Recurrent aspiration and upper lobe cavitation

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In May, 2010, a 49-year-old woman presented to the outpatient clinic with a 4-month history of feeling generally unwell with night sweats and a persistent productive cough of green and yellow sputum. She described coughing when lying fl at, particularly in the early morning hours. Medical history included laparo scopic adjustable gastric banding fi tted in September, 2008, for class III obesity, when her body-mass index (BMI) was 45·4 kg/m². She had been referred to a weight management clinic in July, 2008, at age 49 (BMI 46·2 kg/m²), and subsequently qualifi ed for gastric banding. Her initial response to surgery was modest and she underwent further band fi lls in 2008 and 2009. She was a known asthmatic and had been treated by her general practitioner for exacerbation of her asthma but with no improvement. On examination, her BMI was 32·6 kg/m² and her observations were within normal limits. Blood tests showed a high concentration of C-reactive protein (81 mg/L) and a high ESR (96 mm/h). Chest radiograph showed left upper zone cavitation. Given the radiographic appearance and the presence of persistent night sweats, tuberculosis was suspected. She was referred to the tuberculosis clinic and a subsequent thoracic CT scan confi rmed the presence of a 3·2 cm × 2·8 cm irregular cavitating lesion within the apical segment of the left upper lobe (fi gure). A moderate dilatation of the oesophagus, but no signifi cant thoracic lymphadenopathy, was also seen. Subsequent early morning sputum samples for acid fast bacilli were persistently negative and sputum culture showed only normal respiratory fl ora. Aspergillus precipitins were negative and an autoimmune screen showed no abnormalities. A bronchoscopy and subsequent washings did not yield acid fast bacilli. At this point, the diagnosis of recurrent aspiration and cavitation secondary to a severe restriction from her gastric banding was suspected. She was allergic to penicillin, and therefore treated with metronidazole and doxycycline.Her symptoms persisted, and after 6 weeks of anti-biotics she had only had short-term symptom relief. Therefore, her gastric band was completely emptied, after which her symptoms quickly resolved. A subsequent barium meal showed resolution of her oesophageal dilatation. Based on chest radiographs, the lung cavitation had fully resolved, along with her symptoms. At last follow-up in May, 2011, her BMI was 34·8 kg/m² and her gastric band had been cautiously refi lled with no symptom recurrence.Laparoscopic adjustable gastric banding is regarded as the least invasive surgical option for morbid obesity. However, the procedure is associated with high frequency of late complications, with pouch expansion and band slippage or erosion being the most common.