopharyngeal insufficiency (VPI). Subsequent esophagogastroduodenoscopy (EGD) identified two Forrest Grade III gastric ulcers. The patient was initiated on proton pump inhibitor therapy, with symptomatic improvement. Discussion This case highlights the diagnostic challenge of recurrent hemoptysis-like symptoms in the absence of a pulmonary source. The patient consistently reported “coughing up blood” and epistaxis witnessed by parents, nurses and physicians, yet multiple FBs, cross-sectional imaging, and serologic evaluations were negative. EGD revealed gastric ulcers despite a lack of typical gastrointestinal symptoms. ENT evaluation raised concern for VPI, a known complication of cleft palate repair, that may allow nasopharyngeal reflux of blood or secretion, mimicking hemoptysis or epistaxis. This case underscores the importance of considering pseudohemoptysis in patients with surgically altered upper airway anatomy and entertaining extra-pulmonary sources of bleeding. Differentiating among hemoptysis, hematemesis, and nasopharyngeal bleeding requires detailed clinical history, anatomical insight, and procedural correlation. When conventional pulmonary work-up is unrevealing, a multidisciplinary approach becomes essential. In such cases, early consideration of GI and ENT source evaluation can help prevent unnecessary pulmonary interventions and guide effective management. This abstract is funded by: None
Reddy et al. (Fri,) studied this question.