C60-18 Multidisciplinary Management of Recurrent Massive Hemoptysis in an Adolescent: Endobronchial Vascular Lesion Missed by CT Angiography

Introduction Recurrent hemoptysis in children and adolescents is rare and prompts extensive evaluation for infectious, autoimmune, and vascular etiologies. Although computed tomography angiography (CTA) is often the first-line diagnostic test, certain lesions may elude detection, complicating diagnosis and management. This case illustrates the limitations of CTA and the importance of multidisciplinary collaboration in the management of recurrent massive hemoptysis in a pediatric patient. Case Description A 17-year-old male presented with recurrent, large-volume hemoptysis. He experienced intermittent episodes since age 12, with recent escalation in severity. Bronchoscopy by pediatric pulmonology demonstrated active right lower lobe (RLL) bronchus bleeding and a non-pulsatile mass. A bronchoscopy during an earlier admission localized bleeding to the same subsegment. Two CTA studies (June and August 2025) showed no evidence of pulmonary embolism, bronchial artery hypertrophy, or vascular malformation. Workup for systemic causes of hemoptysis was unrevealing: rheumatologic studies such as anti-neutrophil cytoplasmic (ANCA), anti-nuclear (ANA), and anti-glomerular basement membrane (anti-GBM) antibodies were negative; inflammatory markers were normal; echocardiogram revealed no evidence of mitral valve disease; and there were no skin findings or epistaxis to suggest hereditary hemorrhagic telangiectasia (HHT). Infectious evaluation during the prior admission revealed Staphylococcus aureus on bronchoalveolar lavage (BAL) without other pathogens. Multidisciplinary discussions with pediatric pulmonology, adult interventional pulmonology (IP), interventional radiology (IR), and pediatric critical care were held, but the absence of radiographic findings limited localization of a vascular source. Despite negative imaging, a vascular etiology remained highly suspected due to the focal, recurrent nature of bleeding. During a repeat bronchoscopy with biopsy by adult IP, the patient developed massive hemorrhage, requiring emergent intubation and bronchial blockade. IR angiography subsequently identified and embolized a markedly abnormal RLL bronchial artery with apparent communication to the pulmonary artery - findings absent on prior CTAs. Pathology confirmed a subepithelial bronchial artery along with mild acute inflammation with focal squamous metaplasia. The patient recovered fully without further bleeding. Discussion This case highlights the limitations of CT angiography in detecting small or subepithelial endobronchial vascular lesions, particularly when nonpulsatile and intermittently thrombosed. Despite two unrevealing CTAs and negative systemic workup, bronchoscopy accurately localized the bleeding site and guided definitive therapy. Multidisciplinary collaboration between pediatric and adult specialties was essential for diagnosis and successful management. Clinicians should maintain a high index of suspicion for vascular lesions in focal, recurrent hemoptysis, even when advanced imaging is unrevealing, and exercise caution with endobronchial biopsy in these scenarios.