Jaclyn Kline MD, Children’s National Health System
Desiree Seeyave MD, Children’s National Health System

The Case
This is a case of an 11 year old with epilepsy who presented in respiratory distress with “bloody emesis.” The challenge of this case involves simultaneous management of respiratory distress while trying to differentiate hemoptysis and hematemesis.

Here’s How You Answered Our Questions

Denouement
The child was placed on high flow nasal cannula and admitted to the PICU. The Neurology service was concerned about his concurrent AOM and possible empyema, so a head CT was performed after admission to PICU, no intracranial process was discovered. The Pulmonary service was also consulted, and a CT of his chest performed.

The read of the chest CT showed: fluffy consolidation with air bronchograms primarily posteriorly involving the upper lobes bilaterally and the lower lobes bilaterally in the superior segments. No cavitation. No associated effusion or adenopathy. Findings were nonspecific with a differential diagnosis of bacterial pneumonia and aspiration.

He had another generalized seizure on HD2, and was loaded with fosphenytoin with cessation of seizures. His respiratory status worsened shortly after admission, and was placed on biPAP for less than 24 hours. He had no further episodes of hematemesis, and no further workup or management for this was done.

At the time of discharge, he was tolerating PO, at his neurologic baseline. His Trileptal dose was increased for his weight, and he was discharged with Neurology followup.

Teaching Points

• First differentiate hemoptysis from hematemesis.  See Desi’s comments for a great DDx.
• Dave’s statement was reinforced: “the stable hemoglobin, normal coags, normal albumin, and leukocytosis all point to something acute and not chronic.”
• Consider HFNC if respiratory distress worsens.  BiPAP is an option, but may be less desirable if there are concerns for aspiration.  Intubate if poor mental status or respiratory decompensation.