Middle Lobe Syndrome Due to Sarcoidosis

Abstract

Mrs. M. S., a 57-year old white school teacher was first seen by one of us (H.A.A.) at her home on January 7, 1955. She had noted rhinorrhea, cough and hoarseness for about five days. Her temperature was 103#{176} F., pulse 100 and blood pressure 120/68. Coarse rales and wheezes were noted throughout the right chest. She was hospitalized and penicillin therapy instituted. It was only after repeated questioning that a further history of wheezes occurring occasionally during the preceding two years, following a “virus infection,” was elicited. Because of consciousness that unilateral wheezes often indicate neoplastic broncho-stenosis, collection of 24 hour sputa was started immediately for examination for neoplastic cells by the Papanicolaou, as well as for tubercle bacilli by the Ziehl-Neelsen, techniques. Two specimens were negative for the latter, one specimen indicated class 2 cells (non-neoplastic) by the former. X-ray films of the chest on January 8 and 17, 1955 (Fig. 1) indicated the following: “There is a rather broad zone of homogeneous increase in density in the region of the fissure between the right middle and lower lobes which appears to be mainly confined to the middle lobe. In addition several horizontal strands of increased density are noted in the posterior portion of the lower lobe rather typical of segmental atelectasis. There is slight retraction of the heart and mediastinal structures to the right and also slight elevation of the anterior portion of the right dome of the diaphragm. These latter findings are all secondary to atelectasis. The right upper lobe and portions of the lower lobe that are not involved with the segmental atelectasis disclose mild compensatory emphysema. In the left apex are several fibrotic and faintly nodular densities that are probably of long standing but from this single examination cannot be considered absolutely inactive. The remainder of the left lung is satisfactorily aerated. The heart is not enlarged.” Following the defervescence of fever and improvement in physical condition bronchoscopy was performed on January 19, 1955 by Dr. Joseph Sirken, who noted stenosis of the right main bronchus. Biopsy indicated only “chronic eroding bronchitis.” Bronchial secretion showed class 2 cells (not neoplastic) by the Papanicolaou technique. Increased aeration of the right lower lobe was noted after this procedure. Partial atelectasis *Medical Service, Albert Einstein Medical Center, Southern Division.