Hot Seat #151: 8 yo M coughing up blood

Posted on: May 9, 2020, by :

Hilary Ong, MD, Children’s National Medical Center

CC: Coughing up blood

HPI: 8yo boy with no past medical history, brought in for coughing up blood. He was in his usual state of health watching TV, when he felt a tickle in his throat, went to the bathroom and coughed up bright red blood and large blood clots. He then had subsequent multiple intermittent episodes of coughing up blood that self-resolved. Last episode of coughing up blood was 30 minutes ago. 

Denies any recent illness, URI symptoms. Denies eating or drinking any red-colored foods. No nose bleeds. No recent dental procedure. No recent trauma. No history of similar episodes. Denies taking any medications.


Constitutional: Denies fever  

Skin:  Denies rash, edema or bruising

ENMT: Denies epistaxis, sore throat, nasal congestion or rhinorrhea

Respiratory: Denies shortness of breath, cough, stridor, cyanosis, apnea or wheezing

Cardiovascular: Denies palpitations, syncope

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea or constipation.

Genitourinary: Denies hematuria or dysuria

Neurologic : Denies headache, dizziness or weakness. 

Hematologic: Denies bleeding tendency

PMH: None

Family Hx: No bleeding or hematologic or pulmonary disorders

Medications:  None.

Social history: Lives with parents and younger sibling

Vaccinations: UTD


PE: T 37.4 HR 95 RR25BP 105/89 SaO2 99% RA

General:  Alert.  Well appearing. NAD. Hoarse voice (not baseline).

Skin:  Warm.  Dry.  Intact.  No pallor.  No rash. No Bruising. No petechiae

Head: Normocephalic. Atraumatic

Neck:  Supple. Trachea midline. FROM. Mild swelling and tenderness over left sternoclenomastoid muscle. Bilateral anterior lymphadenopathy, that is < 0.5cm and nontender.

Eye:  Normal conjunctiva, PERLA, EOMI

Ears, nose, mouth and throat:  Nares clear. OP with mild erythema and +2 symmetric tonsils bilaterally with exudates. No active bleeding. No blood clots. Tympanic membranes clear.  Oral mucosa moist.

Cardiovascular:  Regular rate and rhythm.  2+ radial pulses. Cap refill <2sec 

Respiratory:  No tachypnea. No increase work of breathing. Clear lungs bilaterally.

Gastrointestinal:  Abdomen soft, non- distended, tympanic.

Musculoskeletal:  Moves all extremities

Neurologic: Alert, non-focal neurologic examination, talking in full sentences.

Mom shows you a video and you see that patient coughs and coughs up a handful of bright red blood with large blood clots

CBC, CMP, PT/PTT all WNL. CXR and lateral neck XR normal. GAS and COV-SAR test negative. Patient’s vital signs and exam stable. No further episode of coughing up blood in ED.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Hilary Ong

Pediatric Emergency Medicine Fellow at Children's National Health System
Hilary was born in Los Angeles, but grew up in Hong Kong. She then moved back to California for college and medical school. Academically, she is interested in disaster medicine and environmental exposures. Global health is also a strong interest of hers. She has done global health research projects in China and Mongolia. Outside of work, she likes to swim, enjoy good food, beer and coffee, and watch movies.
Hilary Ong

2 thoughts on “Hot Seat #151: 8 yo M coughing up blood

  1. With the picture evidence of a large clota and multiple episodes, I’m slightly concerned about an upper GI source. I have respect for variceal bleeders and gastric ulcers that can cause painless bleeding and lots of it. His first set of labs, H/H might be “high” if he’s hemoconcentrated from volume loss. Less likely but still on DDx are Mallory Weiss, posterior epistaxis (though usually there’s blood anteriorly). Without respiratory symptoms I suspect the cough is a red herring.
    Ideally, I’d make sure he has 2 lines and send a Type and cross and call GI. They’ll want a covid year before scoping.
    At the very least, would administer an H2 blocker, recommend observation and a repeat H and H at 6 hours before thinking about sending him home and strict instructions to parents to call 911 if it happens again.

  2. I agree with Maybelle. This isn’t some kid who coughed and had a tiny streak of blood come up. He coughed up clots of bright red blood. I am still worried that this is oncologic with spontaneous bleeding and palpable lymph nodes. Perhaps there is a juvenile angiofibroma somewhere in his nasopharynx. He’s in the right age range for that, though usually they present with nose bleeds. But that “tickle” in the back of his throat makes me think something started up high and dripped down and then he coughed it up.
    Definitely isn’t going home tonight. I would be hard pressed to decide who to consult–perhaps ENT if that is my concern? Or get more definitive imaging of this kids nasopharynx with CT.

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