Internal mammary artery pseudoaneurysm: A rare fatal complication of tubercular empyema
A 15-year-old male had complaints of fever and cough with expectoration on and off for 8 months. On evaluation, sputum was found positive for acid fast bacilli and he was on anti-tubercular treatment (ATT, Directly Observed Treatment Short course, Category II) for the last 3 months.\nHe had small amounts of blood-streaked sputum for the past 2 weeks, but had coughed up approximately “a cup” of bright red blood a day prior to his referral to emergency department. While still in the emergency, he had an episode of large volume hemoptysis, estimated to be approximately 200-250cc of fresh blood. The patient had a past history of TB 6 years back, for which he had taken a complete course of ATT for 6 months.\nThe patient underwent computed tomographic bronchial angiography (CTBA) to identify the cause of hemoptysis. The CTBA showed approximately 45 mm × 35 mm × 32 mm sized contrast filled outpouching seen arising from the left internal mammary artery (LIMA) in relation to one of the pocket of empyema located anteriorly in the paramidline location [Figure and ]. In addition, multiple other loculated pockets of empyema were also seen. Multiple coalescing centrilobular nodules were seen scattered in bilateral lungs [], suggestive of reactivation.\nPatient became hemodynamically unstable with falling blood pressure and went into shock. The decision was taken for angioembolization of the pseudoaneurysm. The LIMA was selectively cannulated, which showed contrast filled outpouching [] with faint abnormal blush. Three multiple curled soft platinum coils (2.0-2, 3.0-3 and 3.0-3) were deployed and the check angiogram showed no residual pseudoaneurysm [].\nHemoptysis stopped post-procedure; however, the patient went into refractory shock. The patient was given crystalloids (in the form of normal saline) and whole blood. As the patient was not responding to the intravenous fluid resuscitation, he was started on vasoactive agents also (noradrenaline and dopamine). However, he could not be revived and died 4 h post-embolization.