대한흉부영상의학회 월례집담회 증례발표 January 2019 분당서울대병원 신 윤 주

58/M C.C.: Blood tinged sputum and dyspnea after strenuous exercise PMHx.: none

2010-07-20 outside chest CT

2010-08-06 Chest CT (contrast) + 3D

Bronchoscopy (2010-11-03) Title

Bronchoscopy (2010-11-03) Bronchial washing negative CT상 bleeding focus및 endobronchial lesion이 의심되었던 LLL posterobasal segment중 LB10의 subsegemental branch에서 hemoptysis가 관찰되나 특별한 endobronchial lesion은 관찰되지 않았음. Bronchial washing, "LLL basal", all negative - Cytology: Negative for malignant cells - Gram stain: Rare(<1) WBC , No Bacteria - 일반미생물: no microorganism isolated - M. tuberculosis Complex: Negative for M.tuberculosis

2015-11-26 Chest HRCT 2015-11-26

2018-12-19 chest HRCT 2018-12-19

Title 2015-11-26 Chest HRCT 2018-12-19 chest HRCT CBC including eosinophil count, coagulation lab, sputum culture: all negative

58/M C.C.: Blood tinged sputum and dyspnea after strenuous exercise (*amateur marathoner) PMHx.: none

Hospital course 2010-07-20: 마라톤 운동. 2년전부터 호흡이 답답함, 정상운동을 과하게 하면 호흡곤란 증가, 간혹 혈담 2010-08-03: hemoptysis 는 없음 2010-11-02: 최근 운동하면서 마라톤 후 혈담, 이후 호전 2010-11-23: no hemoptysis기침, 가래 2015-11-24: 심한 운동후 : 마라톤, 산악 마라톤 : 100 k 울트라 혈담이 간혹 나옴 : 22일 2018-12-11: 그동안 운동을 계속함, 울트라 마라톤 100km, 9월 300km 달리는 중 심하게 운동하면 BTS, 이후 서서히 감소함, 대회 중 BTS 2019-01-10: 울트라 마라톤 100km, 하루 15-20km, 강도가 낮아 혈담 -

over 5-6km/hr

Exercise-Induced Pulmonary Hemorrhage (EIPH) Occurs frequently in Thoroughbred horses; almost all thoroughbreds demonstrate bleeding in the lower respiratory tract after a race. Lung 2006; 184:331–333, Tuberc Respir Dis 2015; 78:375–379 Veterinary Medicine-Research and Reports, 2016; 7:133–148

Exercise-Induced Pulmonary Hemorrhage (EIPH) Occurs frequently in Thoroughbred horses; almost all thoroughbreds demonstrate bleeding in the lower respiratory tract after a race. Exercise-induced pulmonary hemorrhage/edema (EIPH/EIPE) in human. Marathon runners, triathletes, cyclists, and swimmers. Clinical manifestations: asymptomatic, dyspnea, hemoptysis, epistaxis Mechanism: capillary wall tearing / remodeling of small pulmonary veins. Exercise elevates pulmonary capillary pressures, can affect the integrity of the blood-gas barrier. With extreme exertion, these changes result in increased permeability. High pulmonary vascular pressure results in pulmonary vein wall remodeling, and diminished vein lumen diameter. Image findings - Radiograph: patchy infiltration in both lower lung fields - CT: multifocal diffuse, patchy ground glass opacity and interlobular septal thickening on both lungs  permeability pulmonary edema or pulmonary hemorrhage were compatible Lung 2006; 184:331–333, Tuberc Respir Dis 2015; 78:375–379 Veterinary Medicine-Research and Reports, 2016; 7:133–148

Exercise-Induced Pulmonary Hemorrhage (EIPH) Figure 1. 위두사진은 증상으로 입원한 첫째날. d양측 lower lung에 ggo (3km running 후 객혈 및 mMRC 4 dyspnea) 아래 두사진은 운동을 피하고 촬영한 f/u CT 치료는 말에서는 furosemide등을 치료/예방으로 쓰나 인간에서는 아직 확립된 치료가 없고, steroird등을 쓰기도 함. (우리 환자도 steroid치료시작) (A) A chest radiograph obtained on the day of admission showed ground glass opacity in both the lower lung fields. (B) A chest computed tomography obtained on the day of admission demonstrates multifocal diffuse, patchy ground glass opacity and interlobular septal thickening in both the lungs and reveals permeability pulmonary edema or hemorrhage. (C) Five days after avoiding exercise, the chest radiograph shows resolving state of diffuse haziness in both the lungs. (D) Two weeks after avoiding exercise, a follow-up chest computed tomography was checked and reveals completely resolved multifocal diffuse, patchy ground glass opacity and interlobular septal thickening in both the lungs. . The patient was managed with supplemental oxygen, antifibrinolytics, antibiotics, and antitussive agent. No more hemoptysis and dyspnea were seen during hospitalization several days later. Five days after avoiding exercise, a chest radiograph showed resolving state of diffuse haziness in both lungs (Figure 1C) Five days after avoiding exercise Two weeks after avoiding exercise Management: lack of information of a medication or management in the treatment and prevention of EIPH/EIPE in humans.