Hemoptysis Causes

Aka: Hemoptysis Causes, Bloody Sputum Causes, Pseudohemoptysis, Pulmonary Hemorrhage Causes

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II. Causes: Respiratory Tract - Common

  1. Infection (60-70% of Hemoptysis in children; 18% in outpatient adults, 23% of inpatient adults)
    1. Acute Bronchitis (26% of Hemoptysis)
      1. Viral Bronchitis
      2. Streptococcus Pneumoniae
      3. HaemophilusInfluenzae
      4. Moraxella catarrhalis
    2. Pneumonia (10% of Hemoptysis)
      1. Staphylococcus aureus
      2. Pseudomonas aeruginosa
    3. Tuberculosis (0.2% of Hemoptysis in outpatient adults, 2.5% of inpatients, 65% in low resource countries)
      1. Nontuberculous Mycobacteria may also cause Hemoptysis
      2. Tuberculosis may cause spontaneous, massive Pulmonary Hemorrhage
    4. Influenza
    5. Leptospirosis
    6. Lung Abscess
    7. Fungal organisms (e.g. fungal ball or Mycetoma)
      1. Aspergillosis (most common of the fungal-related Pulmonary Hemorrhage Causes)
      2. Actinomycosis
      3. Blastomycosis
    8. Parasite Infections
      1. Paragonimiasis (trematode or fluke infection)
  2. Lung Cancer (7% of Hemoptysis in children, 4% in outpatient adults, 18% in inpatient adults)
    1. Hemoptysis is rarely due to metastases
    2. Bronchial Tumors
  3. Obstructive Lung Disease (6% of Hemoptysis in outpatient adults)
    1. Asthma
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Bronchiectasis (e.g. Cystic Fibrosis)

III. Causes: Respiratory Tract - Less Common

  1. Trauma
    1. Lung Contusion
    2. Airway Trauma (Hematoma, fistula)
    3. Airway Foreign Body (esp. children)
    4. Post-procedure (e.g. lung biopsy, heart catheterization, bronchoscopy)
  2. Cardiovascular causes
    1. Pulmonary venous Hypertension (Acute Pulmonary Edema)
      1. Congestive Heart Failure
      2. Severe Mitral valve stenosis
    2. Pulmonary Hypertension
    3. Bronchovascular Fistula
    4. Dieulafoy Lesion
    5. Pulmonary Embolism or infarction
    6. Aneurysm (e.g. thoracic artery, aorta)
    7. Arteriovenous Malformation
    8. Pulmonary artery rupture
    9. Systemic Coagulopathy
    10. Catamenial Hemoptysis (pulmonary Endometriosis)
    11. Endocarditis (right-sided)
  3. Rheumatologic causes
    1. Goodpasture's Syndrome (anti-glomerular basement membrane disease)
    2. Eosinophilic Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
    3. Lupus pneumonitis (Systemic Lupus Erythematosus)
    4. Idiopathic pulmonary Hemosiderosis
    5. Henoch-Schonlein Purpura
    6. Behcet Disease
    7. Takayasu Arteritis
    8. Sarcoidosis
    9. Antiphospholipid Syndrome
    10. Mixed cryoglobulinemia
  4. Other Lung and Tracheobronchal causes
    1. Bronchiectasis (e.g. Cystic Fibrosis)
    2. Broncholithiasis
    3. Acute Lung Allograft rejection
    4. Idiopathic pulmonary Hemosiderosis
    5. Pulmonary Capillary Hemangiomatosis
    6. Lymphangiomyomatosis
  5. Medications and Toxins
    1. Anticoagulation (e.g. Warfarin, DOACs)
    2. Antiplatelet agents (Clopidogrel, Aspirin)
    3. Thrombolytics
    4. Bevacizumab (Avastin)
    5. Cocaine Inhalation
  6. Hematologic
    1. Coagulopathy (e.g. Hemophilia, Von Willebrand Disease)
    2. Thrombocytopenia

IV. Causes: Pseudohemoptysis

  1. Non-lower respiratory tract sources
    1. Nasopharyngeal source of bleeding
      1. Evaluate for Oral Ulceration, Gingivitis, tongue Varices or other pharyngeal source
      2. Evaluate for Epistaxis or sinus drainage
    2. Upper Gastrointestinal Bleeding (Peptic Ulcer, Varices)
      1. Coffee ground Emesis or darker blood (contrast with frothy Bloody Sputum from the airway)
      2. Associated with gastrointestinal symptoms (e.g. Nausea or Vomiting)
      3. Evaluate for epigastric tenderness or stigmata of Chronic Liver Disease
  2. Other causes
    1. Malingering
    2. Serratia marecens
      1. Associated with recent hospitalization, broad spectrum Antibiotic use, or Mechanical Ventilation
      2. Gram Negative Bacteria produces a red pigment that may appear bloody
      3. Sputum exam negative for Red Blood Cells

V. Causes: Blood streaked Sputum

  1. Upper respiratory inflammation
    1. Nose or nasopharynx
    2. Gums
    3. Larynx
  2. Severe coughing paroxysms
  3. Trauma

VI. Causes: Pink Sputum

  1. Blood and secretions mix in alveoli, small Bronchioles
  2. Conditions associated with pink Sputum
    1. Pneumonia
    2. Pulmonary Edema

VII. Causes: Heavy Bleeding into respiratory tree (Massive Pulmonary Hemorrhage)

  1. Pulmonary Tuberculosis
  2. Lung Abscess
  3. Bronchiectasis
  4. Pulmonary Infarction
  5. Pulmonary Embolism
  6. Pulmonary artery rupture
  7. Arteriovenous Malformation
  8. Bronchogenic Carcinoma
  9. Broncholithiasis
  10. Mitral Stenosis
  11. Actinomycosis Lung Abscess
  12. Blastomycosis Lung Abscess

VIII. References

  1. John, Reeder and Thomas (2023) Crit Dec Emerg Med 37(12): 23-9
  2. Abdulmalak (2015) Eur Respir J 46(2): 503-11 [PubMed]
  3. Bhalla (2017) Int J Mycobacteriol 6(3): 307-10 [PubMed]
  4. Earwood (2015) Am Fam Physician 91(4): 243-9 [PubMed]
  5. Gagnon (2017) Can Respir J 2017:1565030 +PMID:29430203 [PubMed]
  6. O'Gurek (2022) Am Fam Physician 105(2): 144-51 [PubMed]
  7. Simon (2017) Pediatr Pulmonol 52(2):255-9 [PubMed]

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