Hot Seat #151. Denouement

Posted on: May 14, 2020, by :

The case: 8 yo M coughing up blood with overall normal exam and normal labs.

Here’s how you answered the questions:

Less than 3 years PEM experience differential:
-Tonsilitis
-Occult Airway trauma
-Infection (TB aspergillosis)
-Mass
-ALL
-Bleeding/clotting disorder
-Foreign Body
-AVM
-Vasculitis
More than 3 years PEM experience differential:
-Upper GI bleed/ulcer
-Pulmonary Infection
-Mass
-Bleeding/clotting disorder
-Foreign Body
-AVM
-ALL
-TB
-Vasculitis

Discussion: The differential for this otherwise healthy child coughing up blood clots is broad: infectious (tonsilitis, TB, aspergillosis), oncologic, vasculitis, vascular malformation, and mechanical/foreign body. In a well appearing child with negative review of systems, everyone would still obtain labs and imaging given the history of coughing up clots of blood. Most agreed that basic screening labs – CBC, coags, CMP, type and screen – were warranted as initial labs and CXR and neck film for imaging. Beyond initial screening labs and imaging, some would also obtain quantiferon gold and consider a CT with contrast to evaluate for the source of bleeding.

With a negative work up that does not reveal the source of bleeding, respondents were split between next steps. A minority would send home, while the majority would consult pulmonology or ENT to consider additional work up to evaluate for the source of the bleeding.

Denouement: After reviewing guardian’s cell phone video of his hemoptysis, Pulmonary admitted for observation with planned ENT beside flexible laryngoscope, possible bronchoscopy and/or endoscopy with Gastroenterology. Laryngoscope revealed small posterior pharyngeal clot with no signs of active bleeding and unknown source of bleeding. No bronchoscopy or endoscopy was performed during hospitalization. Patient was well appearing with no further episodes of hemoptysis and stable repeat CBC before discharge. 

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.

Mary Beth Howard

Pediatric Emergency Medicine Fellow at Children's National Health System
Mary Beth Howard

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