A 36-year-old California man shocked the medical world after he was hospitalized for aggressive end-stage heart failure and coughed up a massive blood clot shaped like his lung.
On November 29, 2018, the New England Journal of Medicine reported the case and published images of the grotesque anomaly. The patient had been admitted to the intensive care unit (ICU) after his symptoms of chronic heart failure became much worse.
Due to the man’s history of poor cardiovascular health, a pacemaker had already been implanted as a precaution against total arterial blockage and heart failure. In the ICU, therapy to reduce blood clotting was administered.
Hemoptysis (airway bleeding that causes the coughing up of blood or blood-stained mucus) developed throughout the first week of the patient’s hospital stay. Caregivers increased the supply of supplemental oxygen to relieve the patient’s suffering.
During an especially violent coughing spell, the man expectorated a cast of his right lung’s bronchial tree composed of the trachea and the two primary bronchi. The tubes that make up the bronchial tree transport air to and from the lungs.
Doctors Gavitt A. Woodard, a clinical fellow in UCSF’s thoracic-surgery department, and Georg M. Wieselthaler, a transplant and pulmonary surgeon, both at the University of California, San Francisco, wrote up the singular case.
In the San Francisco ICU, Dr. Wieselthaler hooked up a ventricular-assist device, a pump that maximizes blood flow through the body, to relieve the patient’s failing heart. Chemicals that inhibit blood clotting were also administered because, as the surgeon explained:
“You have high turbulence inside the pumps, and that can cause clots to form inside. So with all these patients, you have to give them anticoagulants to make the blood thinner and prevent clots from forming.”
Anticoagulants are known to create additional medical problems because they prevent the lungs from stopping small fissures in the bronchial network that can introduce blood into places where it doesn’t belong.
Blood eventually broke out of the patient’s pulmonary network, leaked into his lower right lung, and filled the bronchial tree. The man had been coughing up smaller clots for days until, one day, he “bore down on a longer, deeper cough and, relieved, spit out a large, oddly shaped clot, folded in on itself.” Dr. Wieselthaler shared his professional reaction:
“We were astonished. It’s a curiosity you can’t imagine – I mean, this is very, very, very rare.”
Out of context, the bright red blood clot looks a lot like a chunk of reef coral. In reality, it was a complete casting created by coagulated blood that measured six inches wide in the perfect form of the right bronchial tree.
For the record, human lungs are too big to fit through the trachea so it is impossible to cough up an entire lung. But it is possible for an extreme bout of coughing to cause a lung to pop through the spaces between the ribs, from where those lung parts are subsequently coughed up.
Dr. Woodard, who helped Wieselthaler capture the image of the bizarre blood clot, speculated that the sheer size of the mass may have allowed the patient to cough it all up and out at once “because it was so large, he was able to generate enough force from an entire right side of his thorax to push this up and out. Had the clot fragmented into smaller pieces, “he might not have been able to generate the force.”
Although the patient gained instant relief after coughing up the blood clot, its size mirrored the severity of the situation. The two doctors had a breathing tube hooked up for their charge and stopped his bleeding with a more invasive surgical procedure. Unfortunately, due to the advancement of his disease, the Californian died a week later.
Some people may find the shocking image of the blood clot disturbing but Woodard and Wieselthaler published it to educate and inspire the public. Woodard explained:
“Recognizing the beautiful anatomy of the human body is the main point of it.”
More recently, in November 2019, a similar case involving a bronchial cast was reported in Britain. A 64-year-old man consulted his doctor about back pain and a fever. He was hospitalized with “profoundly low” blood pressure. Chest imaging showed a pulmonary embolism and rising fluid in his lungs.
Then, the patient began coughing blood. A bronchoscopy revealed a “large pale blood clot” that had conformed to the furcated shape of the bronchial tree lodged inside the man’s breathing tube. Several attempts to remove the blood clot with suction failed so the man was sedated and paralyzed for a surgical removal procedure.
Doctors at a London hospital run by Imperial College Healthcare noted that the man’s breathing was restored “immediately” – as published in BMJ Case Reports. However, the patient, who had already had a heart valve replacement, tested positive for bowel cancer, septic shock, and a powerful staph infection in his cardiac muscle.
The man’s family consented to have doctors switch off life support to end his suffering.