GIANT PULMONARY BULLA IN A 2-YEAR-OLD CHILD

Abstract

SESSION TITLE: Critical Care and Pediatrics SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Cystic anomalies of the lung in the pediatric population represent entities with several differentials mainly divided into congenital and acquired lesions. It can be caused by a diverse array of pathologic processes. CASE PRESENTATION: A 2yr-old female child was admitted due to recurrent cough. Her condition started 5 weeks prior to admission when patient had non-productive cough but without fever. Chest radiograph revealed Koch's pneumonia, massive pneumothorax with minimal hydrothorax on the left lung (fig1). Chest tomography showed a large pulmonary bulla with deviation of the mediastinal structures to the right (fig 2). Mantoux test was 0mm. Pertinent chest and lung findings include chest asymmetry, positive chest lag on left hemithorax, no retractions, hyperresonant and decrease tactile fremitus as well as decrease breath sounds on the left. CBC, electrolytes, protime and APTT were normal. Patient underwent thoracotomy and bullectomy on the left lung. Post-operative chest xray revealed interval resolution of previously noted cystic lucency and rightward mediastinal shift (fig 3). Lung biopsy showed fragments of lung tissue with focal intra-alveolar hemorrhages and mild emphysematous changes and thin fibrous cyst wall favors Pulmonary Bulla. No complications noted and patient was discharged. DISCUSSION: The morphologies of pulmonary cystic and cavitary lesions exhibit a broad spectrum. On chest xray and computed tomography, a cyst appears as a round parenchymal lucency with a well-defined interface of normal lung . Bulla is an air space in the lung measuring more than 1cm in diameter. A Giant bulla occupy at least 30% of the hemithorax .A single bulla is rare and occupy portions of upper anterior and mediastinal aspect of the lung. Bulla formation begins when there is confluence of two or more of the terminal elements of the bronchial tree.Patients with giant bullae may be asymptomatic or in distress.Complications include repeated infections, hemorrhage or spontaneous pneumothorax. Management depends on the degree of symptoms. For asymptomatic patients medical and surgical therapy is usually deferred. Bullectomy involves the surgical removal of one or more giant bullae by thoracotomy or VATS. Indications for bullectomy aside from a symptomatic patient includes a bulla that occupies greater than 30% of the hemithorax and a radiographic evidence that the bulla is compressing adjacent structures which were the indications for doing bullectomy in this patient. Following bullectomy, expansion of surrounding healthy lung tissue and improvement in chest mechanics by remodeling of the thorax and diaphragm occurs. CONCLUSIONS: This is a rare case of a 2-yr old child presented with recurrent cough who was asymptomatic but had a large (>30%) pulmonary cystic lesion in the left lung. CT scan revealed a giant pulmonary bulla and the patient underwent bullectomy with no post-op complications. Reference #1: Na Rae Kim and Joungho Han; Pathologic Review of Cystic and Cavitary Lung Diseases; Korean JPathol. 2012 Oct;46(5):407-414 Published online 2012 Oct25.https://doi.org/10.4132/KoreanJPathol.2012.46.5.407 Reference #2: Jay H. Ryu, MD and Stephen J. Swensen; Cystic and Cavitary Lung Diseases: focal and diffuse; MayoClinic Proceedings, 2003 Jun; 78(6); 744-52 Reference #3: Suhail Raoof et al; Cystic Lung Diseases algorithmic approach ; CHEST JOURNAL October 2016 , Vol150, No.4 DISCLOSURES: No relevant relationships by Brenda Lou Lovely Abanilla, source=Web Response