Can Hemoptysis Occur with Pulmonary Embolism?
Yes, hemoptysis (coughing up blood) can occur with pulmonary embolism, though it is relatively uncommon, occurring in approximately 11% of patients with confirmed PE. 1
Clinical Presentation and Frequency
Hemoptysis is a recognized symptom of PE, though it occurs less frequently than dyspnoea or chest pain:
- In patients with confirmed PE, hemoptysis occurs in 11% of cases 1
- Among patients without PE, hemoptysis is present in only 7%, making it somewhat specific when present 1
- PE is suspected on the basis of dyspnoea, chest pain, pre-syncope/syncope, and/or haemoptysis in most patients 1
- Cough develops in nearly half of patients with documented PE, and cough can occasionally be the presenting complaint 1
Pathophysiological Mechanism
The mechanism of hemoptysis in PE is well-characterized:
- Small distal emboli create areas of alveolar haemorrhage resulting in haemoptysis, pleuritis, and pleural effusion 1
- This clinical presentation is known as "pulmonary infarction" and is usually due to distal emboli causing pleural irritation 1
- The histopathological correlate is alveolar haemorrhage, which is only exceptionally associated with haemoptysis despite being improperly termed "pulmonary infarction" 1
- The effect on gas exchange is normally mild, except in patients with pre-existing cardiorespiratory disease 1
Clinical Significance
When evaluating patients with respiratory symptoms:
- Pleuritic chest pain combined with dyspnoea is one of the most frequent presentations of PE 1
- PE should be considered in patients with cough, particularly when accompanied by risk factors such as history of DVT/PE, immobilization in past 4 weeks, or malignancy 1
- The presence of hemoptysis increases the clinical probability of PE when combined with other symptoms and risk factors 1
Important Clinical Caveat
The coexistence of hemoptysis and PE creates a significant therapeutic dilemma, as hemoptysis may initially preclude systemic anticoagulation, which is the standard treatment for PE 2, 3, 4. In cases of massive hemoptysis with concurrent PE, bronchial artery embolization may be required first to control bleeding before anticoagulation can be safely initiated 3, 4, 5.