Hemoptysis requiring bronchial artery embolization in patients with nontuberculous mycobacterial lung disease

This study was performed through a retrospective review of medical records at Ewha Womans University Mokdong Hospital, a tertiary referral hospital in Seoul, Korea. We reviewed 272 patients who had at least one NTM isolation in the sputum or bronchial lavage specimen culture between January 2006 and December 2016. Among them, 207 patients were diagnosed with NTM lung disease according to the ATS/IDSA diagnostic criteria [4]; 183 patients with available medical records were included in the final analysis. The enrolled patients were divided into two groups according to the occurrence of hemoptysis. Patients with hemoptysis received medical management when the amount of hemoptysis was low or vital signs were stable, and further management—such as bronchial artery embolization (BAE) and surgery—was considered if the hemoptysis persisted or the vital signs were unstable. We evaluated the development rate of hemoptysis, the characteristics of hemoptysis patients, and the complications that occurred among patients who underwent BAE.

Data for all enrolled patients were collected from the hospital’s electronic medical records. We recorded various demographic and comorbidity data, including sex, age, and body mass index, as well as the presence of diabetes mellitus (DM) and hypertension. We also noted the administration of antiplatelet and anticoagulation medication, which may be associated with hemoptysis. All enrolled patients underwent chest X-ray and chest computed tomography (CT) scans, which were reviewed retrospectively by the same chest radiologist (SS Shim). For the purposes of this study, we evaluated chest CT images from when hemoptysis was present for patients with hemoptysis; for patients without hemoptysis, we used the most recent follow-up chest CT images. Radiologic findings were classified as either nodular bronchiectatic type or fibrocavitary type. The extent of lung involvement was classified as either localized disease with involvement of 1 to 3 lobes or extensive disease with involvement of 4 to 5 lobes. Potential comorbidities were compared using the Charlson Comorbidity Index [10].

Hemoptysis was defined as the patient who underwent chest CT scan for hemoptysis evaluation. We excluded patients who did not undergo CT scan when defining hemoptysis. BAE was defined by actual embolizations; this definition did not include simple angiographies. The analysis included 33 consecutive patients who underwent BAE performed by two interventional radiologists (SY Choi, MW Kim). Medications, including antitussives, antibiotics, and tranexamic acid, were used for patients who had hemoptysis but did not undergo BAE.

Results for all continuous variables are reported as mean ± standard deviation, and all categorical variables are reported as numbers and percentages. Between groups, continuous variables were analyzed using t-tests, and categorical variables were analyzed using the χ² test and Fisher’s exact test. Multivariate analysis was performed using the results of initial univariate analysis and logistic regression. All statistical analyses were performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). In all comparisons, a P-value of < 0.05 was considered statistically significant.

The baseline characteristics of enrolled patients from January 2006 to December 2016 are summarized in Table 1. Among 183 patients, there were 74 males (40.4%), and the mean age at diagnosis was 62.9 ± 12.7 years. Mycobacterium intracellulare (n = 64, 35%) was the most frequent cause of NTM infection, followed by Mycobacterium avium (n = 59, 32.2%), MABSC (n = 40, 21.9%). Fiberoptic bronchoscopy was conducted on 53% of patients for the diagnosis of NTM infection or evaluation of hemoptysis. Patients with the nodular bronchiectatic type of NTM disease were more common than those with the fibrocavitary type (n = 155, 84.7% vs. n = 28, 15.3%, respectively). Of the 155 patients with nodular bronchiectatic NTM disease, 113 had localized disease, and 42 had extensive disease. Of the 28 patients with fibrocavitary NTM disease, 12 had localized disease, and 16 had extensive disease. During a mean follow-up period of 48.7 ± 37.8 months, 78 patients (42.6%) developed hemoptysis, and 33 of 78 (42.3%) developed hemoptysis requiring BAE. No patients underwent surgery to treat hemoptysis.

For comparison, enrolled patients were divided into two groups according to the occurrence hemoptysis (Table 2). There was no significant difference between the groups in terms of follow-up duration, the proportion of male sex, radiologic finding classification, extent of lung involvement, presence of pulmonary tuberculosis history, antiplatelet/anticoagulation therapy, and species of NTM. However, patients in the hemoptysis group tended to be younger than those without hemoptysis (mean age 65.7 ± 12.8 vs. 59.7 ± 11.8 years, P = 0.002). Additionally, patients without hemoptysis had a significantly higher DM prevalence than those with hemoptysis (18.1% vs. 7.7%, P = 0.043). In the multivariate analysis including sex, the presence of a pulmonary tuberculosis history, and variables with P-values < 0.1 from the univariate analysis, only age at diagnosis showed a statistically significant between-group difference (odds ratio: 0.969, 95% confidence interval: 0.944–0.996, P = 0.023).

Of 78 patients with hemoptysis, 33 patients received BAE, and 45 patients received medical treatment (Table 3). All patients who received BAE showed immediate clinical improvement, and there were no patients who required surgery for hemoptysis. Among patients with hemoptysis, those requiring medical therapy and those requiring intervention therapy with BAE were not significantly different in terms of demographic characteristics, radiologic findings, extent of lung involvement, and comorbidity index. Additionally, there were no procedure-related complications or deaths, and there was no hemoptysis-related mortality. Eight of the 33 patients who underwent BAE subsequently underwent repeat BAE due to rebleeding, and the median interval between first and second BAE was 10 months (interquartile range 7.5–53.5 month). Four patients experienced recurrent hemoptysis within 12 months after the first BAE, and three of them required more than two more BAEs (total 8, 5, and 5 BAEs, respectively). On the other hand, 12 out of the 45 patients who received medical therapy experienced recurrence of their hemoptysis. Recurrent hemoptysis in both groups was mainly the nodular bronchiectatic type. However, patients in the BAE group were mainly infected with MABSC, and patients who received medical treatment were mainly infected with Mycobacterium avium complex. Table 4 shows the clinical characteristics among recurrent hemoptysis patients after BAE and medical therapy.