Cite this article: Guerron AD, Raymond DP (2017) An Unusual Case of Hemoptysis. JSM Cardiothorac Surg 2(1): 1008. Central Bringing Excellence in Open Access   JSM Cardiothoracic Surgery *Corresponding author Da nie l P Ra ymo nd , De p a rtme nt o f Tho ra c ic a nd C a rd io va sc ula r Surg e ry, He a rt a nd Va sc ula r Institute , C le ve la nd C linic Fo und a tio n, C le ve la nd , O hio 44195, USA, Te l: 216-636-1623; Ema il: Submitte d: 11 April 2017 Accepted: 24 April 2017 Publishe d: 25 April 2017 ISSN: 2378-9565 Copyright © 2017 Ra ymo nd e t a l. OPEN ACCESS Ke ywo rds • He mo p tysis • Surg ic a l b uttre ss • Fo re ig n b o dy Case Report An Unusual Case of Hemoptysis Alfredo D. Guerron 1 and Daniel P. Raymond 2 * 1 Department of General Surgery, Duke University Health System, USA 2 Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, USA Abstract The patient is a 63-year-old with a history of histoplasmosis who has undergone two prior thoracotomies for diag-nostic wedge resection revealing granulomatous lesions. She presented with hemoptysis and underwent two embo-lization procedures providing temporary control of her hemoptysis. Radiologic examinations revealed a large cavitary partially calcifed mass in the right lower lobe. Due to high risk of recurrent bleeding she underwent right lower lobectomy which ultimately revealed an infamma-tory, cavitary mass surrounding surgical felt. The material had been placed to buttress a parenchymal suture line and had eroded into the pulmonary parenchyma and hilar vasculature resulting in hemoptysis. Retained surgical material is a rare cause of hemoptysis. We present a case of massive hemoptysis due to retained surgical material resembling a cavitary lesion. BACKGROUND Massive hemoptysis is a life-threatening condition. It can cause sudden airway or hemodynamic compromise. Despite adequate treatment, relapses are unpredictable. Localized lesions require pulmonary resections for optimal treatment. Concern for bronchopleural fistulas prompted the use of devices and synthetic materials to avoid this complication. Erosion of foreign materials or retained materials is a known complication in surgical procedures. Retained materials often resemble cavitary lesion or other pulmonary pathology. We present a case of a surgical buttress material presenting as a cavitary lesion eroding into the parenchyma of the lung trigering massive hemoptysis. CASE PRESENTATION The patient is a 63-year-old female 25 pk-yr former smoker who had previously undergone bilateral thoracotomies (right 1997; left 2007) for diagnostic wedge resection ultimately demonstrating caseating granulomatous inflammation. She was treated for histoplasmosis after each event although cultures and staining did not reveal fungal organisms. She was subsequently followed with serial imaging due to waxing and waning pulmonary nodules as well as a partially calcified right lower lobe cavitary mass, which demonstrated slow, progressive enlargement over more than 10 years (3 x 3.5 cm in 2004 to 3.7 x 4.3 in 2013). Due to the increase in size of the nodule she underwent bronchoscopy evaluation including on 6/19/13 including BAL, brushings, and fluoroscopically guided needle aspiration biopsy. There was distortion of the RLL bronchus and complete occlusion of superior segment of right lower lobe (RLL) due to a calcified lymph node. Final pathologic and microbiologic analysis was completely negative for malignancy or identifiable organisms. The patient was subsequently admitted to the hospital on 7/16/13 due to an episode of hemoptysis estimated at 300 mL. She was clinically stable and was admitted to the ICU. She subsequently underwent bronchial artery embolization to a hypertrophied RLL bronchial artery, no active extravasation was identified during the procedure. Approximately 24 hours later, the patient had another large volume event, she was intubated for airway protection and transferred to our institution for further evaluation. She was stable upon arrival and underwent emergent pulmonary arteriogram and bronchial arteriogram. There were no pulmonary artery abnormalities identified and no evidence of bronchial artery extravasation. An upper lobe bronchial artery was embolized due to a focal 6 mm hypervascular nodule. The patient was subsequently extubated. Due to the presence of the cavitary lesion and the potential for future, life-threatening events the patient was counseled to undergo urgent right lower lobectomy. The patient subsequently underwent redo right thoracotomy and right lower lobectomy during the same hospital admission. Intraoperative findings include dense pleural adhesions and multiple calcified, hilar lymph nodes. Following lobectomy, the specimen was incised on the back table to obtain a microbiologic specimen and a 4.5 cm x 2 cm piece of surgical felt was removed from the cavity (Figure 2). The felt was covered with a purulent exudate and appeared to have eroded into the central hilar structures resulting in hemoptysis. Pathologic evaluation of the lung revealed a 4 cm bronchiectatic cavity consisting of a dilated and heavily inflamed bronchus with extensive squamous