Hemoptysis in a patient with MDR-tuberculosis: successful diagnosis with photon counting CT and embolization of a Rasmussen aneurysm.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) remains a significant clinical challenge and may be complicated by life-threatening hemoptysis. One rare but serious cause of hemoptysis in TB patients is the development of pulmonary artery pseudoaneurysms, known as Rasmussen aneurysms, which typically arise within or adjacent to tuberculous cavitary lesions.

CASE PRESENTATION: We report the case of a 57-year-old male patient who was diagnosed with MDR-TB in July 2024, confirmed by phenotypic resistance against rifampicin and isoniazid. According to WHO recommendations treatment with the BPaLM regimen (bedaquiline, pretomanid, linezolid, and moxifloxacin) was initiated in early August 2024 and was administered according to an extended 9-month schedule due to clinical considerations. After approximately seven months of therapy, the patient was re-hospitalized in March 2025 due to hemoptysis. A thoracic photon counting CT scan revealed regressing bilateral cavitary lesions. During the same month, a pseudoaneurysm arising from a subsegmental pulmonary artery within a cavity-consistent with a Rasmussen aneurysm-was identified. Successful embolization of the feeding vessel was performed under angiographic guidance. Post-interventional bronchoscopy showed minimal residual bloody secretions at the embolization site but no evidence of active bleeding after thorough irrigation. At that time, pending cultures for M. tuberculosis finally converted negative. The patient recovered well, and no further hemoptysis occurred.

CONCLUSIONS: This case highlights the importance of considering Rasmussen aneurysms as a potential cause of hemoptysis in patients with cavitary MDR-TB, even several months after starting antibiotic therapy. Prompt imaging-based diagnosis and endovascular intervention are critical to avoid life-threatening complications.