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• W2893706877 abstract "To the Editor: Dieulafoy disease of the bronchus is a vascular anomaly characterized by an abnormally enlarged submucosal artery, sometimes crossing to the bronchial mucosa. It is usually diagnosed after spontaneous or iatrogenic hemoptysis, during the biopsy of bronchial lesions. Therefore, bronchoscopic identification is important to avoid bronchial biopsies that can lead to a life-threatening hemoptysis. Linear endobronchial ultrasound (EBUS) enables the real-time visualization of the structures surrounding the airways and Doppler examination may help the bronchoscopist to differentiate blood vessels from solid structures. We present a case where linear EBUS shows the clinical utility in the evaluation of bronchial alterations giving rise to suspicion of Dieulafoy disease and in the prevention of iatrogenic hemoptysis. A 67-year-old man presented with a history of dry cough and progressive dyspnea. He was a former smoker with occupational exposure to asbestos for 5 years. A chest computed tomography showed bilateral ground glass opacities, and signs of pulmonary fibrosis. He underwent a bronchoscopy. A rounded endobronchial lesion of 3 mm in diameter at the entrance to the middle lobe was observed. The lesion was not pulsatile or hyperascularized and had a smooth surface and a soft consistency (Fig. 1). A linear EBUS (Fujifilm EB-530US; Tokyo, Japan) showed an anechoic area circumscribed with arterial flow in Doppler images. In view of these findings, a biopsy was not performed (Fig. 2). Bronchial artery computed tomoangiography showed hypertrophy of the right bronchial artery with a tortuous pathway in the intermediate bronchus and the right lower lobe. Following consultation with the radiology team and the patient, bronchial artery embolization (BAE) was not performed as the patient was asymptomatic and the risks of the procedure may have outweighed any potential benefits.FIGURE 1: Bronchoscopy found a rounded endobronchial lesion located at the entrance to the ML (arrows). ML indicates middle lobe.FIGURE 2: Linear endobronchial ultrasound showed an anechoic area with Doppler ultrasounds highly suggestive of vascular structure at the entrance to the ML. ML indicates middle lobe.To our knowledge, this is the first case of Dieulafoy disease of the bronchus diagnosed as incidental finding where linear-EBUS examination helped the bronchoscopist to recognize suspicious vascular lesions and refrain from biopsying them. The diagnosis of the disease is confirmed on histologic examination of resected lung tissue. It is not known whether the origin of this vascular anomaly is congenital, acquired, or a variation of normal. A frequent presentation is spontaneous hemoptysis1 even though other patients may be asymptomatic, as happened in our case. The prevalence is unknown and probably underestimated, because bronchoscopic lesions may be located in the distal subsegmental bronchi or be surrounded by blood and clots if there may be significant prior hemoptysis. In incidental findings, the identification is crucial for the bronchoscopist to avoid biopsies that can lead to massive, sometimes fatal hemoptysis.2 A pulsatile or nonpulsatile sessile mass or nodule under the normal overlying mucosa, sometimes with a white cap,3 has been described in Dieulafoy disease. However, there is no pathognomonically distinct appearance in bronchoscopy.4 Gurioli et al3 evaluated a mucosal alteration of the bronchus with histology of Dieulafoy disease with linear-EBUS probe. Unlike in our case, linear EBUS was performed “a posteriori,” after biopsy with iatrogenic hemoptysis. In the management of the disease, conservative measures followed by BAE can control 90% of hemoptisis.5 Argon plasma coagulation can be a safe and effective treatment option in some cases.6 Surgery is the definitive treatment if BAE fails. The use of BAE has been described for the initial management of hemoptysis, but there is no experience with regard to its indication for treatment in patients in whom the lesion is found incidentally at bronchoscopy. It is reasonable to look for vascular malformations with bronchial artery computed tomoangiography in these cases and to inform the patient of the potential risks if a spontaneous hemoptysis should happen or a biopsy sample is taken during a bronchoscopic procedure. Furthermore, the patient should be aware of the potential complications of a BAE, some of which are very dangerous, such as the dissection of the subintimal layer of the aorta and spinal cord injuries that are related to the nonvisible anastomosis between the bronchial circulation and the anterior spinal artery. In our case, we decided not to perform BAE because the patient was asymptomatic, the probability of future bleeding was unknown, and BAE may be associated with potentially dangerous complications. In conclusion, linear EBUS with power-Doppler may be a good diagnostic tool in our clinical practice for determining the nature of an endobronchial lesion when it is suspected of being vascular in nature, allowing us to avoid life-threatening biopsies. BAE should be the first option in treating a massive hemoptysis with Dieulafoy disease but its indication in asymptomatic patients in whom Dieulafoy disease is an incidental finding at bronchoscopy is not yet clear. Elisa Mincholé, MD, PhD* Rosa M. Penin, MD, PhD†‡ Antoni Rosell, MD, PhD*‡§∥ Departments of *Respiratory Medicine †Pathology, Bellvitge Hospital ‡Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet of Llobregat ∥University of Barcelona (UB), Faculty of Medicine, Barcelona §CIBER of Respiratory Diseases (CIBERES), Bunyola, Mallorca, Spain" @default.
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• W2893706877 title "The Utility of Linear Endobronchial Ultrasound for the Incidental Finding of Dieulafoy Disease of the Bronchus" @default.
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