Bronchial Dieulafoy’s disease complicated by pulmonary embolism after successful hemostasis: a case report and review of the literature

Bronchial Dieulafoy’s disease complicated by pulmonary embolism after successful hemostasis: a case report and review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bronchial Dieulafoy’s disease complicated by pulmonary embolism after successful hemostasis: a case report and review of the literature Yunxiao Li, Ruimin Ma, Xiaohua Wu, Yuefeng Hu, Shuhong Zhang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8516053/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Bronchial Dieulafoy’s disease (BDD) is a rare vascular anomaly characterized by a large-caliber submucosal artery that can cause sudden, massive, and potentially fatal hemoptysis. Because of its deceptively benign endobronchial appearance, the disease is frequently underrecognized and carries a high risk of catastrophic bleeding following bronchoscopic manipulation. Case presentation A 77-year-old woman without underlying lung disease developed massive hemoptysis and hemorrhagic shock shortly after diagnostic bronchoscopy for an indeterminate endobronchial lesion. Emergency bronchial artery embolization (BAE) achieved durable hemostasis. During recovery, the patient developed intermediate-risk pulmonary embolism, posing a major therapeutic dilemma regarding anticoagulation after recent life-threatening airway bleeding. A stepwise anticoagulation strategy was cautiously implemented after secure hemostasis, resulting in complete resolution of pulmonary embolism without recurrent hemoptysis. Histopathological examination confirmed the diagnosis of bronchial Dieulafoy’s disease. Conclusions This case highlights the diagnostic pitfalls of bronchial Dieulafoy’s disease, the lifesaving role of bronchial artery embolization, and the complexity of managing thromboembolic complications following control of massive hemoptysis. Clinicians should maintain a high index of suspicion for BDD in patients with unexplained hemoptysis and benign-appearing endobronchial lesions, and bronchoscopic biopsy should be avoided whenever a vascular etiology is suspected. Bronchial Dieulafoy’s disease massive hemoptysis bronchial artery embolization pulmonary embolism anticoagulation case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Bronchial Dieulafoy’s disease (BDD) is an uncommon but potentially lethal cause of hemoptysis, characterized by a dysplastic, large-caliber artery running superficially within the bronchial submucosa [ 1 , 2 ]. Because the overlying mucosa often appears intact and nonulcerated, the lesion may mimic benign inflammatory nodules or endobronchial tumors, leading to inadvertent biopsy and catastrophic bleeding [ 3 , 4 ]. Early recognition and appropriate management are therefore critical, and pathological confirmation—when available—remains the gold standard for diagnosis, typically demonstrating a large-caliber aberrant artery located immediately beneath the bronchial epithelium without features of vasculitis or malignancy [ 1 , 5 ]. Case presentation A 77-year-old woman with no smoking history and no known underlying lung disease, including chronic obstructive pulmonary disease, bronchiectasis, or prior tuberculosis, was admitted for evaluation of lung consolidation detected on imaging. Contrast-enhanced chest computed tomography revealed a consolidation-like lesion in the left hilar region with focal enhancement and internal punctate hyperdense foci of indeterminate etiology. Flexible bronchoscopy demonstrated extrinsic compression and luminal narrowing of the basal and posterior segments of the left lower lobe. A small, broad-based nodular lesion protruding from the left main bronchial wall was observed, covered by a whitish cap-like structure. No active bleeding was observed on gentle contact. Endobronchial biopsy, brushing, and bronchoalveolar lavage were performed. During bronchoscopy under general anesthesia, the patient suddenly developed massive hemoptysis. Initial hemostatic measures, including intravenous vasopressin, topical thrombin application, and blood transfusion, achieved only transient control. Recurrent hemorrhage occurred during transfer, and emergency bronchial artery embolization (BAE) was performed under general anesthesia. The estimated total blood loss was approximately 1500 mL. Selective angiography revealed marked enlargement of the left upper bronchial artery with tortuous distal branches and focal contrast extravasation. Superselective embolization using gelatin sponge particles (560–710 μm and 710–1000 μm) and detachable coils was performed. Additional embolization was required for abnormal distal branches of the left lower bronchial artery and the left fourth to fifth intercostal arteries showing systemic–pulmonary shunting. Post-embolization angiography confirmed cessation of contrast extravasation and marked reduction of distal arterial branches. Hemoptysis resolved promptly. Repeat bronchoscopy showed large intrabronchial clots, which were removed. The patient was transferred to the intensive care unit and later returned to the respiratory ward. She subsequently developed aspiration pneumonia and was treated with empirical broad-spectrum antibiotics. Despite hemodynamic stabilization after bronchial artery embolization, the patient remained in a critical condition with severe hypoxemia and had not yet passed the immediate high-risk period; therefore, transfer for computed tomography pulmonary angiography (CTPA) was deferred, and bedside transthoracic echocardiography was performed instead. Transthoracic echocardiography demonstrated newly developed pulmonary hypertension, with an estimated pulmonary artery systolic pressure of 42 mmHg compared with a baseline value of 17.67 mmHg. Cardiac biomarkers were elevated, including cardiac troponin I (0.122 ng/mL) and NT-proBNP (2636 pg/mL), raising strong suspicion for acute pulmonary embolism. Given the recent life-threatening hemoptysis, anticoagulation was cautiously initiated with reduced-dose low-molecular-weight heparin (enoxaparin 60 mg [6000 IU anti-Xa] once daily). Oxygenation improved slowly but remained inadequate. On day 9 after embolization, CTPA confirmed acute pulmonary embolism involving the anterior and apical segments of the right upper lobe and the lingular segment of the left upper lobe, consistent with intermediate-risk pulmonary embolism. After multidisciplinary discussion, anticoagulation was escalated to therapeutic dosing (enoxaparin 60 mg every 12 hours, approximately 1 mg/kg). No recurrent hemoptysis occurred. Histopathological examination of the biopsy specimen revealed a markedly dilated artery located superficially within the bronchial submucosa. Elastic fiber staining demonstrated a well-defined elastic lamina, and immunohistochemical staining for desmin highlighted concentric smooth muscle bundles within the vessel wall, confirming the diagnosis of bronchial Dieulafoy’s disease[1, 5]. The patient was discharged in stable condition. She reported significant anxiety during the episode of massive hemoptysis but experienced marked relief after successful bronchial artery embolization. She tolerated subsequent anticoagulation therapy well, with no recurrent bleeding, and was satisfied with the overall treatment outcome. Anticoagulation was continued for three months. Follow-up imaging showed complete resolution of pulmonary embolism, and no recurrence of hemoptysis was observed. Discussion BDD poses a major diagnostic challenge because of its deceptively benign bronchoscopic appearance. Small, mucosa-colored nodules covered by a whitish fibrinous layer (“white cap”) are commonly described and may closely mimic nonvascular lesions [2–4]. In our patient, the absence of active bleeding and the benign appearance contributed to diagnostic biopsy, reflecting a well-recognized pitfall rather than an isolated procedural error. Notably, the absence of apparent vascular features—even when advanced imaging modalities such as narrow-band imaging (NBI) are applied—does not exclude a vascular lesion. This may relate to the optical principle of NBI, which primarily enhances superficial mucosal microvasculature with relatively limited depth penetration, whereas bronchial Dieulafoy-type lesions typically originate from a large-caliber submucosal artery that may not produce conspicuous surface vascular changes detectable by NBI [6]. Numerous reports have demonstrated that bronchoscopic manipulation or biopsy of bronchial Dieulafoy lesions can precipitate catastrophic arterial hemorrhage [1, 3, 7, 8]. This case reinforces that any broad-based endobronchial nodule associated with unexplained hemoptysis should be approached with extreme caution, and biopsy should be avoided unless a vascular lesion has been reasonably excluded. In addition, bronchial Dieulafoy’s disease should be differentiated from other rare vascular or tumor-associated conditions, such as paravertebral neurilemmoma–associated vascular anomalies, which may present with similar endobronchial appearances but differ fundamentally in pathogenesis and management [8]. Angiography plays a central role in the diagnosis and management of BDD, typically demonstrating hypertrophied and tortuous bronchial arteries with abnormal distal branching or contrast extravasation [8, 9]. Bronchial artery embolization is widely regarded as the first-line therapy for acute bleeding control and achieves high immediate success rates [9, 10]. In selected and complex cases, including pediatric or atypical presentations, multimodality imaging such as CT angiography may further facilitate early identification of the bleeding source and guide timely endovascular or bronchoscopic intervention [11]. In the present case, superselective embolization resulted in durable hemostasis without recurrence during follow-up. Pulmonary embolism is not a commonly reported complication of bronchial artery embolization itself. In this patient, the thromboembolic event was likely multifactorial, related to hemorrhagic shock, prolonged immobilization, systemic inflammation, and transient hypercoagulability. Management posed a major therapeutic dilemma, as anticoagulation carries an inherent risk of precipitating recurrent airway bleeding after recent massive hemoptysis. A stepwise anticoagulation strategy—beginning with reduced dosing after secure hemostasis and escalating to full therapeutic dosing after confirmation and stabilization—was well tolerated and resulted in complete resolution of pulmonary embolism without recurrent bleeding. Recent reviews have emphasized that bronchial Dieulafoy’s disease remains underrecognized in clinical practice and that heightened awareness is essential to prevent iatrogenic complications and optimize outcomes [11]. Severe hemoptysis requiring advanced life-support measures has also been reported in special populations, such as pregnant patients, in whom extracorporeal membrane oxygenation combined with interventional management was successfully applied as rescue therapy [12]. These reports further underscore the extreme clinical spectrum of massive airway bleeding and the necessity of individualized, multidisciplinary decision-making when balancing hemorrhagic and thrombotic risks. Clinical implications Bronchial Dieulafoy’s disease should be considered in patients with unexplained hemoptysis and benign-appearing endobronchial nodules, especially those with a “white cap” appearance. Bronchoscopic biopsy of such lesions carries a high risk of catastrophic hemorrhage and should be avoided unless a vascular etiology has been reasonably excluded. The absence of abnormal vascular patterns on NBI does not exclude bronchial Dieulafoy’s disease, as the culprit vessel is often submucosal and beyond the effective imaging depth of NBI Bronchial artery embolization is a lifesaving first-line intervention for massive hemoptysis caused by BDD. After secure hemostasis, anticoagulation for concomitant pulmonary embolism may be feasible in carefully selected patients, but treatment decisions must be individualized. Declarations Data availability The data are available upon reasonable request from the corresponding author. Author contributions YL and RMwas the primary physician involved in the patient’s management, conceived the report, collected clinical data, performed the literature review, and drafted the manuscript. XW provided expert interpretation of CT/CTPA images. YH performed the life-saving bronchial artery embolization for hemostasis. SZ provided guidance on pathological specimen processing, and interpretation of the biopsy samples. PL provided guidance on the interpretation of the pathological slides. HJ coordinated nursing care. FL and FY supervised the overall clinical rescue and treatment and critically revised the manuscript. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Funding This work was supported by the National Natural Science Foundation of China (Grant No. 82000043) and the Capital’s Funds for Health Improvement and Research (Grant No. 2024-2-1101). Ethics approval and consent to participate This case report was performed in accordance with the Animal Ethics Committee of Beijing Friendship Hospital, Capital Medical University (Approval No. 2026-P2-016-01). Consent to Publish declarations: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Acknowledgements The authors would like to thank Dr. Chen Guang and Hu Yuefeng from the Interventional Radiology Department for performing the life-saving bronchial artery embolization for this patient. We also acknowledge Dr. Liu Ping from Luzhou People’s Hospital for her valuable guidance in the pathological identification of the characteristic features of Dieulafoy’s disease. References Löschhorn C, Nierhoff N, Mayer R, Zaunbauer W, Neuweiler J, Knoblauch A. Dieulafoy’s disease of the lung: A potential disaster for the bronchoscopist. Respiration. 2006;73:562–5. https://doi.org/10.1159/000088059. Kolb T, Gilbert C, Fishman E, Terry P, Pearse D, Feller-Kopman D, et al. Dieulafoy’s Disease of the Bronchus. Am J Respir Crit Care Med. 2012;186:1191–1191. https://doi.org/10.1164/rccm.201206-1016IM. Hadjiphilippou S, Shah PL, Rice A, Padley S, Hind M. Bronchial dieulafoy lesion. A 20-year history of unexplained hemoptysis. Am J Respir Crit Care Med. 2017;195:397–397. https://doi.org/10.1164/rccm.201609-1932IM. Kuzucu A, Gürses İ, Soysal Ö, Kutlu R, Özgel M. Dieulafoy’s disease: A cause of massive hemoptysis that is probably underdiagnosed. The Annals of Thoracic Surgery. 2005;80:1126–8. https://doi.org/10.1016/j.athoracsur.2004.02.118. Parrot A, Antoine M, Khalil A, Théodore J, Mangiapan G, Bazelly B, et al. Approach to diagnosis and pathological examination in bronchial Dieulafoy disease: a case series. Respir Res. 2008;9:58. https://doi.org/10.1186/1465-9921-9-58. Zaric B, Stojsic V, Sarcev T, Stojanovic G, Carapic V, Perin B, et al. Advanced bronchoscopic techniques in diagnosis and staging of lung cancer. J Thorac Dis. 2013;5 Suppl 4:S359–70. https://doi.org/10.3978/j.issn.2072-1439.2013.05.15. van der Werf TS, Timmer A, Zijlstra JG. Fatal haemorrhage from dieulafoy’s disease of the bronchus. Thorax. 1999;54:184–5. https://doi.org/10.1136/thx.54.2.184. Yang H, Liu Y, Lou J, Chen X, Zhang Q, Zhang X, et al. Diagnosis and treatment of bronchial dieulafoy’s disease: A case series. Respiration. 2025;104:597–602. https://doi.org/10.1159/000545261. Richart V, Gelabert A, Zugazaga A. A rare cause of massive hemoptysis: Bronchial dieulafoy’s disease treated with embolization. Archivos de Bronconeumología. 2024;60:792–3. https://doi.org/10.1016/j.arbres.2024.08.003. Bonnefoy V, Garnier M, Tavolaro S, Antoine M, Assouad J, Fartoukh M, et al. Bronchial dieulafoy’s disease: Visualization of embolization particles in bronchial aspirate. Am J Respir Crit Care Med. 2018;198:954–5. https://doi.org/10.1164/rccm.201711-2184IM. Woodhull S, Bush A, Tang AL, Padley S. Massive paediatric pulmonary haemorrhage in dieulafoy’s disease: Roles of CT angiography, embolisation and bronchoscopy. Paediatr Respir Rev. 2020;36:100–5. https://doi.org/10.1016/j.prrv.2020.06.001. Li K, Wen L, Zhou H, Zhou Z. Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report. Heliyon. 2024;10:e23702. https://doi.org/10.1016/j.heliyon.2023.e23702. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Apr, 2026 Reviews received at journal 18 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviews received at journal 13 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor invited by journal 23 Jan, 2026 Editor assigned by journal 23 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 21 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8516053","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":593577017,"identity":"5e559d39-a88d-407d-bb5d-2c239c57a3cc","order_by":0,"name":"Yunxiao Li","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yunxiao","middleName":"","lastName":"Li","suffix":""},{"id":593577018,"identity":"c945264d-c4c9-4115-9bcb-bf3ae66b7c74","order_by":1,"name":"Ruimin Ma","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruimin","middleName":"","lastName":"Ma","suffix":""},{"id":593577019,"identity":"8ac8b472-6074-45a2-8038-957624565916","order_by":2,"name":"Xiaohua Wu","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaohua","middleName":"","lastName":"Wu","suffix":""},{"id":593577020,"identity":"56bc2674-f5fa-4b15-bb05-0f83a29b13c9","order_by":3,"name":"Yuefeng Hu","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuefeng","middleName":"","lastName":"Hu","suffix":""},{"id":593577021,"identity":"68f69e9e-aba7-4819-8d64-c72f62d399f8","order_by":4,"name":"Shuhong Zhang","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuhong","middleName":"","lastName":"Zhang","suffix":""},{"id":593577022,"identity":"9bc1745d-e1f9-4288-86ed-ad404d180486","order_by":5,"name":"Haixin Jia","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haixin","middleName":"","lastName":"Jia","suffix":""},{"id":593577023,"identity":"977151b0-330f-4de0-8822-91c7fb2dcd1c","order_by":6,"name":"Bo Xu","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Xu","suffix":""},{"id":593577024,"identity":"22451e5e-c6f3-45fe-a902-6ce5fde9bede","order_by":7,"name":"Fugui Yan","email":"","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fugui","middleName":"","lastName":"Yan","suffix":""},{"id":593577025,"identity":"e65bf526-25bc-4d35-9084-1da83779b959","order_by":8,"name":"Fang Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACPmYGhg8JFTZy/MzMBx8QpYWNmYFxxoczacaS7WzJBsRpYWBgnDmz7XDihvM8ZgLEaWHnPdjM28ZsbHyYwYyBocYmmgiH8SU285xjkzM7zJD2gOFYWm4DYS085o95yniMgVqOGzA2HCZKi2EzD5tE4uZmxjYJorU0zmgzSNzAzMxGvJaGD2cSjCUOszEbJBDjF37+M4YNCRX/5fj7z3988KHGhrAWVJBAmvJRMApGwSgYBbgAAKPuONAqXkvzAAAAAElFTkSuQmCC","orcid":"","institution":"Beijing Friendship Hospital","correspondingAuthor":true,"prefix":"","firstName":"Fang","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2026-01-05 02:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8516053/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8516053/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103165238,"identity":"224892b8-3320-412f-996e-9843af6748e7","added_by":"auto","created_at":"2026-02-22 12:25:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5398743,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBronchoscopic (white-light and NBI) and contrast-enhanced CT findings.\u003cbr\u003e\n \u003c/strong\u003e(A) White-light bronchoscopy shows a small, broad-based nodular lesion protruding into the bronchial lumen (arrow). (B) Narrow-band imaging (NBI) view of the same lesion demonstrates no obvious abnormal superficial vascular pattern. (C, D) Pre-interventional contrast-enhanced chest CT demonstrates patchy consolidation in the left hilar region with punctate hyperdense foci and evident contrast enhancement. Arrows indicate enhancing tubular foci within the consolidation, likely corresponding to tortuous and dilated vascular structures.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8516053/v1/985e3faa66c7c981aba143b8.png"},{"id":103165235,"identity":"bfb65f28-54c3-4ca7-ba4c-c8d076abc140","added_by":"auto","created_at":"2026-02-22 12:25:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13743550,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHistopathological features of bronchial Dieulafoy disease.\u003cbr\u003e\n \u003c/strong\u003eHematoxylin and eosin (H\u0026amp;E) staining (A, ×100; B, ×200) demonstrates a markedly dilated, thick-walled aberrant artery located in the subepithelial layer of the bronchial wall, in close proximity to the bronchial mucous glands (yellow arrows). The vessel shows a prominent muscular wall (black arrows), consistent with an arterial structure rather than a venous or capillary lesion. Immunohistochemical staining for desmin (C, ×200) highlights concentric smooth muscle bundles within the vascular wall (red arrows), confirming the presence of vascular smooth muscle. Elastic fiber staining (D, ×200; Verhoeff–Van Gieson) reveals a well-defined elastic lamina surrounding the vessel (white arrows), further supporting the diagnosis of an aberrant bronchial artery consistent with bronchial Dieulafoy disease.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8516053/v1/8c4624f4c19367e4422fca75.png"},{"id":103165234,"identity":"270a1180-3c9c-4687-a7b0-90b8dc63b35d","added_by":"auto","created_at":"2026-02-22 12:25:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1834785,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePulmonary embolism following bronchial artery embolization and its resolution after anticoagulation therapy.\u003c/strong\u003e\u003cbr\u003e\nComputed tomography pulmonary angiography (CTPA) images demonstrate acute pulmonary embolism involving the anterior and apical segments of the right upper lobe pulmonary artery (A, arrows) and the superior lingular segment of the left upper lobe pulmonary artery (B, arrows). Follow-up CTPA performed after therapeutic anticoagulation shows complete resolution of the previously identified emboli with restoration of normal pulmonary arterial patency (C, D, arrows).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8516053/v1/9fb6b68fe3469a00ec2f7200.png"},{"id":103165236,"identity":"37e13ee1-c3d5-41ff-91f1-11ab5032a61d","added_by":"auto","created_at":"2026-02-22 12:25:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10881211,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBronchial artery embolization for massive hemoptysis.\u003c/strong\u003e\u003cbr\u003e\nSelective angiography before bronchial artery embolization (BAE) demonstrates abnormal systemic arterial supply. (A) The left upper bronchial artery is markedly dilated with tortuous, disorganized distal branches and focal contrast extravasation. (B) The distal left lower bronchial artery shows tortuous course and intense parenchymal staining without definite contrast leakage. (C) Abnormal tortuous branches arising from the left fourth to fifth intercostal artery with an intercostal–pulmonary arterial fistula and increased staining, without contrast extravasation. After-embolization angiography (D–F) shows successful occlusion of the culprit vessels. (D) Coil embolization of the left upper bronchial artery (MWCE-18S-6/2) results in marked reduction of distal branches and disappearance of contrast extravasation. (E) Embolization of the left lower bronchial artery using gelatin sponge particles (560–710 μm) eliminates distal arterial opacification. (F) Gelatin sponge particle embolization (560–710 μm) of the intercostal artery achieves complete occlusion of abnormal distal branches. Hemoptysis improved markedly with no evidence of active bleeding.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8516053/v1/9633f89c954e514e3e9f3383.png"},{"id":103165293,"identity":"90e5352c-39a6-41f4-bf77-608f5dac65ed","added_by":"auto","created_at":"2026-02-22 12:25:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":41043594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8516053/v1/6ae7ec6d-e5bb-4f45-bd33-c7df2d6b427a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eBronchial Dieulafoy’s disease complicated by pulmonary embolism after successful hemostasis: a case report and review of the literature\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eBronchial Dieulafoy\u0026rsquo;s disease (BDD) is an uncommon but potentially lethal cause of hemoptysis, characterized by a dysplastic, large-caliber artery running superficially within the bronchial submucosa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause the overlying mucosa often appears intact and nonulcerated, the lesion may mimic benign inflammatory nodules or endobronchial tumors, leading to inadvertent biopsy and catastrophic bleeding [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Early recognition and appropriate management are therefore critical, and pathological confirmation\u0026mdash;when available\u0026mdash;remains the gold standard for diagnosis, typically demonstrating a large-caliber aberrant artery located immediately beneath the bronchial epithelium without features of vasculitis or malignancy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 77-year-old woman with no smoking history and no known underlying lung disease, including chronic obstructive pulmonary disease, bronchiectasis, or prior tuberculosis, was admitted for evaluation of lung consolidation detected on imaging. Contrast-enhanced chest computed tomography revealed a consolidation-like lesion in the left hilar region with focal enhancement and internal punctate hyperdense foci of indeterminate etiology.\u003c/p\u003e\n\u003cp\u003eFlexible bronchoscopy demonstrated extrinsic compression and luminal narrowing of the basal and posterior segments of the left lower lobe. A small, broad-based nodular lesion protruding from the left main bronchial wall was observed, covered by a whitish cap-like structure. No active bleeding was observed on gentle contact. Endobronchial biopsy, brushing, and bronchoalveolar lavage were performed.\u003c/p\u003e\n\u003cp\u003eDuring bronchoscopy under general anesthesia, the patient suddenly developed massive hemoptysis. Initial hemostatic measures, including intravenous vasopressin, topical thrombin application, and blood transfusion, achieved only transient control. Recurrent hemorrhage occurred during transfer, and emergency bronchial artery embolization (BAE) was performed under general anesthesia. The estimated total blood loss was approximately 1500 mL.\u003c/p\u003e\n\u003cp\u003eSelective angiography revealed marked enlargement of the left upper bronchial artery with tortuous distal branches and focal contrast extravasation. Superselective embolization using gelatin sponge particles (560\u0026ndash;710 \u0026mu;m and 710\u0026ndash;1000 \u0026mu;m) and detachable coils was performed. Additional embolization was required for abnormal distal branches of the left lower bronchial artery and the left fourth to fifth intercostal arteries showing systemic\u0026ndash;pulmonary shunting. Post-embolization angiography confirmed cessation of contrast extravasation and marked reduction of distal arterial branches.\u003c/p\u003e\n\u003cp\u003eHemoptysis resolved promptly. Repeat bronchoscopy showed large intrabronchial clots, which were removed. The patient was transferred to the intensive care unit and later returned to the respiratory ward. She subsequently developed aspiration pneumonia and was treated with empirical broad-spectrum antibiotics.\u003c/p\u003e\n\u003cp\u003eDespite hemodynamic stabilization after bronchial artery embolization, the patient remained in a critical condition with severe hypoxemia and had not yet passed the immediate high-risk period; therefore, transfer for computed tomography pulmonary angiography (CTPA) was deferred, and bedside transthoracic echocardiography was performed instead. Transthoracic echocardiography demonstrated newly developed pulmonary hypertension, with an estimated pulmonary artery systolic pressure of 42 mmHg compared with a baseline value of 17.67 mmHg. Cardiac biomarkers were elevated, including cardiac troponin I (0.122 ng/mL) and NT-proBNP (2636 pg/mL), raising strong suspicion for acute pulmonary embolism.\u003c/p\u003e\n\u003cp\u003eGiven the recent life-threatening hemoptysis, anticoagulation was cautiously initiated with reduced-dose low-molecular-weight heparin (enoxaparin 60 mg [6000 IU anti-Xa] once daily). Oxygenation improved slowly but remained inadequate. On day 9 after embolization, CTPA confirmed acute pulmonary embolism involving the anterior and apical segments of the right upper lobe and the lingular segment of the left upper lobe, consistent with intermediate-risk pulmonary embolism. After multidisciplinary discussion, anticoagulation was escalated to therapeutic dosing (enoxaparin 60 mg every 12 hours, approximately 1 mg/kg). No recurrent hemoptysis occurred.\u003c/p\u003e\n\u003cp\u003eHistopathological examination of the biopsy specimen revealed a markedly dilated artery located superficially within the bronchial submucosa. Elastic fiber staining demonstrated a well-defined elastic lamina, and immunohistochemical staining for desmin highlighted concentric smooth muscle bundles within the vessel wall, confirming the diagnosis of bronchial Dieulafoy\u0026rsquo;s disease[1, 5].\u003c/p\u003e\n\u003cp\u003eThe patient was discharged in stable condition. She reported significant anxiety during the episode of massive hemoptysis but experienced marked relief after successful bronchial artery embolization. She tolerated subsequent anticoagulation therapy well, with no recurrent bleeding, and was satisfied with the overall treatment outcome. Anticoagulation was continued for three months. Follow-up imaging showed complete resolution of pulmonary embolism, and no recurrence of hemoptysis was observed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBDD poses a major diagnostic challenge because of its deceptively benign bronchoscopic appearance. Small, mucosa-colored nodules covered by a whitish fibrinous layer (\u0026ldquo;white cap\u0026rdquo;) are commonly described and may closely mimic nonvascular lesions [2\u0026ndash;4].\u0026nbsp;In our patient, the absence of active bleeding and the benign appearance contributed to diagnostic biopsy, reflecting a well-recognized pitfall rather than an isolated procedural error.\u0026nbsp;Notably, the absence of apparent vascular features\u0026mdash;even when advanced imaging modalities such as narrow-band imaging (NBI) are applied\u0026mdash;does not exclude a vascular lesion. This may relate to the optical principle of NBI, which primarily enhances superficial mucosal microvasculature with relatively limited depth penetration, whereas bronchial Dieulafoy-type lesions typically originate from a large-caliber submucosal artery that may not produce conspicuous surface vascular changes detectable by NBI\u0026nbsp;[6]. Numerous reports have demonstrated that bronchoscopic manipulation or biopsy of bronchial Dieulafoy lesions can precipitate catastrophic arterial hemorrhage\u0026nbsp;[1, 3, 7, 8]. This case reinforces that any broad-based endobronchial nodule associated with unexplained hemoptysis should be approached with extreme caution, and biopsy should be avoided unless a vascular lesion has been reasonably excluded. In addition, bronchial Dieulafoy\u0026rsquo;s disease should be differentiated from other rare vascular or tumor-associated conditions, such as paravertebral neurilemmoma\u0026ndash;associated vascular anomalies, which may present with similar endobronchial appearances but differ fundamentally in pathogenesis and management\u0026nbsp;[8].\u003c/p\u003e\n\u003cp\u003eAngiography plays a central role in the diagnosis and management of BDD, typically demonstrating hypertrophied and tortuous bronchial arteries with abnormal distal branching or contrast extravasation [8, 9]. Bronchial artery embolization is widely regarded as the first-line therapy for acute bleeding control and achieves high immediate success rates [9, 10]. In selected and complex cases, including pediatric or atypical presentations, multimodality imaging such as CT angiography may further facilitate early identification of the bleeding source and guide timely endovascular or bronchoscopic intervention\u0026nbsp;[11]. In the present case, superselective embolization resulted in durable hemostasis without recurrence during follow-up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePulmonary embolism is not a commonly reported complication of bronchial artery embolization itself. In this patient, the thromboembolic event was likely multifactorial, related to hemorrhagic shock, prolonged immobilization, systemic inflammation, and transient hypercoagulability. Management posed a major therapeutic dilemma, as anticoagulation carries an inherent risk of precipitating recurrent airway bleeding after recent massive hemoptysis. A stepwise anticoagulation strategy\u0026mdash;beginning with reduced dosing after secure hemostasis and escalating to full therapeutic dosing after confirmation and stabilization\u0026mdash;was well tolerated and resulted in complete resolution of pulmonary embolism without recurrent bleeding. Recent reviews have emphasized that bronchial Dieulafoy\u0026rsquo;s disease remains underrecognized in clinical practice and that heightened awareness is essential to prevent iatrogenic complications and optimize outcomes [11].\u003c/p\u003e\n\u003cp\u003eSevere hemoptysis requiring advanced life-support measures has also been reported in special populations, such as pregnant patients, in whom extracorporeal membrane oxygenation combined with interventional management was successfully applied as rescue therapy [12].\u0026nbsp;These reports further underscore the extreme clinical spectrum of massive airway bleeding and the necessity of individualized, multidisciplinary decision-making when balancing hemorrhagic and thrombotic risks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical implications\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eBronchial Dieulafoy\u0026rsquo;s disease should be considered in patients with unexplained hemoptysis and benign-appearing endobronchial nodules, especially those with a \u0026ldquo;white cap\u0026rdquo; appearance.\u003c/li\u003e\n \u003cli\u003eBronchoscopic biopsy of such lesions carries a high risk of catastrophic hemorrhage and should be avoided unless a vascular etiology has been reasonably excluded.\u0026nbsp;The absence of abnormal vascular patterns on NBI does not exclude bronchial Dieulafoy\u0026rsquo;s disease, as the culprit vessel is often submucosal and beyond the effective imaging depth of NBI\u003c/li\u003e\n \u003cli\u003eBronchial artery embolization is a lifesaving first-line intervention for massive hemoptysis caused by BDD.\u003c/li\u003e\n \u003cli\u003eAfter secure hemostasis, anticoagulation for concomitant pulmonary embolism may be feasible in carefully selected patients, but treatment decisions must be individualized.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The data are available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;YL and RMwas the primary physician involved in the patient\u0026rsquo;s management, conceived the report, collected clinical data, performed the literature review, and drafted the manuscript. XW provided expert interpretation of CT/CTPA images. YH performed the life-saving bronchial artery embolization for hemostasis. SZ provided guidance on pathological specimen processing, and interpretation of the biopsy samples. PL provided guidance on the interpretation of the pathological slides. HJ coordinated nursing care. FL and FY supervised the overall clinical rescue and treatment and critically revised the manuscript. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (Grant No. 82000043) and the Capital\u0026rsquo;s Funds for Health Improvement and Research (Grant No. 2024-2-1101).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was performed in accordance with the Animal Ethics Committee of Beijing Friendship Hospital, Capital Medical University (Approval No. 2026-P2-016-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declarations:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors would like to thank Dr. Chen Guang and Hu Yuefeng from the Interventional Radiology Department for performing the life-saving bronchial artery embolization for this patient. We also acknowledge Dr. Liu Ping from Luzhou People\u0026rsquo;s Hospital for her valuable guidance in the pathological identification of the characteristic features of Dieulafoy\u0026rsquo;s disease.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eL\u0026ouml;schhorn C, Nierhoff N, Mayer R, Zaunbauer W, Neuweiler J, Knoblauch A. Dieulafoy\u0026rsquo;s disease of the lung: A potential disaster for the bronchoscopist. Respiration. 2006;73:562\u0026ndash;5. https://doi.org/10.1159/000088059.\u003c/li\u003e\n\u003cli\u003eKolb T, Gilbert C, Fishman E, Terry P, Pearse D, Feller-Kopman D, et al. Dieulafoy\u0026rsquo;s Disease of the Bronchus. Am J Respir Crit Care Med. 2012;186:1191\u0026ndash;1191. https://doi.org/10.1164/rccm.201206-1016IM.\u003c/li\u003e\n\u003cli\u003eHadjiphilippou S, Shah PL, Rice A, Padley S, Hind M. Bronchial dieulafoy lesion. A 20-year history of unexplained hemoptysis. Am J Respir Crit Care Med. 2017;195:397\u0026ndash;397. https://doi.org/10.1164/rccm.201609-1932IM.\u003c/li\u003e\n\u003cli\u003eKuzucu A, G\u0026uuml;rses İ, Soysal \u0026Ouml;, Kutlu R, \u0026Ouml;zgel M. Dieulafoy\u0026rsquo;s disease: A cause of massive hemoptysis that is probably underdiagnosed. The Annals of Thoracic Surgery. 2005;80:1126\u0026ndash;8. https://doi.org/10.1016/j.athoracsur.2004.02.118.\u003c/li\u003e\n\u003cli\u003eParrot A, Antoine M, Khalil A, Th\u0026eacute;odore J, Mangiapan G, Bazelly B, et al. Approach to diagnosis and pathological examination in bronchial Dieulafoy disease: a case series. Respir Res. 2008;9:58. https://doi.org/10.1186/1465-9921-9-58.\u003c/li\u003e\n\u003cli\u003eZaric B, Stojsic V, Sarcev T, Stojanovic G, Carapic V, Perin B, et al. Advanced bronchoscopic techniques in diagnosis and staging of lung cancer. J Thorac Dis. 2013;5 Suppl 4:S359\u0026ndash;70. https://doi.org/10.3978/j.issn.2072-1439.2013.05.15.\u003c/li\u003e\n\u003cli\u003evan der Werf TS, Timmer A, Zijlstra JG. Fatal haemorrhage from dieulafoy\u0026rsquo;s disease of the bronchus. Thorax. 1999;54:184\u0026ndash;5. https://doi.org/10.1136/thx.54.2.184.\u003c/li\u003e\n\u003cli\u003eYang H, Liu Y, Lou J, Chen X, Zhang Q, Zhang X, et al. Diagnosis and treatment of bronchial dieulafoy\u0026rsquo;s disease: A case series. Respiration. 2025;104:597\u0026ndash;602. https://doi.org/10.1159/000545261.\u003c/li\u003e\n\u003cli\u003eRichart V, Gelabert A, Zugazaga A. A rare cause of massive hemoptysis: Bronchial dieulafoy\u0026rsquo;s disease treated with embolization. Archivos de Bronconeumolog\u0026iacute;a. 2024;60:792\u0026ndash;3. https://doi.org/10.1016/j.arbres.2024.08.003.\u003c/li\u003e\n\u003cli\u003eBonnefoy V, Garnier M, Tavolaro S, Antoine M, Assouad J, Fartoukh M, et al. Bronchial dieulafoy\u0026rsquo;s disease: Visualization of embolization particles in bronchial aspirate. Am J Respir Crit Care Med. 2018;198:954\u0026ndash;5. https://doi.org/10.1164/rccm.201711-2184IM.\u003c/li\u003e\n\u003cli\u003eWoodhull S, Bush A, Tang AL, Padley S. Massive paediatric pulmonary haemorrhage in dieulafoy\u0026rsquo;s disease: Roles of CT angiography, embolisation and bronchoscopy. Paediatr Respir Rev. 2020;36:100\u0026ndash;5. https://doi.org/10.1016/j.prrv.2020.06.001.\u003c/li\u003e\n\u003cli\u003eLi K, Wen L, Zhou H, Zhou Z. Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report. Heliyon. 2024;10:e23702. https://doi.org/10.1016/j.heliyon.2023.e23702. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bronchial Dieulafoy’s disease, massive hemoptysis, bronchial artery embolization, pulmonary embolism, anticoagulation, case report","lastPublishedDoi":"10.21203/rs.3.rs-8516053/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8516053/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBronchial Dieulafoy\u0026rsquo;s disease (BDD) is a rare vascular anomaly characterized by a large-caliber submucosal artery that can cause sudden, massive, and potentially fatal hemoptysis. Because of its deceptively benign endobronchial appearance, the disease is frequently underrecognized and carries a high risk of catastrophic bleeding following bronchoscopic manipulation.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 77-year-old woman without underlying lung disease developed massive hemoptysis and hemorrhagic shock shortly after diagnostic bronchoscopy for an indeterminate endobronchial lesion. Emergency bronchial artery embolization (BAE) achieved durable hemostasis. During recovery, the patient developed intermediate-risk pulmonary embolism, posing a major therapeutic dilemma regarding anticoagulation after recent life-threatening airway bleeding. A stepwise anticoagulation strategy was cautiously implemented after secure hemostasis, resulting in complete resolution of pulmonary embolism without recurrent hemoptysis. Histopathological examination confirmed the diagnosis of bronchial Dieulafoy\u0026rsquo;s disease.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case highlights the diagnostic pitfalls of bronchial Dieulafoy\u0026rsquo;s disease, the lifesaving role of bronchial artery embolization, and the complexity of managing thromboembolic complications following control of massive hemoptysis. Clinicians should maintain a high index of suspicion for BDD in patients with unexplained hemoptysis and benign-appearing endobronchial lesions, and bronchoscopic biopsy should be avoided whenever a vascular etiology is suspected.\u003c/p\u003e","manuscriptTitle":"Bronchial Dieulafoy’s disease complicated by pulmonary embolism after successful hemostasis: a case report and review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 12:25:08","doi":"10.21203/rs.3.rs-8516053/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T06:14:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T23:35:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304843857842687715949999111334143145977","date":"2026-02-15T14:08:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T23:56:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229055437407354346180123905582173041058","date":"2026-02-13T23:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T13:51:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-23T08:11:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-23T07:34:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T13:25:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2026-01-21T13:13:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43fa5b61-3f76-4e54-aa10-089f0c38cf8f","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T10:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 12:25:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8516053","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8516053","identity":"rs-8516053","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}