Spontaneous pulmonary haemorrhage into an existing emphysematous bulla

A patient with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis presented dyspnoeic with productive cough and large-volume haemoptysis, 1 month after coronary stenting and commencement of clopidogrel. A chest radiograph showed a well-circumscribed opacity in the left lower zone with surrounding consolidation, where previously an emphysematous bulla had been. A CT scan of the thorax confirmed a 14 cm bulla in the left lower lobe, which was 70% filled with blood with associated surrounding consolidation. A diagnosis of pulmonary haemorrhage into an existing emphysematous bulla with co-existing infective exacerbation of COPD was performed. Owing to his significant comorbidities, the patient was managed conservatively, returning to baseline over several days. He had two further admissions due to pulmonary infection over 2 months, where the haematoma was nominally smaller, and died during the second of these.