Hemoptysis and Lung Nodule • Xray of the Week
This 40 year old female presented with hemoptysis. What is the diagnosis?
Left image: CXR with mass in RUL
Right image: Coronal CT showing RUL mass with feeding artery and draining vein diagnostic of pulmonary AVM.
Video of pulmonary AVM in this patient, and a surprising second finding.
Pulmonary arteriovenous malformations (AVM) are caused by an abnormal connection between the pulmonary arterial system and pulmonary venous system due to a direct fistula between a branch of the pulmonary artery and a branch of the pulmonary vein. This is a rare anomaly with an incidence of approximately 2/100,000.
The patients may be seen with an incidental lung nodule. However, due to the right to left shunt, patients may present with shortness of breath, hemoptysis, or paradoxical emboli to the brain or elsewhere in the systemic circulation.
Pulmonary AVM's are associated with hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. Approximately a third of patients with a single AVM and up to half of patients with multiple AVM's have HHT.
On plain radiographs, the AVM's usually have the appearance of a nodule or multiple nodules. On CT scan, the nodule has a feeding artery and draining vein. Treatment options include percutaneous catheter directed embolization and surgical excision.
1. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998; 158(2): 643-61.
2. Remy-Jardin M, Dumont P, Brillet PY, Dupuis P, et. al. Pulmonary arteriovenous malformations treated with embolotherapy: helical CT evaluation of long-term effectiveness after 2-21-year follow-up. Radiology. 2006;239(2): 576-85.
3. Pulmonary Arteriovenous Malformations: Safety and Efficacy of Microvascular Plugs. AJR: 1135-1143. 10.2214/AJR.17.19200
4. Guttmacher AE, Marchuk DA, White RI Jr. Hereditary hemorrhagic telangiectasia. N Engl J Med. 1995; 333(14): 918-24.
5. Remy J, Remy-Jardin M, Wattinne L, Deffontaines C. Pulmonary arteriovenous malformations: evaluation with CT of the chest before and after treatment. Radiology. 1992; 182(3): 809-16.
Kevin M. Rice, MD is the president of Global Radiology CME and serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
Follow Dr. Rice on Twitter @KevinRiceMD
All posts by Kevin M. Rice, MD