THE EVANESCENT LUNG

Abstract

SESSION TITLE: Medical Student/Resident Obstructive Lung Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Vanishing lung syndrome (VLS), also known as giant bullous emphysema, is a chronic progressive condition predominantly seen in upper lobes of lungs, occupying at least one-third of the hemithorax and can compress normal lung parenchyma. It is commonly seen in young males with a history of chronic smoking. Other risk factors include α-1-antitrypsin deficiency and marijuana (1). Complications include tension pneumothorax. Bullectomy is usually the treatment of choice. Herein, we describe a rare case where an elderly male with symptoms of pneumonia was found to have an incidental finding of VLS on computed tomography pulmonary angiogram (CTPA). CASE PRESENTATION: A 76-year-old African American male with a medical history of prostate cancer status post-radiotherapy and hypertension came in with a 2-day history of sudden onset shortness of breath, cough with yellowish-brownish sputum and subjective fevers. He had a 60 pack-year smoking history. Vitals were remarkable for a body mass index of 15, heart rate of 125/min, respiratory rate of 22/min, and fever of 100.8 but there was no hypoxia. On comprehensive physical examination, he had stage 3 nail clubbing. Pulmonary examination revealed hyper resonant percussion in the right upper zone and decreased air entry. Laboratory investigation was unremarkable except for leukocytosis of 15.8 X 103 /mm3. A chest radiograph demonstrated acute infiltrates in the right lung inferior to the right hilum. There was a large bleb within the right hemithorax occupying most of the right hemithorax. Left hemithorax exhibited chronic emphysematous changes with peripheral blebs. Since the patient had a history of malignancy and was tachycardic on admission. CTPA was done which revealed very large right pulmonary bleb and air space opacities suggestive of acute bronchopneumonia or bronchitis. Ceftriaxone and azithromycin were started after which the patient clinically improved in one day. Investigating the imaging findings, α-1 antitrypsin levels were normal. HIV testing was negative. Cardiothoracic surgery was consulted and a decision was taken to do bullectomy but the patient refused the procedure as he was asymptomatic. DISCUSSION: VLS is a rare condition usually seen in young males with chronic smoking history or marijuana abuse. A common presentation is tension pneumothorax as a result of the rupture of the bulla. What makes this case unique is that our patient was an asymptomatic elderly male without any prior diagnosis of the same. He presented with clinical features of pneumonia and was incidentally found to have VLS at this age(2). CONCLUSIONS: VLS becomes evident as it progresses and can lead to tension pneumothorax. Patients should be referred for pulmonary function tests for diagnosis of chronic obstructive pulmonary disease and cardiothoracic surgery for bullectomy which is the treatment of choice and improves the function of the lung significantly (3). Reference #1: 1. Barry Ladizinski, M.D., and Christopher Sankey, M.D.; Vanishing Lung Syndrome N Engl J Med 2014; 370:e14, DOI: 10.1056/NEJMicm1305898 Reference #2: 2. Amarjit Singh Vij, Robert James, Akashdeep Singh, Amrinder Singh Dhaliwal, Ajay Chhabra, Kamaljeet Kaur Vij; A Rare Case of Vanishing Lung Syndrome; J Assoc Physicians India. 2014 Dec;62(12):51-3. PMID: 26259424 Reference #3: 3. Nidhi Sood, Nikhil Sood; A Rare Case of Vanishing Lung Syndrome; Case Rep Pulmonol. 2011; 2011: 957463. doi: 10.1155/2011/957463. PMID: 22937434 DISCLOSURES: No relevant relationships by Ankit Agrawal, source=Web Response No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Monarch Shah, source=Web Response