Table: Some Causes of Hemoptysis-Merck Manual Professional Edition

Some Causes of Hemoptysis

Cause	Suggestive Findings	Diagnostic Approach*
Tracheobronchial source
Bronchitis (acute or chronic)	Acute: Productive or nonproductive cough Chronic: Cough on most days of the month or for 3 months per year for 2 successive years in patients with known COPD or smoking history	Acute: Clinical evaluation Chronic: Chest x-ray
Bronchiectasis	Chronic cough and mucus production in patients with a history of recurrent infections	High-resolution chest CT Bronchoscopy
Broncholithiasis	Calcified lymph nodes in patients with history of prior granulomatous disease	Chest CT Bronchoscopy
Foreign body (typically chronic and undiagnosed)	Chronic cough (typically in an infant or young child) without symptoms of an upper respiratory infection Sometimes fever	Chest x-ray Sometimes bronchoscopy
Tumor (bronchogenic, bronchial, metastatic, Kaposi sarcoma)	Night sweats Weight loss History of heavy smoking Risk factors for Kaposi sarcoma (eg, HIV infection)	Chest x-ray CT Bronchoscopy
Pulmonary parenchymal source
Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic) or mycetoma (including aspergilloma, fungus ball)	Fever, cough, night sweats, and weight loss in patients with known exposures Often history of immunosuppression	Chest x-ray Chest CT Microbiologic testing of sputum samples or bronchoscopy washings (may reveal diffuse alveolar hemorrhage)
Goodpasture syndrome	Fatigue Weight loss Often hematuria Sometimes edema	Urinalysis Creatinine levels Renal biopsy Antiglomerular basement membrane testing ANCA testing
Granulomatosis with polyangiitis	Often chronic, bloody nasal discharge and nasal ulcerations Often joint pain and skin manifestations (nodules, purpura) Gingival thickening and mulberry gingivitis Saddle nose and nasal septum perforation Sometimes renal insufficiency	Biopsy of any affected area (eg, kidney, skin) with ANCA testing and demonstration of vasculitis in small to medium-sized arteries Bronchoscopy (may reveal diffuse alveolar hemorrhage)
Lung abscess	Subacute fever Cough Night sweats Anorexia Weight loss Poor dentition	Chest x-ray or CT showing irregularly shaped cavity with air-fluid levels
Lupus pneumonitis	Fever, cough, dyspnea, and pleuritic chest pain in patients with a history of systemic lupus erythematosus	Chest CT (showing alveolitis) Sometimes bronchoscopy washings (showing lymphocytosis or granulocytosis or diffuse alveolar hemorrhage)
Pneumonia	Fever, productive cough, dyspnea, pleuritic chest pain Decreased breath sounds or egophony Elevated WBC count	Chest x-ray Blood and sputum cultures in hospitalized patients
Primary vascular source
Aortic aneurysm with leakage into the pulmonary parenchyma	Back pain	Chest x-ray showing widened mediastinum Chest CT angiography
Arteriovenous malformation	Presence of mucocutaneous telangiectasia or peripheral cyanosis	Chest CT angiography Pulmonary angiography
Elevated pulmonary venous pressure (especially in mitral stenosis, left-sided heart failure)	Crackles Signs of central or peripheral volume overload (eg, elevated neck veins, peripheral edema) Dyspnea while lying flat (orthopnea) or appearing 1–2 hours after falling asleep (paroxysmal nocturnal dyspnea)	ECG BNP measurement Echocardiography
Pulmonary artery rupture	Recent placement or manipulation of a pulmonary artery catheter	Emergency chest CT angiography or emergency pulmonary angiography
Pulmonary embolism, causing pulmonary infarction	Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known risk factors for pulmonary embolism	CT angiography or V/Q scanning Doppler or duplex studies of extremities showing findings of DVT
Tracheal-innominate artery fistula	Placement of tracheostomy tube within the previous 3 days to 6 weeks	Identifying hemorrhage from endotracheal tube in compatible clinical setting
Miscellaneous
Pulmonary endometriosis (catamenial hemoptysis)	Recurrent hemoptysis during menstruation	Sometimes therapeutic trial of oral contraceptives
Systemic coagulopathy or use of anticoagulants or thrombolytics	Patients receiving systemic anticoagulants for treatment of pulmonary embolism, DVT, or atrial fibrillation Patients receiving thrombolytics for treatment of stroke or myocardial infarction Sometimes a family history	PT/PTT or anti-factor Xa levels Cessation of hemoptysis with correction of coagulation deficit
* All patients with hemoptysis should have chest x-ray and pulse oximetry.
BNP = brain (B-type) natriuretic peptide; ANCA = antineutrophil cytoplasmic antibody; COPD = chronic obstructive pulmonary disease; DVT = deep venous thrombosis; PT = prothrombin time; PTT = partial thromboplastin time; V/Q = ventilation/perfusion; WBC = white blood cell.

Cause

Suggestive Findings

Diagnostic Approach*

Tracheobronchial source

Acute: Productive or nonproductive cough

Chronic: Cough on most days of the month or for 3 months per year for 2 successive years in patients with known COPD or smoking history

Acute: Clinical evaluation

Chronic: Chest x-ray

Bronchiectasis

Chronic cough and mucus production in patients with a history of recurrent infections

High-resolution chest CT

Bronchoscopy

Broncholithiasis

Calcified lymph nodes in patients with history of prior granulomatous disease

Chest CT

Bronchoscopy

Foreign body (typically chronic and undiagnosed)

Chronic cough (typically in an infant or young child) without symptoms of an upper respiratory infection

Sometimes fever

Chest x-ray

Sometimes bronchoscopy

Tumor (bronchogenic, bronchial, metastatic, Kaposi sarcoma)

Night sweats

Weight loss

History of heavy smoking

Risk factors for Kaposi sarcoma (eg, HIV infection)

Chest x-ray

Bronchoscopy

Pulmonary parenchymal source

Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic) or mycetoma (including aspergilloma, fungus ball)

Fever, cough, night sweats, and weight loss in patients with known exposures

Often history of immunosuppression

Chest x-ray

Chest CT

Microbiologic testing of sputum samples or bronchoscopy washings (may reveal diffuse alveolar hemorrhage)

Goodpasture syndrome

Fatigue

Weight loss

Often hematuria

Sometimes edema

Urinalysis

Creatinine levels

Renal biopsy

Antiglomerular basement membrane testing

ANCA testing

Granulomatosis with polyangiitis

Often chronic, bloody nasal discharge and nasal ulcerations

Often joint pain and skin manifestations (nodules, purpura)

Gingival thickening and mulberry gingivitis

Saddle nose and nasal septum perforation

Sometimes renal insufficiency

Biopsy of any affected area (eg, kidney, skin) with ANCA testing and demonstration of vasculitis in small to medium-sized arteries

Bronchoscopy (may reveal diffuse alveolar hemorrhage)

Lung abscess

Subacute fever

Cough

Night sweats

Anorexia

Weight loss

Poor dentition

Chest x-ray or CT showing irregularly shaped cavity with air-fluid levels

Lupus pneumonitis

Fever, cough, dyspnea, and pleuritic chest pain in patients with a history of systemic lupus erythematosus

Chest CT (showing alveolitis)

Sometimes bronchoscopy washings (showing lymphocytosis or granulocytosis or diffuse alveolar hemorrhage)

Pneumonia

Fever, productive cough, dyspnea, pleuritic chest pain

Decreased breath sounds or egophony

Elevated WBC count

Chest x-ray

Blood and sputum cultures in hospitalized patients

Primary vascular source

Aortic aneurysm with leakage into the pulmonary parenchyma

Back pain

Chest x-ray showing widened mediastinum

Chest CT angiography

Arteriovenous malformation

Presence of mucocutaneous telangiectasia or peripheral cyanosis

Chest CT angiography

Pulmonary angiography

Elevated pulmonary venous pressure (especially in mitral stenosis, left-sided heart failure)

Crackles

Signs of central or peripheral volume overload (eg, elevated neck veins, peripheral edema)

Dyspnea while lying flat (orthopnea) or appearing 1–2 hours after falling asleep (paroxysmal nocturnal dyspnea)

ECG

BNP measurement

Echocardiography

Pulmonary artery rupture

Recent placement or manipulation of a pulmonary artery catheter

Emergency chest CT angiography or emergency pulmonary angiography

Pulmonary embolism, causing pulmonary infarction

Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known risk factors for pulmonary embolism

CT angiography or V/Q scanning

Doppler or duplex studies of extremities showing findings of DVT

Tracheal-innominate artery fistula

Placement of tracheostomy tube within the previous 3 days to 6 weeks

Identifying hemorrhage from endotracheal tube in compatible clinical setting

Miscellaneous

Pulmonary endometriosis (catamenial hemoptysis)

Recurrent hemoptysis during menstruation

Sometimes therapeutic trial of oral contraceptives

Systemic coagulopathy or use of anticoagulants or thrombolytics

Patients receiving systemic anticoagulants for treatment of pulmonary embolism, DVT, or atrial fibrillation

Patients receiving thrombolytics for treatment of stroke or myocardial infarction

Sometimes a family history

PT/PTT or anti-factor Xa levels

Cessation of hemoptysis with correction of coagulation deficit

* All patients with hemoptysis should have chest x-ray and pulse oximetry.

BNP = brain (B-type) natriuretic peptide; ANCA = antineutrophil cytoplasmic antibody; COPD = chronic obstructive pulmonary disease; DVT = deep venous thrombosis; PT = prothrombin time; PTT = partial thromboplastin time; V/Q = ventilation/perfusion; WBC = white blood cell.