Lung physiology at play: Hemoptysis due to underwater hockey
A 34 year-old male presented to the Emergency Department with hemoptysis following a strenuous game of underwater hockey. Underwater hockey is played in a swimming pool at a depth of 2–4 m. Wearing a snorkel mask and fins, players pass a weighted puck from the bottom of the pool, during repeated apneic dives. The patient reported a cough productive of approximately four teaspoons of bright red blood. Similar episodes of hemoptysis had occurred twice previously, each time following a game of underwater hockey. He denied ever experiencing shortness of breath or chest pain with exercise. Review of systems was negative. There was no history of respiratory disease, and he was a non-smoker.\nOn presentation to hospital, vital signs were normal and physical examination was unremarkable.\nBlood work was normal and included: hemoglobin 155 g/L, platelet count 182 × 109/L, INR 1.0, PTT 26.1 s, anti-nuclear antibody 1:40 (homogenous), rheumatoid factor <8 (negative), negative anti-neutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane antibody levels. Chest x-ray was normal. CT angiogram of the chest revealed normal lung parenchyma, no vascular abnormalities, and no evidence of pulmonary emboli. Trans-thoracic echocardiogram showed borderline concentric left ventricular hypertrophy but normal left ventricular diastolic function. The right ventricular systolic pressure (RVSP) was at the upper limit of normal at 35 mmHg. Stress echocardiogram was normal after 14 min of exercise, with an increase in RVSP from 40 to 50 mmHg. Bronchoscopy revealed slightly erythematous mucosa but no frank bleeding or endobronchial lesions. Bronchoalveolar lavage demonstrated no abnormalities.\nThe patient was discharged from our clinic with no clear diagnosis. Interestingly, he was referred back seventeen years later for an incidental finding of a pulmonary nodule. He reported that he had ultimately stopped playing underwater hockey and experienced no further episodes of hemoptysis. In retrospect, recent literature, reviewed below, quite clearly characterizes the cause of his previous hemoptysis.