Surgical management of refractory massive hemoptysis from pulmonary artery pseudoaneurysm due to Streptococcus constellatus: a rare case report and literature review.

Pulmonary artery pseudoaneurysm (PAP) is a rare but potentially fatal vascular lesion resulting from focal disruption of the pulmonary arterial wall. Although hemoptysis from the pulmonary arterial system is uncommon, PAP carries a high risk of rupture, with reported mortality rates up to 50%. PAP is most often caused by trauma or infection, with pyogenic bacteria and fungi as typical pathogens, while Streptococcus constellatus is an exceptionally rare cause. A 60-year-old woman with well-controlled type 2 diabetes presented with recurrent massive hemoptysis, fever, and right-sided pleuritic chest pain, without prior lung disease or trauma. She initially underwent emergency bronchial artery embolization (BAE) and antibiotic therapy for necrotizing pneumonia-associated hemoptysis, with no clinical improvement. Following the second BAE for recurrent massive hemoptysis, a PAP, possibly related to a bronchial-pulmonary arterial shunt, was suspected in the right lower lobe on angiography and subsequently confirmed on contrast-enhanced computed tomography. Despite optimal medical therapy, repeated BAE, and coil embolization of the PAP, hemoptysis persisted, and respiratory status deteriorated. The patient ultimately underwent video-assisted thoracoscopic right lower lobectomy, with intraoperative cultures of lung tissue and pleural fluid confirming S. constellatus, and achieved complete recovery without recurrent hemoptysis. PAP is a rare but potentially fatal cause of hemoptysis that requires a high index of suspicion. Although endovascular intervention is effective for initial hemorrhage control, persistent infection or refractory hemoptysis may necessitate surgical resection to achieve definitive management. This case highlights S. constellatus as an exceptionally rare infectious cause of PAP and underscores the importance of a multidisciplinary approach in complex, antibiotic-resistant cases.