A man undergoing heart failure treatment spat out an enormous clot of intact blood that formed a perfect cast of air passages in his lung.
The integrity of the clot, once unfolded in blue medical tissue, astounded the doctors; they could trace the three branches of the upper lobe of the lung, the two branches in the middle lobe and five segmental branches in the lower one.
Spanning about 15cm by 17cm, it was a perfect set of airways that they knew exactly where the clot had come from, the bronchial tree right from the patient's lung.
Although called a tree, more resembles roots. Imagine pulling a sturdy dandelion when suddenly all the intricate root system slides off the floor without parts loosening.
Instead of the doctors pulling the red and bloody mass of the patient's lung, however, the man interrupted him unexpectedly, as the doctors noted later: "During an extreme coughing crisis."
The strange sample of a medical anomaly led two of his physicians at the University of California, San Francisco – Gavitt Woodard, a thoracic surgeon, and Georg Wieselthaler, cardiothoracic surgeon – to write a note on the case, published this week in the journal. New England Journal of Medicine.
The audience response was a mixture of wonder and horror.
Several media reports have distorted the science of the thing, presenting it as a patient literally spitting out a lung, a common expression for what it feels like to cough profusely.
"The man coughs part of the lung while being treated for heart failure," a Fox News headline says, failing to notice or realize that it is a mold inside the lung – like pouring concrete into a mold and then removing the mold, only with blood instead of concrete – that came out of his mouth instead of his own lung.
The Daily Mail Online capitalized on its bad direction in its title: "Man, 36, coughing part of his LUNG," he says.
The intricate expectorate is where the blood leaked into the patient's lung air passages and hardened, which is medically called coagulation. The solidifying blood caused an intense cough to clear them. Of course they did.
Any relief from productive coughing did not last, though. The patient was already dying of heart failure. Despite the intervention, he died nine days after cutting the clot.
Doctors do not identify his patient by name, but say he was a 36-year-old man undergoing treatment at the intensive care unit with chronic heart failure.
He has had considerable intervention including aortic valve replacement, aortic aneurysm stent implantation, and definitive pacemaker implant for complete heart block.
The unusual clot is probably explained by the next intervention.
Doctors have placed an Impella ventricular assist device in their heart through an artery, which is a heart pump that holds a patient temporarily, moving the blood through the heart to the rest of the body's organs. According to the manufacturer's website, it is a treatment designed for "patients with no option".
Blood clots are a possible known side effect of the pump.
"Blood clots can develop, which can travel through blood vessels and block blood flow to other organs, including the lungs, making it difficult to breathe," according to the Impella website.
To reduce clotting, doctors use an anticoagulant called heparin.
During the following week, the patient had periodic coughing attacks, cutting small amounts of blood or blood-stained mucus, the doctors wrote in their published case note.
He had difficulty breathing and needed supplemental oxygen to relieve the pain.
"During an extreme coughing crisis, the patient spontaneously expectorated an intact cast of the right bronchial tree," the doctors wrote.
Tubes were inserted into his throat and a scope used to examine the patient's airway. Two days later, the tubes were removed and he had no more bloody cough, the doctors wrote.
A week later, however, the patient died of heart failure complications.