Although it resembles coral, a root system, or some other type of growth, the above photograph actually shows a six-inch-wide blood clot in the nearly perfect shape of the right bronchial tree of a human lung, the Atlantic reported Thursday. Even more disconcerting is the revelation that it was not exempted from medical personnel, but exhaled by a patient with heart failure.
The photo was published in late November as part of the Images in Clinical Medicine series of the New England Journal of Medicine. The doctors at the University of California at San Francisco, Gavitt A. Woodard and Georg M. Wieselthaler, wrote that it was from their patient, a 36-year-old man who was struggling with chronic heart failure for a long time. The patient was reported to have a medical history including "heart failure with a 20% ejection fraction, bioprosthetic aortic valve replacement for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm and placement of a permanent cardiac pacemaker for a complete heart block." The patient was admitted to intensive care Hospital, he was connected to a pump that was supposed to promote blood circulation throughout the body:
An Impella chamber assist device was placed for the treatment of acute heart failure and a continuous heparin infusion was initiated for systemic anticoagulation. The next week, the patient had episodes of small-volume hemoptysis, increased respiratory distress, and increased use of supplemental oxygen (up to 20 liters delivered through a high-flow nasal cannula). In an extreme coughing attack, the patient spontaneously spat out an intact imprint of the right bronchial tree.
The patient was later extubated and "had no further hemoptysis episodes," the doctor wrote, but unfortunately, a week later, he "died of complications of heart failure (volume overload and poor cardiac output) despite the placement of the ventricular device."
In the Atlantic Ocean, Wieselthaler said using the pump requires anticoagulants "to thinner the blood and prevent the formation of blood clots," although this carries the risk of uncontrolled internal bleeding. In this case, Wieselthaler told the journal, the blood leaving the heart to replenish itself with fresh oxygen in the circulatory system seems to have gathered in the right bronchial tree to be clotted and was then ejected by the patient in a confused form:
After carefully unrolling and laying out the bundle, Wieselthaler and his team found that the airway architecture was so perfectly preserved that they could identify it as the right bronchial tree, based solely on the number of branches and their orientation.
Wieselthaler added that one way in which the clot remained intact and would not have been broken was a high concentration of fibrinogen, a protein in the blood plasma that contributes to the formation of clots. The patient had an infection that both exacerbated heart failure and resulted in accumulation of fibrinogen in the blood, resulting in a more rubbery clot, he told the Atlantic.
Woodard told the magazine that it was also possible that the size of the lump could actually have contributed to the ejection, as the patient "could generate enough force from the entire right side of his chest to push it up." "(Gizmodo has contacted Woodard to clarify some questions and we will update this article when we hear that.)
It may be a bit of a mystery to stare at the product of a medical misfortune, but even most doctors may never have the opportunity to see it. Although there are other conditions that can lead to bronchial casts, including infections and asthmatic conditions or lymphatic flow disturbances that can cause deposits of mucus or lymph fluid, Wieselthaler emphasized that the size of this vessel is virtually unprecedented.
"We were amazed," said Wieselthaler the Atlantic. "It's a curiosity you can not imagine – I mean, that's very, very, very rare."
[New England Journal of Medicine via the Atlantic]