Hemoptysis in a Patient With Cavitary Mycobacterium Avium Complex (MAC) Pulmonary Disease

Abstract Introduction: Hemoptysis frequently develops in patients with cavitary MAC pulmonary disease. Bronchial Artery Embolization (BAE) has been established as one of the useful treatments for massive and persistent hemoptysis. However, rebleeding can still occur. We present a case of hemoptysis in a female who had established cavitary MAC pulmonary disease. Case Presentation: A 64-year-old female with severe COPD, tobacco use, cavitary lung disease secondary to MAC on treatment with rifampin, azithromycin and ethambutol, chronic hypoxic respiratory failure, and chronic pulmonary embolism on warfarin presented with worsening shortness of breath and hemoptysis requiring intubation and admission to the intensive care unit. CT scan of the chest on presentation showed fluid with debris in the central and left lower lobe airways and aspiration pneumonia in the right lower lobe. Progression of the cavitary MAC disease was noted in the right lower lobe compared to the imaging performed a year ago. An urgent bronchoscopy was performed which revealed active bleeding originating in the left upper lobe airways. Tranexamic acid nebulization treatment was started. Patient was taken for embolization by interventional radiology after reversing the INR with fresh frozen plasma and vitamin K. Bronchial angiography revealed left bronchial artery at the approximately T6 level with tortuosity and likely bleed. Post embolization, no significant blood flow was noted. After the procedure, initially the bleeding improved, and respiratory status stabilized. However, a rebleed occurred the next day. Given her underlying severe COPD and advanced cavitary MAC lung disease, her family decided to pursue hospice care. Discussion: Cavitary MAC pulmonary disease is associated with hemoptysis. In advanced stages, the prognosis can be poor. Tranexamic acid nebulization can be used for mild hemoptysis episodes, whereas BAE is required if massive hemoptysis occurs. Our case demonstrates relative success of both treatments. However, clinical outcomes after BAE vary depending on the underlying lung diseases. There are limited studies regarding efficacy and safety of BAE for patients with bronchial bleeding due to cavitary MAC pulmonary disease. Further investigation is required to explore prevention of rebleed after BAE for MAC associated hemoptysis.