HEMOPTYSIS AS PRIMARY MANIFESTATION IN A WOMAN WITH CHORIOCARCINOMA WITH PULMONARY METASTASIS

ABSTRACT

SESSION TITLE Systemic Diseases Causing Pulmonary Havoc SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 1015 am - 1110 am INTRODUCTION: Choriocarcinoma is the most common type of gestational trophoblastic neoplasm (GTN) and can occur in association with any pregnancy [1]. The main risk factors are advanced or very young maternal age, ethnicity, ectopic pregnancy, abortion, and prior molar pregnancy. The most common sites of choriocarcinoma metastasis are lungs, liver, and brain [2]. This case describes a patient with choriocarcinoma that presented with hemoptysis. CASE PRESENTATION The patient is a 22 year-old G2P1 female presenting at 36 weeks-gestation with one week of hemoptysis. She denied any other symptoms. On presentation, she was tachycardic. Physical examination demonstrated bibasilar crackles. Admission chest x-ray revealed diffuse bilateral infiltrates (Fig 1). Hs-troponin was elevated to 144 ng/L;however, EKG did not show ischemic changes. Cultures were obtained prior to empirically initiating antibiotics. Despite antibiotic treatment, hemoptysis worsened over her course and oxygen requirements increased. Infectious workup was negative. CT obtained for pulmonary embolism revealed bilateral patchy airspace opacities in lungs, suspected due to multifocal pneumonia (Fig 2). AFB smear and quantiferon were negative. After an emergent C-section for increased oxygen requirements, bronchoscopy with BAL was obtained and demonstrated diffuse alveolar hemorrhage. BAL was only positive for mildly increased CD4CD8 ratio. Transbronchial biopsy was aborted due to bleed risk. Subsequent right lobe wedge biopsy confirmed metastatic choriocarcinoma. Her serum human chorionic gonadotropin (ß-hCG) level was found to be 20,713 milli-international units/mL. DISCUSSION: The etiology of hemoptysis was initially thought to be secondary to pneumonia. Differential diagnoses also included an acute COVID infection, alveolar hemorrhage, tuberculosis in a recently-immigrated patient, myocarditis, autoimmune etiology, and malignancy. Patient's risk factors included a prior miscarriage. Rarely, bleeding can occur as a result of metastatic lesions and may result in abdominal pain, hemoptysis, melena, or evidence of increased intracranial pressure from intracerebral hemorrhage [2]. Patients, such as the one described in this case, can exhibit pulmonary symptoms of dyspnea, cough, and chest pain caused by lung metastases. Upon closer examination of the CT scans, several of the opacities are nodular and consistent with GTN. Patients treated with surgery, chemotherapy, or a combination of both demonstrated similar treatment outcomes;chemotherapy may still be the preferred option. The overall cure rate in treating these tumors is currently > 90% [2]. CONCLUSIONS: GTN, although rare, should be considered as a differential diagnosis in women with a pregnancy history and risk factors that present with the primary symptom of hemoptysis. High index of suspicion and awareness of these neoplasms are necessary for timely diagnosis. Reference #1 Savage P. Winter M. Parker V. et al. Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma a UK population study. BJOG. 2020;127 1102-1107 Reference #2 Lurain, J., 2010. Gestational trophoblastic disease I epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology, 203(6), pp.531-539. DISCLOSURES No relevant relationships by Crystal Ajja No relevant relationships by Heba Osman No relevant relationships by James Rowley