Medicine – Causes of Haemoptysis

Haemoptysis means coughing up blood that originates from the lower respiratory tract, usually from the bronchi or lungs. It can range from small blood-streaked sputum to life-threatening pulmonary haemorrhage.

The important clinical priorities are to determine the amount of bleeding, whether the patient is haemodynamically or respiratory compromised, and what the underlying cause is.

1. Lung Cancer

Lung cancer is an important cause of haemoptysis, particularly in older patients and those with a significant smoking history.

Bleeding may occur because a tumour erodes into bronchial mucosa or nearby blood vessels.

Associated warning features include persistent cough, unexplained weight loss, chest pain, recurrent pneumonia, hoarseness, and reduced appetite.

Even small-volume recurrent haemoptysis in a high-risk patient warrants further investigation.

2. Pneumonia

Pneumonia can cause haemoptysis because inflammation damages the airway and alveolar tissues.

The sputum may be blood-streaked or occasionally more heavily blood-stained.

Associated features commonly include fever, productive cough, pleuritic chest pain, dyspnoea, and focal chest signs.

3. Tuberculosis

Pulmonary tuberculosis is a classic cause of haemoptysis.

Bleeding can occur from inflamed or cavitating lung tissue, particularly in post-primary disease.

Typical associated symptoms include chronic cough, weight loss, fever, night sweats, fatigue, and sometimes upper-lobe cavitation on imaging.

Significant bleeding can occur if a pulmonary vessel adjacent to a cavity is eroded.

4. Pulmonary Embolism

A pulmonary embolism (PE) may cause haemoptysis, particularly when there is associated pulmonary infarction.

The amount is usually relatively small rather than massive.

Associated features may include sudden breathlessness, pleuritic chest pain, tachycardia, hypoxaemia, syncope, or signs of deep-vein thrombosis.

5. Bronchiectasis

Bronchiectasis is a common structural cause of recurrent haemoptysis.

Chronically inflamed and abnormally dilated bronchi develop enlarged and fragile bronchial arteries, which can bleed.

Patients often have chronic productive cough, large volumes of purulent sputum, recurrent chest infections, and intermittent haemoptysis.

In some patients, bronchiectasis can cause massive haemoptysis.

6. Aspergilloma

An aspergilloma is a fungal ball, usually composed of Aspergillus hyphae, that colonises a pre-existing lung cavity.

The cavity may have resulted from previous tuberculosis, sarcoidosis, or other cavitating lung disease.

Haemoptysis is a classic presentation and may range from mild to severe.

On imaging, an aspergilloma may appear as a mobile intracavitary mass surrounded by an air crescent.

7. Pulmonary Abscess

A lung abscess is a localized area of suppurative infection with destruction and cavitation of lung tissue.

Inflammation and necrosis can damage nearby blood vessels, producing haemoptysis.

Associated features may include fever, productive cough, foul-smelling sputum, weight loss, and an air-fluid level on imaging.

8. Wegener’s Granulomatosis

The older term Wegener’s granulomatosis is now called granulomatosis with polyangiitis (GPA).

GPA is a necrotising small- and medium-vessel vasculitis that commonly affects the upper respiratory tract, lungs, and kidneys.

Pulmonary involvement may produce nodules, cavitation, pulmonary capillaritis, and diffuse alveolar haemorrhage, leading to haemoptysis.

Associated features can include sinusitis, nasal crusting, otitis, haematuria, renal impairment, and systemic inflammatory symptoms.

9. Goodpasture’s Syndrome

Goodpasture’s syndrome, more precisely called anti-glomerular basement membrane disease, can cause severe pulmonary haemorrhage.

Autoantibodies attack basement membranes in the lungs and kidneys.

Patients may present with haemoptysis, breathlessness, anaemia, haematuria, and rapidly progressive glomerulonephritis.

Pulmonary bleeding may be extensive and can cause life-threatening hypoxaemia.

Causes of Haemoptysis – Note Form

Lung cancer: tumour erosion into bronchial tissue or vessels, especially important in smokers and older patients.

Pneumonia: inflammatory damage to airways and alveoli can cause blood-streaked sputum.

Tuberculosis: cavitation and tissue destruction may produce recurrent or severe haemoptysis.

Pulmonary embolism: haemoptysis may occur with pulmonary infarction, usually together with sudden dyspnoea and pleuritic pain.

Bronchiectasis: chronically inflamed dilated bronchi with fragile bronchial arteries; can cause recurrent or massive bleeding.

Aspergilloma: fungal ball within an old lung cavity; haemoptysis is a classic feature.

Pulmonary abscess: cavitating infection with necrosis and vessel damage.

Granulomatosis with polyangiitis: pulmonary vasculitis and alveolar haemorrhage can cause haemoptysis.

Anti-GBM disease: pulmonary capillary bleeding associated with rapidly progressive renal disease.

Key Clinical Pattern

A useful way to remember haemoptysis is to think in broad groups:

Malignancy → lung cancer.

Infection → pneumonia, tuberculosis, lung abscess.

Structural airway disease → bronchiectasis.

Cavitary fungal disease → aspergilloma.

Vascular/thromboembolic → pulmonary embolism.

Pulmonary–renal syndromes → granulomatosis with polyangiitis and anti-GBM disease.

Large-volume haemoptysis is a medical emergency because the immediate danger is often airway obstruction and asphyxiation, not simply blood loss.