Got a bad cough? Think you might hork up a lung? Don’t.

I didn’t know you even could. This is a gross story, don’t look below the fold if you’re at all sensitive.

The NEJM reports that a 36 year old patient with a whole series of severe cardiovascular problems did something strikingly bizarre and ultimately tragic.

During an extreme bout of coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree. The right bronchial tree consists of three segmental branches in the upper lobe (blue arrows), two segmental branches in the middle lobe (white arrows), and five segmental branches in the lower lobe (black arrows).

There is a photo at the link. The patient died of heart failure a bit more than a week later.


  1. marinerachel says

    Wow. It’s actually very beautiful. I thought it would just look like a tube, not have all that intact branching.

    How the heck did the cast form though? What was layering its self onto the inside of his bronchi? I’ve seen uterine casts from ectopic pregnancies. A bronchial tree cast though, I don’t understand the formation of.

    Regardless, how terrible to die of heart failure at only thirty-six.

  2. davidc1 says

    All a bit above my head ,is that a part of him or is it something that grew inside him ?

  3. xmp999 says

    I’ve seen some amazing mucus masses come out of people with cystic fibrosis, but this…. wow… just wow… That must have hurt :(

  4. Snidely W says

    This might be the most comparable vertebrate thing to molting by a complex-shaped arthropod, only internal and not external.
    Yeah, the analogy is a little stretched. But it does involve the separation of a lot of surface area.
    That must have been a very uncomfortable bout of coughing. I wonder if it felt a whole lot better once he got it out? Probably quite sore though.
    Ultimately tragic regardless.

  5. davex says

    @2 and @3 Thanks. — I was confused as to what was doing the casting too — I was about to google ‘hemoptysis’ for clues but came back here to read the comments first. Sounds like a week’s worth of blood-clotting in his lung. Amazing.

  6. wzrd1 says

    Worse, in the article, it was mentioned that they installed an endotracheal tube, then inserted a bronchoscope to see where the bleeding was and blood was observed even lower into the bronchial tree. So, that one lung was fully obstructed and CHF was obviously wreaking havoc on the other lung as well.
    Additionally, he had an aortic valve replaced, aortic aneurysm repaired and complete heart block. He also had a ventricular assist device and pacemaker surgically inserted. That was a very, very sick young man!
    That level of disease is usually only seen in people 50 – 60 years his elder. I strongly suspect he had one of several dyslipidemia diseases. Familial hypercholesterolemia, likely, as it’s frequently missed, despite it effecting one out of every five hundred people.
    The tragedy is, it was likely treatable if it had been caught early. What a damned waste.

  7. eliza422 says

    I can’t even imagine what he must have thought when he coughed that up. I would have absolutely freaked out, thinking I had actually torn out part of my lung!
    I’m horrified and mesmerized at the same time!
    How gross! How neat! And ultimately, how sad for the poor guy.

  8. Raucous Indignation says

    Wow. Ya don’t see that every day.

    I have a similar and equally disgusting story. One of my patients developed a terrible pneumonia. He was coughing up huge amounts of green foul sputum. HIs thoracic surgeon took him to the OR to try to clean out the some infected fluid and tissue. When he got inside the chest, he found that the right middle lobe was a bag of pus. He resected the lobe and then opened it ex vivo. The lung tissue had been completely eaten away by the infection leaving the pleura intact and a denuded skeleton of the bronchial tree. So yeah, having gone over to the dark side that lobe had to go.

  9. Raucous Indignation says

    @8 wzrd1. I’m not sure, but you might just be talking out your ass. They do not identify the cause of the heart failure. The write up makes no mention of dyslipidemia or elevated cholesterol. Which are things that might have been mentioned if they were relevant to the case presentation. But I’m sure we are all thankful for your baseless speculation about this young person’s cause of illness and death.

  10. Raucous Indignation says

    @ 3 Jazzlet. Exactly so! That is a mature endobronchial thrombus. It must have taken a few days at least to form. It would have to be mature or “hard” clot to survive expectoration intact.