The full spectrum of COVID-19 disease is still emerging, but the most common signs and symptoms at onset are fever, dry cough, myalgia, anosmia and ageusia, fatigue, and dyspnoea (Guan et al. 2020; Lapostolle et al. 2020).
Pulmonary bleeding seems to be an atypical manifestation of SARS-CoV-2 infection, as COVID-19-associated haemoptysis has rarely been reported in the literature (Lapostolle et al. 2020). In a selected Chinese cohort, haemoptysis was present in 0.9% of 1099 COVID-19 patients (2.3% in severe cases) (Guan et al. 2020). Recently, Lapostolle et al. reported a 3% haemoptysis rate in a large cohort of confirmed COVID-19 patients managed in an outpatient setting (Lapostolle et al. 2020).
Very few major haemorrhagic complications have been described in hospitalised COVID-19 patients, with only a few cases of spontaneous abdominal internal bleeding and none at the bronchial level (Conti et al. 2020). Minor or occult bleeding was reported, especially due to SARS-CoV-2 associated digestive tract lesions (Lin et al. 2020).
A hallmark of severe COVID-19 is altered coagulation with a predominantly pro-thrombotic status and a high risk of thromboembolic events (Helms et al. 2020). The initial coagulopathy of COVID-19 presents a prominent elevation of D-dimer and fibrin/fibrinogen degradation products, while abnormalities in PT, APTT, and platelet counts are relatively uncommon in initial presentations (Connors and Levy 2020). In some centres, venous and pulmonary thromboembolic complications are found in one-third of critically ill patients, leading to prophylactic doses higher than the thrombosis prophylaxis recommendation even in the absence of randomised evidence.
The lungs are the target organ for SARS-CoV-2, and progressive respiratory failure is the primary cause of death in COVID-19 patients. Pathological examination of the lungs of deceased COVID-19 patients showed diffuse alveolar damage associated with both thrombotic and haemorrhagic lesions: severe endothelial injury, alveolar capillary microthrombi, and increased angiogenesis (Ackermann et al. 2020).
In this context, we hypothesised that the life-threatening haemoptysis presented by our patient was consecutive to severe lung damage induced by SARS-CoV-2 combined with the anticoagulant effect of UNFH therapy, resulting in peripheral bronchial artery damage. In such cases, bronchial artery embolisation could be indicated.
Faced with haemoptysis, chest CTA is recommended to specify the nature, extent, and topography of pulmonary lesions. CTA allows the evaluation of the bronchial artery anatomy and the exploration of pulmonary arteries, which are a less common cause of haemoptysis. A recent study showed that preprocedural CTA helps detect culprit ectopic bronchial arteries and non-bronchial systemic arteries originating from the subclavian and internal mammary arteries during bronchial artery embolisation (Li et al. 2019). Li et al. observe that chest CTA improve the haemoptysis-free early survival rate in patients with haemoptysis (Li et al. 2019).
At the time of writing, this is the first reported case of bronchial artery embolisation used for COVID-19-related haemoptysis. Our experience suggests that the embolisation of bronchial arteries is feasible and may help control bleeding in cases of COVID-19 pneumonia associated with life-threatening haemoptysis. However, the impact on survival remains uncertain. The risk incurred by medical and paramedical staff is an issue that must also be taken into account. We hope that other authors will report their similar experiences in order to provide answers to these questions.