Hot Seat #151: 8 yo M coughing up blood
Posted on: May 9, 2020, by : Hilary Ong
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.
ROS:
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.
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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.
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.