Case Report

“A 70 Years Old Man Came in with Hemoptysis since 1 Day before

Admission”

By:
Nisa Auliya
M. Rasyid Ridho

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI, FINASIM

Moderator:
Kamila Auliya

Opponents:
1. Gregorius Abram N. 8. Nina Vella Rizky 16. Nadya Ayu S.
2. Efti Daiyah 9. Erentina Suarna P. 17. Shakti Swary
3. Khairunnisa 10. Allind Praditya R. 18. Khairinnisa
4. Sarah Amalia 11. Tri Wulandari 19. Jason Liando
5. Stevanus Handrawan 12. Rismitha Andini 20. Dhanty Mukhlisa
6. Aprilia Kartini 13. Sandra Magdalena D. 21. Ghiena Inayati A.
7. Muhammad Wasistha 14. Annisa Khaira N. 22. Albaroka
Adriantama 15. M. Mardian Safitra 23. Endy Averossely

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOHAMMAD HOESIN GENERAL HOSPITAL
2017
A 70 Years Old Man Came in with Hemoptysis since 1 Day before Admission
Nisa Auliya*, M. Rasyid Ridho*, Eddy M. Salim**
ABSTRACT
It was reported a case with hemoptysis at
RSMH. A 70 years-old man was admitted with a
chief complaint of hemoptysis since 1 day before
admission. Two months before admitted, patient
started to cough. There was clear sputum from the
cough and there was no blood. Difficulty of breath
(-). Chest pain (-). There was intermittent fever that
mostly appear at the night with the temperature was
not too high. Night sweats (+). Loss of appetite (+).
The patient went to get treatment to Puskesmas and
got Ambroxol and Amoxicillin but the symptoms was
not cure. One month before admitted, the cough was
still present. There was viscous yellowish sputum
from the cough and there was no blood. Difficulty of
breath (-). Chest pain (-). The intermittent fever that
mostly appear at the night with not too high
temperature was still present. Night sweats (+). Loss
of appetite (+). The patient said that he loss 4
kilograms of weight in one month. The patient did
not go to get treatment. One day before admitted, the
patient started to hemoptysis five times at home. The
amount of blood from each cough is ¼ of glass.
Sputum (-). There was no blood that coming out from
nose. Nusea (-). Vomitus (-). Difficult to breath (+).
The patient went to emergency unit of RSMH.
The patient was a smoker during 50 years
and has stopped smoking about 10 years ago. There
is no history of hypertension and diabetes mellitus on
this patient. There is family history of chronic cough
from his younger brother. Based on physical
examination, there was quick respiratory rate (29
x/minute), and there is ronkhi on left lung
auscultation.
The laboratory findings Hb: 14,0 mg/dl,
erythrocyte: 5,01x106, leucocyte: 11.400/mm3,
hematocrite: 42 %, DC : 0/0/80/12/8, ureum: 16
mg/dL, creatinine: 0,78 mg/dL, Na 142 mEq/L, K 4,2
mEq/L, Ca 9,3 mg/dL.
Keywords: hemoptysis, pulmonary tuberculosis
* Medical Student of Sriwijaya University, Clerkship Program
Moh.Hoesin General Hospital
** Staff of Allergy-Immunology Division of Internal Medicine
Department of Dr. Moh. Hoesin General Hospital
INTRODUCTION
1
Hemoptysis derived from the
tracheobronkial or pulmonary parenchyma. The
common causes are infections (pulmonary
tuberculosis, fungi), chronic bronchitis, pneumonia,
bronchiectasis, and lung tumors.1
Tuberculosis (TB), which is caused by
bacteria of the Mycobacterium tuberculosis complex,
is one of the oldest diseases known to affect humans
and a major cause of death worldwide. This disease
most often affects the lungs, although other organs
are involved in up to one-third of cases.2
Based on World Health Organization
(WHO) data in 2014, there were 9.6 million people
infected by Mycobacterium tuberculosis. The number
of cases of pulmonary tuberculosis in Africa is 37%
and in Southeast Asia is 28%.4 In Indonesia,
pulmonary tuberculosis is the third leading cause of
death after cardiovascular and respiratory diseases. In
South Sumatra, the number of tuberculosis cases in
2015 is 116 from 100,000 population. The death from
pulmonary tuberculosis in Indonesia is estimated at
61,000 deaths per year.3
M. tuberculosis is most commonly
transmitted from a person with infectious pulmonary
TB by droplet nuclei, which are aerosolized by
coughing, sneezing, or speaking. The tiny droplets
dry rapidly; the smallest (<5–10 μm in diameter) may
remain suspended in the air for several hours and
may reach the terminal air passages when inhaled.
There may be as many as 3000 infectious nuclei per
cough. The probability of contact with a person who
has an infectious form of TB, the intimacy and
duration of that contact, the degree of infectiousness
of the case, and the shared environment in which the
contact takes place are all important determinants of
the likelihood of transmission.2
Early in the course of disease, symptoms
and signs are often nonspecific and insidious,
consisting mainly of diurnal fever and night sweats
due to defervescence, weight loss, anorexia, general
malaise, and weakness. However, in up to 90% of
cases, cough eventually develops—often initially
nonproductive and limited to the morning and
subsequently accompanied by the production of
purulent sputum, sometimes with blood streaking.
Hemoptysis develops in 20–30% of cases, and
massive hemoptysis may ensue as a consequence of
the erosion of a blood vessel in the wall of a cavity.
Hemoptysis, however, may also result from rupture
of a dilated vessel in a cavity (Rasmussen’s
aneurysm) or from aspergilloma formation in an old
cavity. Pleuritic chest pain sometimes develops in
patients with subpleural parenchymal lesions or
pleural disease. Extensive disease may produce
dyspnea.2
The diagnosis of tuberculosis is determined
by anamnesis, physical examination, labotarorium
examination, and other investigation. From the
anamnesis, the patients usually complaint cough for
two weeks or more, sputum mixed with blood,
hemoptysis, difficulty of breath, body weakness, loss
of appetite, loss of weight, malaise, night sweats
without physical activity, and intermittent fever more
than one month. The risk factor can also be determine
during the anamnesis, for example the history of
family with tuberculosis.4 From physical
examination, pale conjunctiva, increasing body
temperature, and thin patient body may be found. If
there is a wide infiltrat in the lung, it can be detected
as dullness from lung percussion on the apex of the
lung and bronchial respiratory sound from lung
auscultation. Additional respiratory sound such as
rhonchi can also be detected. The most important
labotarorium examination is sputum examination, it
can evaluate whether the sputum contains
Mycobacterium tuberculosis or not. Sputum
examination can determine the diagnosis of
tuberculosis. The other investigation can also be
performed, such as radiology examination. Chest X-
ray can detect tuberculosis lession on lung. 5
Obat Anti Tuberkulosis (OAT) are the most
important component in tuberculosis treatment.
Tuerculosis treatment should always include initial
and advanced treatment. Initial treatment is given
everyday to reduce the amount of the Mycobacterium
tuberculosis. Initial treatment of all new patients,
should be given for two months. Meanwhile,
advanced treatment aims to kill the remaining
residual Mycobacterium tuberculosis that are still
exist in the body, so that it can prevent the
recurrence.4
CASE ILLUSTRATION
A 70 years-old man who lives in Lebong
Gajah, Sematang Borang, Palembang, was admitted
in Mohammad Hoesin General Hospital on the 28 th
July 2017 with a chief complaint of hemoptysis since
1 day before admission. Two months before
admitted, patient started to cough. There was clear
sputum from the cough and there was no blood.
2
Difficulty of breath (-). Chest pain (-). There was
intermittent fever that mostly appear at the night with
the temperature was not too high. Night sweats (+).
Loss of appetite (+). The patient went to get
treatment to Puskesmas and got Ambroxol and
Amoxicillin but the symptoms was not cure.
One month before admitted, the cough was
still present. There was viscous yellowish sputum
from the cough and there was no blood. Difficulty of
breath (-). Chest pain (-). The intermittent fever that
mostly appear at the night with not too high
temperature was still present. Night sweats (+). Loss
of appetite (+). The patient said that he loss 4
kilograms of weight in one month. The patient did
not go to get treatment.
One day before admitted, the patient started
to hemoptysis five times at home. The amount of
blood from each cough is ¼ of glass. Sputum (-).
There was no blood that coming out from nose.
Nusea (-). Vomitus (-). Difficult to breath (+). The
patient went to emergency unit of RSMH.
The patient was a smoker during 50 years
and has stopped smoking about 10 years ago. There
is no history of hypertension and diabetes mellitus on
this patient. There is family history of chronic cough
from his younger brother.
Based on the condition of the patient, he
was fully conscious, general appearance was
moderately sick with body weight 55 kg and height
165 cm, blood pressure 120/80 mmHg, pulse rate 84
x/minute regular, respiration rate 29 x/minute regular,
and body temperature 36.5oC. Physical examination
of the head, mouth, ears, throat, showed no
abnormalities, eyes upon inspection showed no
swelling at his eyelid with pale conjungtiva palpebra.
Physical examination of the neck showed no
enlargement of lymph nodes and jugular venous
pressure (5-2) cm H2O. The chest was symmetric
both in static and dynamic breathing. Tactile fremitus
was symmetric upon both lungs, vesicular sound was
normal, rales present on left lung and there was no
wheezing. For heart examination, ictus cordis was
neither visible nor palpable, upon percussion shows
normal result. On auscultation, heart sound AI<AII,
PI<PII, MI>MII, TI>TII normal, no murmur and no
gallop heard. Inspection on the abdominal region
showed no abnormalities. In abdominal percussion
there was no shifting dullness. On the palpation liver
and lien showed no abnormalities and normal bowel
sound was detected during auscultation. On the upper
extremities showed no swelling and lower extremities
negative pretibial edema.
 The laboratory findings Hb: 14,0 mg/dl,
erythrocyte: 5,01x106, leucocyte: 11.400/mm3,
hematocrite: 42 %, DC: 0/0/80/12/8, ureum: 16
mg/dL, creatinine: 0,78 mg/dL, Na 142 mEq/L, K 4,2
mEq/L, Ca 9,3 mg/dL. The sputum and thorax X-ray
examination is planned to be examined to support the
diagnosis.
The patient and the family were informed
about the aspect of non-pharmacological treatment,
patient was bed rest and the family who also had
chronic cough symptom was suggested to check the
sputum. The pharmacological treatment includes NS
0,9% gtt xx/minute, intravenous tranexamic acid
3x500 mg, and n-acetylcysteine 3x200 mg.
Differential diagnosis of hemoptysis ec. susp
pulmonary tuberculosis is hemoptysis ec. susp lung
tumor. The patient’s prognosis is quo ad vitam dubia
ad bonam, quo ad fungtionam dubia ad bonam, and
duo ad sanationam dubia ad malam.
DISCUSSION
Tuberculosis is a disease caused by germs
that are spread from person to person through the air.
Tuberculosis usually affects the lungs, but it can also
affect other parts of the body, such as the brain, the
kidneys, or the spine. A person with tuberculosis can
die if they do not get treatment.
Transmission of pulmonary tuberculosis
occurs because the germs are coughed or muddled
out into droplets nuclei in the air around us. These
infectious particles can settle in free air for 1-2 hours,
depending on the presence or absence of ultraviolet
light, poor ventilation and moisture. In a humid and
dark atmosphere, germs can last for days for months.
If the infection particles are sucked by a healthy
person, it will stick to the respiratory tract or lung
tissue. Particles can enter the alveolar when the
particle size is <5 micrometers. Germs will be first
encountered by neutrophils, then new by
macrophages. Most of these particles will die or be
cleared by macrophages out of the tracheobronchial
branches along with the cilia motion with the
secretions.
When germs settle in lung tissue, multiply in
macrophage cytoplasm. Here it can be carried into
other body organs. Germs that nest in the lung tissue
will take the shape of a nest of small pneumoni
tuberculosis and called Ghon Focus. When the
bacteria enter the pulmonary artery then the spread to
all parts of the lungs to TB billion.
3
The general symptoms of tuberculosis
disease include feelings of sickness or weakness,
weight loss, fever, and night sweats. The symptoms
of tuberculosis disease of the lungs also include
coughing, chest pain, and hemoptysis. Symptoms of
tuberculosis disease in other parts of the body depend
on the area affected. Presence of cough, especially
lasting 3 weeks or longer • Respiratory tract disease,
especially with involvement of the larynx (highly
infectious) • Failure to cover the mouth and nose
when coughing • Inappropriate or inadequate
treatment (drugs, duration).
People with latent tuberculosis infection
have tuberculosis germs in their bodies, but they are
not sick because the germs are not active. These
people do not have symptoms of tuberculosis disease,
and they cannot spread the germs to others. However,
they may develop tuberculosis disease in the future.
They are often prescribed treatment to prevent them
from developing tuberculosis disease.
People with tuberculosis disease are sick
from tuberculosis germs that are active, meaning that
they are multiplying and destroying tissue in their
body. They usually have symptoms of tuberculosis
disease. People with tuberculosis disease of the lungs
or throat are capable of spreading germs to others.
They are prescribed drugs that can treat tuberculosis
disease.
A person with latent tuberculosis infection
cannot spread germs to other people. You do not need
to be tested if you have spent time with someone with
latent tuberculosis infection. However, if you have
spent time with someone with tuberculosis disease or
someone with symptoms of tuberculosis, you should
be tested.
People with tuberculosis disease are most
likely to spread the germs to people they spend time
with every day, such as family members or
coworkers. If you have been around someone who
has tuberculosis disease, you should go to your
doctor or your local health department for tests.
There are tests that can be used to help
detect tuberculosis infection: a skin test or
tuberculosis blood tests. The Mantoux tuberculin skin
test is performed by injecting a small amount of fluid
(called tuberculin) into the skin in the lower part of
the arm. A person given the tuberculin skin test must
return within 48 to 72 hours to have a trained health
care worker look for a reaction on the arm. The
tuberculosis blood tests measures how the patient’s
immune system reacts to the germs that cause
tuberculosis. Sputum examination is important
because with the discovery of BTA germs,
tuberculosis diagnosis can be ascertained. In addition,
sputum examination can also provide an evaluation
of treatment that has been given
A positive test for tuberculosis infection
only tells that a person has been infected with
tuberculosis germs. It does not tell whether or not the
person has progressed to tuberculosis disease. Other
tests, such as a chest x-ray and a sample of sputum,
are needed to see whether the person has tuberculosis
disease.
BCG is a vaccine for tuberculosis disease.
BCG is used in many countries, but it is not generally
recommended in the United States. BCG vaccination
does not completely prevent people from getting
tuberculosis. It may also cause a false positive
tuberculin skin test. However, persons who have been
vaccinated with BCG can be given a tuberculin skin
test or tuberculosis blood test.
In this case report, patient came with
hemoptyis, as known it is an abnormal coughing
symptom. Hemoptyis can occur due to various
conditions such as infection (tuberculosis,
bronchiectasis, lung abscess, and mycetoma),
neoplasma (bronchogenic carcinoma), cardiovascular
problem (pulmonary infarction, pulmonary edema,
and mitral stenosis). Based on the anamnesis,
hemoptysis in this patient occured five times in one
day, was not contain sputum. The amount of blood
from each cough is about ¼ glass. There was no
nausea and vomitus. In physical findings there was
no blood clot in the nose. From the patient history it
has known that the patient had chronic cough. Night
sweats (+). Loss of appetite (+). Loss of weight (+).
Hemoptysis on this patient was most probably caused
by pulmonary tuberculosis.
Haemoptysis is a blood expectoration
derived from the lower airway (under the vocal
cords). Because basically the process of tuberculosis
is a process of necrosis, if between the necrotizing
tissue there is a blood vessel, it is likely that the
patient will have coughing up blood, which can range
from infrequent Once until often / every day. Another
variation is the amount of blood coughed out from
very little (in the form of lines on the sputum) to the
great number (profus), depending on the affected
blood vessels.
Hemoptysis will endanger the psyche if it is
profus, as it can cause death by shock and acute
anemia. In addition, blood to be coughed out will
involve in the trachea / larings and will cause acute
asphyxia which can be fatal.
For a minimal cough of blood to somewhat,
can be given coagulant and / or thrombolytic drugs
4
(tranexamic acid) alone. If the bleeding is rather
severe, consideration should be given to fresh blood
transfusions. If this is often repeated, it should also
be considered lobectomy or arterial embolization,
which becomes a problem.
In the acute stage until a few days thereafter,
it should also be given antitussives to prevent
coughing, should also be given antitusif to prevent
cough, at least reduce the frequency of cough to give
a sufficient opportunity to rest for the lesion, until the
thrombus formed strong enough.
Haemoptysis is said to be massive when a
blood cough reaches> 600 ml of blood in 24 to 48
hours.
From the laboratory findings, the leucocyte,
was increase. From the the white blood cell
differential count there was an increasing of neutrofil
and monocyte. This findings points out that there is
an on-going infection.
On Radiology findings, the most suspected
site of pulmonary TB lesions is the apex (peak) of the
lung. In auscultation, only wet ronki will be found as
the only abnormality of physical examination. When
suspected of a rather broad infiltrate, percussion is
obtained that dim, fremitus strengthened and
auscultation of bronchial breath sounds.
When the cavity has occurred, will be found
cavitary symptoms, a tympani voice in percussion
accompanied by the sound of amorphous breath.
Conversely, if atelectasis occurs, for example in
"destroyed lung", the sound of local breath will
weaken until it disappears altogether.
In general, will always be obtained wet
rhonchi remember that always also formed sekret and
nekrotik network. The more the secretions and the
bigger the bronchi where the secret is, the more
rough it becomes. Seeing all this, it is increasingly
apparent that the abnormalities found in TB are
highly variable, of either type, intensity, number or
place of discovery (pleiomorfi).
Differential diagnosis of hemoptysis ec.
pulmonary tuberculosis is hemoptysis ec. lung tumor.
Prognosis is quo ad vitam dubia ad bonam, quo ad
fungtionam dubia ad bonam, quo ad sanationam
dubia ad malam. Management for suspected
pulmonary tuberculosis patients consists of
pharmacology and non-pharmacological therapy.
Non-pharmacological therapy includes education for
the patient family whom also had chronic cough to
get sputum examination. Bed rest is recommended as
one of non-pharmacological management. The
pharmacological therapy includes NS 0,9% gtt
xx/minute, intravenous tranexamic acid 3x500 mg, n-
acetylcysteine 3x200 mg, intravenous ceftriaxon
2x500 mg.

CONCLUSION
We have discussed a case of hemoptysis ec.
susp pulmonary tuberculosis in a 70 year old, male
patient who also had chronic cough that has been
going on for two months, intermittent fever (+), night
sweats (+), loss of appetite (+), loss of weight (+).
Family history chronic cough came also from brother.
Rhonchi (+) on the left lung.

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