A wide spectrum of etiological factors can result in haemoptysis. The most common causes of haemoptysis in a community vary according to the extent of overall development of the community. In developing countries like India, pulmonary tuberculosis accounts for the majority of cases of massive and nonmassive hemoptysis. In developed countries where the prevalence of tuberculosis significantly decreased in the latter half of the last century, bronchiectasis, bronchitis, and lung cancer are most common etiologies. [1] This study was conducted to study the aetiological profile of haemoptysis in Kashmir valley, the northern most part of India.

This prospective, observational, hospital based study was conducted in Sher-I- Kashmir Institute of Medical Sciences, Soura. SKIMS is a 1200 bedded tertiary care hospital in the valley of Kashmir in the state of J&K. All adult patients (above the age of 18 years) admitted with hemoptysis were included in the study. A detailed history and examination was conducted as per a pre-formed protocol. The history focused on the details of the presenting symptoms which included hemoptysis (amount, time of onset in relation to duration of other symptoms), cough, sputum production, chest pain, dyspnoea, fever, weight loss, anorexia, sore throat, and symptoms suggestive of malignancy. The patients were divided into four groups based on the amount of blood expectorated in 24 hours. Those who expectorated less than 30ml of blood were classified as ‘mild’ haemoptysis; 31-100 ml as ‘moderate’ haemoptysis; 100-600 ml as ‘severe’ haemoptysis. Those who expectorated more than 100 ml of blood and developed respiratory or haemodynamic compromise were classified to have ‘massive’ haemoptysis. A detailed general physical examination was performed. The vital signs were noted to check for respiratory and cardiovascular compromise. Patients were examined for pallor, lymphadenopathy, clubbing, and other dermatological findings that would suggest an etiology like tuberculosis, malignancy or an autoimmune disease. This was followed by a thorough systemic examination covering all the systems to look for any signs of disease. Baseline investigations including Complete blood count, ESR, liver function tests, kidney function tests, PT, INR, aPPT, arterial blood gases, electrolytes and Urine Routine Examination. If suspected then ANA, anti-dsDNA, pANCA, cANCA, antiGBM antibodies were done. Sputum for gram staining and culture/sensitivity, sputum for ZN staining for AFB, sputum for Gene Xpert and AFB culture were sent. Radiological testing included basic X-rays and CT scans. Bronchoscopy was done in patients in whom the etiology couldn’t be ascertained via radiological tests alone or in patients who needed BAL or a bronchoscopic guided biopsy was deemed necessary for a diagnosis

A total of 134 patients with haemoptysis were included in this study. 63.4% among them were males and the rest were females, with a male: female ratio of 1.73. The mean age (±SD) of our patients was 47.6 ± 19.1 years with the majority (39.6%) between the ages of 51-70 years; 25.4% of the patients were between 18-30 years. The total range was 18- 85 years. Majority of the patients (61.9%) had mild haemoptysis, 26.1% had moderate haemoptysis, 1.5% had severe haemoptysis and 10.4% had massive haemoptysis. Fifty percent patients presented with fever; 47% had dry cough and 44% had productive cough. Massive haemoptysis was seen in 10 patients with dry cough and in none with productive cough (p= 0.003). 19.4% of the patients had history of chest pain. In the study, 39.6% patients had grade 0 dyspnoea on modified medical research council dyspnoea scale while 11.9% and 25.4% patients had grade 1 and grade 2 dyspnoea respectively. Patients with grade 3 and grade 4 dyspnoea were 19.4% and 3.7% respectively. 7.5% patients were on anticoagulants, 3% were on antiplatelets and the rest had no history of any anticoagulant or antiplatelet use. 87.3% patients had no history of malignancy while 3.7% had lung cancer. Other malignancies seen in patients were stomach cancer, thyroid cancer, renal cell carcinoma, and non-Hodgkin’s lymphoma with 2 patients each while malignancies like CML, multiple myeloma, mucoepidermoid tumour and myelofibrosis were present in one patient each (p=0.009). Out of the total patients 47% had a history of smoking while 53% didn’t smoke. 14.1% patients had underlying COPD and 1.4% were known cases of bronchiectasis. History of significant weight was seen in 10.5% patients. 2.9% of patients complained of unilateral calf tenderness. Twenty patients (14.9%) had a past history of ATT intake. Of these, 8 patients had mild haemoptysis, 8 had moderate and 4 had massive haemoptysis. The underlying co-morbidities of all the patients are shown in table 1 Table 1: Co-morbidities in patients with haemoptysis Co-morbidity Massive Mild Moderate Severe Total % No co-morbidity 34 22 0 10 66 49.3 Hypertension 29 13 1 1 44 32.8 Diabetes mellitus 9 4 0 0 13 9.7 Thyroid disorders 6 3 1 0 10 7.5 Immunosuppression 13 1 1 3 18 13.4 RHD 3 0 0 0 3 2.2 CAD 2 1 0 0 3 2.2 SLE 1 0 0 0 1 0.7 CKD 4 1 0 1 6 4.5 CLD 2 0 0 0 2 1.5 Old stroke 1 1 0 0 2 1.5 Dementia 1 0 0 0 1 0.7 DCM 2 0 0 0 2 1.5 Gouty arthritis 0 1 0 0 1 0.7 ASD 1 0 0 0 1 0.7 An X-RAY of all the 134 patients was done. Chest infiltrates were the most common finding seen in 38.1% patients which was followed by radio-opaque shadows seen on about 32.8% patients. However, the most common finding in patients with severe to massive haemoptysis was a radio-opaque shadow. It was also noted that the majority of patients i.e., 41.8% had a right sided involvement as compared to only 27.6% patients who had left sided involvement. 21.6% patients had bilateral abnormalities in the X-RAY. X-RAY lateralised the source of bleed in 70.8% patients. It could identify the cause of the bleed in only 17.9%. The CT scan was performed in 111 patients. The bleed could be lateralized in 82.8% patients and identified the cause of the bleed in 80.1% patients. Out of the 134 patients, the sputum cultures of 67.9% patients came back sterile, an organism was grown in 11.9% of the patients (p=0.024) and in 20.1% patients, sputum cultures were not sent. Sputum samples only from patients with mild to moderate haemoptysis grew an organism while none of the patients with severe or massive haemoptysis grew any organism. 74.6% patients had a sputum for AFB done out of which 14% came out to be positive. GENE XPERT for MTB was sent in 55.9% patients, out of which 18.6% of the tests came back positive. The vasculitic profile of 7 patients came back positive. 5 of these patients had mild and 2 had moderate haemoptysis. None of the patients with severe or massive haemoptysis had a positive vasculitic profile. BAL was taken in 7 patients out of the 20 in whom bronchoscopy was done. AFB was detected in 2 patients. The patients with suspected lung lesions underwent a biopsy of the lesion. Primary lung cancer was detected in 9 patients. HPE was suggestive of a hydatid cyst in 2 patients.

Haemoptysis has a long aetiological list. The most common causes prevalent in a community vary according to the extent of overall development of the community. For developed countries, in the beginning of the twentieth century, infectious diseases including tuberculosis were widely prevalent as evidenced by the studies done by Heller N, Abbott et al, Levitt N.[2,3,4] As the medical sciences advanced and the standard of living in these countries improved, a decline in the number of tuberculosis cases was seen and malignancy overtook as the most common cause of haemoptysis. Being a developing country, as of now, tuberculosis is still the most common cause of haemoptysis as evidenced by some recent studies by Patel et al, Singh et al, Shah N et al.,[5,6,7] despite tremendous efforts to control tuberculosis. The implementation of various health care programmes like RNTCP, socio-economic growth and urbanisation has caused the tuberculosis burden of our country to lessen to a great extent, but with modernisation and development, the prevalence of malignancies has increased over the past decades. Despite the increasing prevalence of lung malignancy, tuberculosis continues to be the most common cause of haemoptysis in India with malignancy close behind. Overall, tuberculosis was the most common cause of haemoptysis. It was closely followed by community acquired pneumonia. Lung malignancy was the third most common cause. Bronchiectasis and hypertrophic bronchial artery took the fourth and fifth place. While studying patients with massive haemoptysis, it was seen that lung malignancy was the most common cause followed by tuberculosis and bronchiectasis. Community acquired pneumonia was the most common cause of mild haemoptysis. The below table (table 2) clearly shows how with the passage of time the aetiological profile of haemoptysis changed in the developed Countries. Table 2: Causes of haemoptysis by percentages in various countries Study Location Year Tuberculosis (%) Carcinoma (%) Pneumonia (%) Bronchiectasis (%) Heller N. UK 1946 39 2 3 7 Abbott et al. Atlanta 1948 22 21 2 21 Levitt N. Michigan 1951 47 12 1 15 Johnston et al. Kansas City 1989 7 19 8 1 Santiago et al. Los Angeles 1991 6 29 11 0.5 McGuinnes et al. New York 1994 16 12 12 25 Hirschberg et al. Israel 1997 1 19 16 20 Rao P. India, Lucknow 1960 79.2 5.7 1.7 3.8 Talwar et al. India, Noida 2012 61 6.6 25.5 21 Patel et al. India, Rajkot 2015 62 14 10 4 Shah N et al. India, Aligarh 2016 27.6 18.6 4.9 16.5 Kumar A et al. India, UP 2016 40 6 2.5 20 Bhalla et al. India, Chandigarh 2017 65 7.18 10.72 9.3 Our study India, Kashmir 2020 20.8 17.1 14.9 11.9 Various aetiological conditions leading to haemoptysis are tabulated in Table 3. Table 3: Aetiology of haemoptysis Aetiology N % Massive Mild Moderate Severe Not Known 11 8.2 2 8 1 0 Active Tuberculosis 15 11.2 3 7 3 2 Post Tubercular Fibrotic Lung Disease 13 9.7 1 9 3 0 Community Acquired Pneumonia 20 14.9 3 17 0 0 Lung Carcinoma 16 11.9 5 10 1 0 Hydatid Cyst 7 5.2 2 3 2 0 Anticoagulant Use 5 3.7 2 3 0 0 Thrombocytopenia 7 5.2 1 5 1 0 Infective Endocarditis 2 1.5 0 2 0 0 Heart Failure 5 3.7 1 4 0 0 Acute Bronchitis 6 4.5 1 3 1 1 Bronchiectasis 16 11.9 3 13 0 0 Antiplatelet Use 2 1.5 0 2 0 0 Metastatic Lung Lesions 7 5.2 1 5 1 0 Aspergilloma 6 4.5 0 3 3 0 PTE 8 6.0 1 6 1 0 Hypertrophic Bronchial Artery 10 7.5 2 8 0 0 Hospital Acquired Pneumonia 4 3.0 1 3 0 0 AVM 1 0.7 0 1 0 0 Lung Abscess 1 0.7 0 1 0 0 Tracheal Diverticulum 1 0.7 0 1 0 0 Pseudo-Aneurysm of Pulmonary Artery 1 0.7 0 1 0 0 Vasculitis 3 2.2 1 2 0 0 Catamenial Haemoptysis 1 0.7 1 0 0 0 Necrotising Pneumonia 1 0.7 1 0 0 0 Bronchial Artery Aneurysm 1 0.7 0 1 0 0 Covid Pneumonia 1 0.7 0 0 1 0 In multiple series across literature the ability of the chest X-RAY to lateralise the bleed has varied between 6.5-82%. This variation is due to variable patient populations, during different eras of medicine, in different parts of the world and inter-observer variations. Its ability to identify the aetiology has been documented to be about 28.7%. In this study the chest X-RAY could lateralize the source of the bleed in 70.8% of the patients. It could identify the cause of the bleed only in about 17.9% patients. Hence, chest X-RAY is a good initial diagnostic test for lateralizing the bleed but further tests are mostly required for diagnosing the aetiology of haemoptysis. We found that CT scan could lateralise the source of the bleed in 82.8% patients and could identify the source of the bleed in 80.1% patients. While studying the radiological test used in patients with haemoptysis, we found the CT scan has a better sensitivity and specificity as compared to X-RAY chest in diagnosing the source and aetiology of bleed. The mean age in our patients was consistent with the other studies conducted in India[1,8] but lower as compared to studies in western countries.[9] The discrepancy seems to be due the difference in the aetiological profile of haemoptysis between developed and developing nations with malignancy being the most common cause in developed countries and tuberculosis the most cause in developing countries. The majority of the patients belonged to the rural areas. The burning of wood for cooking and heating purposes in rural areas is one major factor. Also, the number of tuberculosis cases reported in our setup is higher in rural population due to overcrowding, poverty and illiteracy. The percentage of smokers is higher as compared to the general population which implies that smokers are predisposed to diseases that cause haemoptysis. The same was found in our study which is in accordance with other similar studies, confirming that the number of smokers among patients with haemoptysis is higher than the general population.[5,10,11] The other factors predisposing a patient to develop haemoptysis as per our study was seen to be a history of ATT intake, anticoagulant intake, an underlying malignancy, underlying COPD, chronic kidney disease and rheumatic heart disease. LIMITATIONS: 1: The total number of the patients included in the study was less due to the ongoing pandemic.

To summarize, tuberculosis continues to be the most common cause of haemoptysis in Kashmir valley; lung carcinoma is on a growing trend (third most common cause) but hasn’t yet surpassed tuberculosis. CT scan is a better radiological test to diagnose the aetiology and know the site of bleed.

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