"Breaking the Bleed" Spontaneous Hemorrhage in an Emphysematous Bulla Complicated by Anticoagulation: A Case Report

We present a case of spontaneous hemorrhage in an emphysematous bulla, complicated by anticoagulation. Bullous emphysema is a well-recognized complication of chronic obstructive pulmonary disease (COPD), and a rare manifestation is hemorrhage into preexisting pulmonary bullae. A 69-year-old male patient presented to the emergency department with hemoptysis, shortness of breath, and productive cough. He had a history of COPD, coronary artery disease, congestive heart failure, and paroxysmal atrial fibrillation, managed with aspirin and rivaroxaban. Chest imaging revealed fluid-filled bulla in the left lower lobe, suggesting spontaneous hemorrhage into an emphysematous bulla. Bronchoscopy confirmed active bleeding, and the patient was managed with medical therapy and video-assisted thoracoscopic surgery with bullectomy. The patient recovered well post-operatively, with no further episodes of bleeding. Long-term follow-up showed improved respiratory function and the successful placement of a left atrial appendage closure device to manage atrial fibrillation to obviate the need for long-term anticoagulation. In this report, we will discuss prior cases of this condition and its management. This case not only sheds light on the rare and complex clinical scenario of a spontaneous bleed in a pre-existing emphysematous bulla but also underscores the successful use of surgical resection in a context where surgical management is not often used. Our patient's positive outcome and recovery over seven months, as evidenced by close longitudinal follow-up, provides valuable insights into the potential benefits of surgical intervention in select cases.