Segment Of Left Lower Lobe Research Articles

POS-133 CASE REPORT OF DISSEMINATED KLEBSIELLA INFECTION IN T2DM LEADING TO CKD

K. pneumoniae can present as two forms of community-acquired pneumonia, acute and chronic. Although acute pneumonia may turn into necrotizing pneumonia, which results in a prolonged clinical course, it often has a rapidly progressive clinical course. In contrast, chronic Klebsiella pneumonia runs a protracted indolent course that mimics other chronic pulmonary infections and malignancies. The Klebsiella pneumoniae bacteria usually affects the right upper lung lobe and results in the creation of a cavity, as well as pus-producing tissue death.K. pneumoniae is an aggressive microorganism, accounting for 0.5 to 5% of pneumonia cases. It can lead to cavitation (30-50% of cases) and necrotising pneumonia (NP) within a short period of time (days). Case : 40 year old male with a history of diabetes mellitus (DM) was admitted 20 days back patient was admitted and treated for DKA and LRTI discharged after treatment. Patient readmitted 20 days later with complaints of right sided loin pain, high grade fever of 8 days, cough with expectoration for one month, pyuria for 5 days and anuria for one day. Patient readmitted On admission – P-96/min, BP-140/90 mmhg, RR-26/min, Spo2-96% with O2. On evaluation patient was found to have raised creat (8mg/dl) initiated on hemodialysis. Patient ultrasound showed of left sided bulky kidney with acute pyelonephritis. CXR showed cavitatory lesion in middle lobe of right side lung. 5days Later patient complaint of increased left loin pain repeat USG showed left sided psoas abscess so CT showed no any evidence of communication of pyelonephritis with abscess. Pigtail drain was placed for psoas abscess, culture which was positive for klebsiella. Sputum culture was positive for klebsiella, A diagnosis of dissiminated klebsiella infection was made. In spite of all necessary investigations and treatment patient was dialysis dependent, patient deteriorated over time and could not be saved. Investigations :Tabled 1ParametersValuesHemoglobin9.8 gm/dlTotal leukocyte counts25,500/cummPlatelets2.4 lac/cummUrea104 mg/dlCreatenine4.2 mg/dlSerum Na136 mmol/lSerum K4.5 mmol/lBilirubin1.5 mg/dlSGOT/SGPT45/32Calcium7.6 mg/dlPhosphorus5.8 mg/dlUric acid6.2 mg/dlHbA1c10.5%Urine examinationAlb ++ Sug + Epi cells 1-2/min Pus cells - plenty RBC - 1-2/hpf24 hr urinary protein1.5 gm/day Open table in a new tab Sputum culture & Pus culture – klebsiella Sputum for MTB - negative Fundus – moderate NPDR CXR – Cavitatory lesion in right lung middle zone USG – RK – 12.5*5.9cm, LK – 13.6*6.2cm mod dilation of pelvicalyceal system bilateral bulky kidneys with left acute pyelonephritis. CT abd – left psoas bulky with evidence of 8*2.5 cm well defined hypodense collection within. CT chest – Thick walled cavitatory lesions with surrounding consolidation noted in medial segment of right middle lobe, postero-basal segment of right lower lobe, superior segment of left lower lobe We conclude that patients with immunocompromised state like Diabetes mellitus are more prone to disseminated infections which can lead to high morbidity and mortality. Good glycemic control, early diagnosis and effective management with could be key role in managing a diabetic patient.

SYNCHRONUS TUMORS: A RARE COMBINATION

TYPE: Late Breaking Abstract TOPIC: Lung Cancer INTRODUCTION: Synchronous tumors refers to cases in which the second primary cancer is diagnosed within 6 months of primary cancer. Carcinoid tumors are rare slow growing tumors arising from the enterochromaffin cells disseminated through out the gastrointestinal and bronchopulmonary systems. Carcinoid tumors are innocuous at time of presentation emphasizing the need for multidisciplinary approach for the diagnosis. CASE PRESENTATION: A 80 year old male patient came with complaints of cough with expectoration on and off for 3 years increased since 1 week with occasional minimal hemoptysis, loose stools, loss of weight and loss of appetite. Chest X-Ray showed ill-defined opacity in the left lower zone. CECT showed two well defined heterogenous enhancing lesion in the superior and lateral basal segment of left lower lobe. Bronchoscopy guided biopsy revealed typical carcinoid. In view of recurrent diarrhea patient underwent endoscopy which revealed poorly differentiated adenocarcinoma. DISCUSSION: Gastrointestinal symptoms along with lung symptoms can be attributed to disseminated carcinoid or carcinoid syndrome. Carcinoid syndrome occurs in fewer than 5% of cases.It presents with symptoms like diarrhea, wheezing, palpitation’s, hypotension. In this case we were attributing the gastric symptoms to carcinoid syndrome. Endoscopy was done in view of diarrhoea which revealed a second malignancy. We lost the patient in view of dual primary within a month. Synchronous tumors with gastric carcinoid have been reported but to our knowledge carcinoid lung with adenocarcinoma of stomach have not been reported. CONCLUSIONS: All symptoms in a tumor patient should not be attributed to paraneoplastic syndromes and metastasis further workup should be done using a multidisciplinary approach. DISCLOSURE: No significant relationships. KEYWORD: Synchronous tumor

Pulmonary sequestration: a rare cause of false-positive uptake in Iodine-131 whole-body scan

BackgroundHigh-dose radioactive iodine-131 (I-131) is generally used post-total or subtotal thyroidectomy in differentiated thyroid cancer (DTC) patients. I-131 whole-body scan (WBS) is performed to localize I-131 accumulation in the body and for restaging after therapy. Nonetheless, there are numerous causes of false-positive uptake in I-131 WBS in the absence of residual thyroid tissue or thyroid cancer metastasis.Case presentationWe present a case of 51-year-old lady with false-positive uptake in I-131 WBS mimicking lung metastasis. Patient underwent total thyroidectomy, and histopathological examination showed well-differentiated papillary thyroid microcarcinoma. Diagnostic I-131 WBS followed by two subsequent high-dose radioiodine ablation showed persistent I-131 uptake in the left lower lung field. However, the serum thyroglobulin (Tg) is incessantly undetectable (< 0.04 μg/ml) with negative anti-thyroglobulin antibody (anti-TgAb). Three serial CT scans over the course of treatment coupled with MRI of the thoracolumbar region revealed stable lung lesion in the posterior segment of left lower lobe which signifies pulmonary sequestration. Based on the clinical assessment, imaging findings and blood investigations, patient was no longer subjected to I-131 therapy and is maintained on TSH suppression with L-thyroxine. After due consideration of the pros and cons of surgical intervention, the patient opted against surgical removal of the pulmonary sequestration.ConclusionsMeticulous assessment of patient with suspected disease recurrence or metastasis in thyroid carcinoma is essential to avoid unnecessary I-131 ablation or surgical intervention. In this case, the positive I-131 imaging is associated with undetectable serum Tg (with negative anti-TgAb). Albeit uncommon, pulmonary sequestration should be taken into consideration as one of the differentials in false-positive findings of an I-131 WBS.

Synchronous Tumours: A Combination of Carcinoid and Adenocarcinoma

Synchronous tumour refers to cases in which the second primary cancer is diagnosed within six months of primary cancer. Carcinoid tumours are innocuous at time of presentation, emphasising the need for multidisciplinary approach for the diagnosis. A 80-year-old male patient came with complaints of cough with expectoration on and off for three years, with occasional minimal haemoptysis, haematemesis on and off for two months, loss of weight and loss of appetite for the past two months and complaints of increased cough for the past 1 week. Chest X-ray showed ill-defined opacity in the left lower zone. Contrast enhanced computed tomography showed two well defined heterogenous enhancing lesion in the superior and lateral basal segment of left lower lobe. Bronchoscopy guided biopsy revealed typical carcinoid. In view of recurrent diarrhoea, patient underwent endoscopy which revealed poorly differentiated adenocarcinoma. Gastrointestinal symptoms along with lung symptoms can be attributed to disseminated carcinoid or carcinoid syndrome. Carcinoid syndrome occurs in fewer than 5% of cases. It presents with symptoms like diarrhoea, wheezing, palpitations, hypotension. In the present case authors were attributing the gastric symptoms to carcinoid syndrome. Endoscopy was done in view of diarrhoea which revealed a second malignancy. Multiple tumours diagnosed have to be evaluated and staged separately and the treatment should be decided on staging to attain maximum clinical response. Patient condition worsened and patient expired in two weeks. All symptoms in a tumour patient should not be attributed to paraneoplastic syndromes and metastasis, further workup should be done using a multidisciplinary approach.

High cholesterol in COVID-19 leading to lung consolidation and bronchiectasis.

A 60-years-old male with high cholesterol and a Modified Medical Research Council (mMRC) dyspnoea score of 2 was admitted with a history of fever, cough, dyspnoea. Initial chest radiograph (A) showed bronchiectasis in right base with pneumonia in the left base. A diagnosis of COVID-19 was confirmed with positive SARS-CoV-2 RT-PCR on nasal swab. There were some typical findings on CT images. According to the CT images (B), the case was classified as of stage I consolidation with multiple peripheral ground glass opacities with interlobular septal thickening were seen in anterior and inferior lingular segment of left upper lobe, posterior basal segment of left lower lobe, posterior segment of right upper lobe, and medial segment of right middle lobe. Initially he was on IV steroids and therapeutic doses of heparin. He was maintaining his oxygen saturation to 96%. Ten (10) days after hospitalization and normalization of all inflammatory markers, he has Modified Medical Research Council (mMRC) dyspnoea score 1 and oxygen-independent. The patient was asked for follow up in 6 weeks. Due to the mMRC of 1 and short history, it is assumed that the fibrosis was not present prior to the COVID-19 diagnosis. The early use of antifibrotics may prevent this devastating complication, but it is difficult to predict who is likely to progress to pulmonary fibrosis. Early rehabilitation protocol for post-acute COVID-19 patients can minimize dyspnea and shortness of breath even for minimal activities.

Role of high-resolution CT in diagnosis, regional distribution and characterize bronchiectasis morphologically

Background: Bronchiectasis causes physical, social, and financial strain on affected patients and results in a significant negative effect on the quality of life of the patient.Objectives: This study was undertaken to find the role of HRCT in diagnosis, regional distribution and characterize bronchiectasis morphologically.Method: A prospective study of sixty patients was done in whom clinically bronchiectasis was suspected and were subjected to HRCT examination. Bronchiectasis was assessed in terms of localization, regional distribution and morphological forms.Results: The mean age for all patients included in the study was 50.7 ± 12.09. The mean age of the male patients was 51.56 ± 12.09 and the mean age of the female patients was 50.16 ± 12.23Out of a total of 60 patients there were 23 (38%) males and 37 (62%) females. 18 patients (30%) had unilateral disease & 42 (70%) had disease in both lungs. Posterior basal segment of left lower lobe was most commonly affected (72%), followed by medial segment of right middle lobe (56%). Cylindrical bronchiectasis was the most common (36%) morphological form of bronchiectasis followed by mixed bronchiectasis. Peripherally visualized bronchi (82%) was the most common findings in our study followed by lack of tapering (75%).Bronchial wall thickening was seen in 72% of patients. Bronchial: pulmonary artery ratio > 1.5 was noted in 63% of patients.Conclusion: Based on our results, it can be concluded that HRCT serves as the best modality in confirming the diagnosis of bronchiectasis. Left lower lobe, especially posterior basal segment is most commonly involved. Bilateral involvement is more common than unilateral involvement peripherally visualized bronchi was the most common findings in our study followed by lack of tapering. Cylindrical bronchiectasis is the most common form of bronchiectasis.

Spectrum of Chest CT Findings in a Familial Cluster of COVID-19 Infection.

HomeRadiology: Cardiothoracic ImagingVol. 2, No. 1 PreviousNext Images in Cardiothoracic ImagingFree AccessPulmonary ImagingSpectrum of Chest CT Findings in a Familial Cluster of COVID-19 InfectionTianzhu Liu*, Peikai Huang*, Hailong Liu, Lesheng Huang, Ming Lei, Wangdong Xu, Xiaolu Hu, Jun Chen, Bo Liu Tianzhu Liu*, Peikai Huang*, Hailong Liu, Lesheng Huang, Ming Lei, Wangdong Xu, Xiaolu Hu, Jun Chen, Bo Liu Author AffiliationsFrom the Department of Radiology, Guangdong Hospital of Traditional Chinese Medicine, Zhuhai, 519000, China (T.L., P.H., H.L., L.H., M.L., W.X., X.H., J.C.) and Department of Radiology, Guangdong Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510000, China (B.L.).Address correspondence to B.L. (e-mail: [email protected]).Tianzhu Liu*Peikai Huang*Hailong LiuLesheng HuangMing LeiWangdong XuXiaolu HuJun ChenBo Liu Published Online:Feb 13 2020https://doi.org/10.1148/ryct.2020200025MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In * The authors contributed equally to this work.On January 29, 2020, a 43-year-old woman presented with a 4-day history of fever, cough, sputum production, and dyspnea. She had a recent history of travel to Wuhan (the center of the COVID-19 outbreak [formerly known as 2019 novel coronavirus]) with her 15-year-old son. Her temperature was 38°C (100.4°F) and she had coarse breath sounds on auscultation. Chest CT showed peripheral multifocal ground-glass opacities (Fig 1a). Her son also presented with prolonged fever (11 days), but without respiratory symptoms. On examination, his temperature was 39°C (102.2°F), and lungs were clear on auscultation. Chest CT showed centrilobular ground-glass nodules in the left lung (Fig 1b). The patient’s 43-year-old husband, who met the definition for a contact person (1), was asymptomatic on screening, but tested positive for COVID-19 on sputum real-time polymerase chain reaction test, as did the son and the wife. His chest CT was unremarkable (Fig1c), and he eventually developed fever on the following day.Figure 1a: (a) Unenhanced CT image in a 43-year-old woman shows multiple ill-defined ground-glass opacities in the lateral segment of right lower lobe and the posterior segment of left lower lobe. (b) Unenhanced CT image in a 15-year-old male patient shows subtle nodular ground-glass opacities in the posterior segment of left lower lobe. (c) Unenhanced CT image in a 43-year-old man shows normal lungs.Figure 1a:Download as PowerPointOpen in Image Viewer Figure 1b: (a) Unenhanced CT image in a 43-year-old woman shows multiple ill-defined ground-glass opacities in the lateral segment of right lower lobe and the posterior segment of left lower lobe. (b) Unenhanced CT image in a 15-year-old male patient shows subtle nodular ground-glass opacities in the posterior segment of left lower lobe. (c) Unenhanced CT image in a 43-year-old man shows normal lungs.Figure 1b:Download as PowerPointOpen in Image Viewer Figure 1c: (a) Unenhanced CT image in a 43-year-old woman shows multiple ill-defined ground-glass opacities in the lateral segment of right lower lobe and the posterior segment of left lower lobe. (b) Unenhanced CT image in a 15-year-old male patient shows subtle nodular ground-glass opacities in the posterior segment of left lower lobe. (c) Unenhanced CT image in a 43-year-old man shows normal lungs.Figure 1c:Download as PowerPointOpen in Image Viewer This familial cluster exemplifies the spectrum of clinical and radiologic presentation that can be encountered in those infected by COVID-19 (2, 3). This heterogeneity should be a focus for future investigations looking into susceptibilities related to the individual’s immune response and the stage of disease.Disclosures of Conflicts of Interest: T.L. disclosed no relevant relationships. P.H. disclosed no relevant relationships. H.L. disclosed no relevant relationships. L.H. disclosed no relevant relationships. M.L. disclosed no relevant relationships. W.X. disclosed no relevant relationships. X.H. disclosed no relevant relationships. J.C. disclosed no relevant relationships. B.L. disclosed no relevant relationships.* The authors contributed equally to this work.Keywords: Adults, Breast, CT, Infection, Inflammation Authors declared no funding for this work.

Common and Uncommon Variations of Pulmonary Venous Drainage in Patients Undergoing Thoracoscopic Lobectomy.

Variations in pulmonary venous anatomy should not be undermined by thoracic surgeons during procedures which involve the pulmonary veins. We have identified vascular anomalies in 25 of 346 patients undergoing video-assisted thoracoscopic surgery lobectomy at our Thoracic Surgery Unit, between December 2016 and November 2018. Some vascular anomalies described have not been reported in recent literature and include right V7 draining into the middle lobe pulmonary vein, accessory right V6 behind the bronchus intermedius, two V6 from the apical segment of left lower lobe, two V6 from the apical segment of right lower lobe, and one of them draining into the superior pulmonary vein. Thoracic surgeons should be aware of this type of anomalies because failure in the preoperative or intraoperative identification of the pulmonary venous variations may lead to serious complications.

Incidentally detected lung lesions in a patient with crohn's disease.

THE CASE A 57-year-old man, nonsmoker, recently diagnosed as having Crohn's disease was referred to us for evaluation of an incidentally detected radiological lesion. As part of the workup for Crohn's disease, a computed tomography (CT) scan of the abdomen was taken, which revealed a few infiltrates in the visualized portion of both lower lobes. He denied having any significant respiratory symptoms apart from an infrequent dry cough. Clinical examination of the respiratory system revealed the presence of random, inspiratory crackles at both lung bases. A high-resolution CT (HRCT) scan was taken [Figure 1].Figure 1: Name the radiological sign seen in this image? What is the most likely diagnosis?QUESTIONS Question 1: Name the radiological sign seen in this image? Question 2: What is the most likely diagnosis? ANSWERS The (Reverse Halo sign) Cryptogenic organizing pneumonia. DISCUSSION The “Reverse halo sign” (also referred to as “reversed halo sign”) is characterized by the presence of a central ground-glass opacity surrounded by a ring [Figure 2, white arrow] or crescent [Figure 3, white arrow] of dense airspace consolidation. It is also called atoll sign since it resembles a coral atoll. Although it was first described in cryptogenic organizing pneumonia (COP) and was thought to be diagnostic of the condition, it has been subsequently described in a variety of other conditions including fungal infections and adenocarcinoma of the lungs. But still, COP remains the most common condition in immunocompetent patients where the reverse halo sign is seen.[1] Table 1 lists the various conditions in which reverse halo sign is seen.[2]Figure 2: Axial section of high-resolution computed tomography scan of the thorax showing ground glass density surrounded by a ring of consolidation, in the superior segment of left lower lobe (white arrow)Figure 3: Axial section of high-resolution computed tomography scan of the thorax showing ground glass density surrounded by a crescent of consolidation, in the anterior segment of left upper lobe (white arrow)Table 1: Differential diagnosis of the reverse halo signCorrelating the clinical details with the CT findings will help to narrow down the diagnosis.[2] For instance presence of this sign in a patient detected to have HIV is suggestive of Pneumocystis jirovecii infection, whereas the same in a patient who has undergone a solid organ transplant would mean pulmonary zygomycosis. If there are coexisting tree-in-bud lesions and centrilobular nodules, it points toward a diagnosis of tuberculosis. Its presence in a patient with Crohn's disease, as in our case would narrow down the differential diagnosis to COP. Lung involvement is uncommon in Crohn's disease. It could either be due to the disease or sometimes due to treatment with drugs such as sulfasalazine and methotrexate. Pulmonary involvement could be upper airway involvement like glottic or subglottic stenosis, and tracheal stenosis, or small airway diseases like COP and diffuse panbronchiolitis or lung parenchymal involvement like interstitial lung disease or necrobiotic nodules.[3] COP is a rare extraintestinal manifestation of Crohn's disease. This disease, which used to be previously referred to as bronchiolitis obliterans organizing pneumonia, is a subacute process characterized by the presence of granulation tissue in the bronchioles and alveolar ducts with extension into the alveoli. The “shared antigen theory” has been postulated to explain the occurrence of organizing pneumonia in Crohn's disease.[4] Patients commonly present with fever, cough, or chest pain. HRCT is the investigation of choice in the evaluation of diffuse lung diseases. The common findings in CT are ground glass opacities and parenchymal consolidation. Fleeting consolidation and the reverse halo sign are sometimes present, which are all the most suggestive of the diagnosis. Since COP is always a diagnosis of exclusion, a flexible bronchoscopy, and lavage to exclude infections is mandatory. Sometimes, surgical lung biopsy is needed to confirm the diagnosis. This case is being presented to highlight the radiological finding of the “Reverse halo sign.” A knowledge of the various etiologies where it occurs would give a clue to make the appropriate diagnosis, avoid unwanted investigations, and institute timely management. As illustrated in our case, the presence of this radiological sign in patients with Crohn's disease should make one think about the possibility of COP. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Endobronchial embolization for life-threatening hemoptysis with Endobronchial Watanabe Spigot

BackgroundMassive hemoptysis is a common encounter in respiratory medicine. Bronchoscopy plays an important role in localizing the origin of bleeding, as well as endoscopic treatment of centrally located lesions. Endobronchial embolization is a novel technique enabling the management of hemoptysis arising even from peripheral lesions, via occlusion of the culprit bronchus, thereby securing the airway. Endobronchial Watanabe Spigot had been advocate in the treatment of bronchopleural fistula and the use of this novel technique had since then been expanded into the management of massive hemoptysis. To the best of our knowledge, this is the first reported case in Malaysia.Case presentation78-year-old lady who presented with life-threatening hemoptysis leading rapidly to cardiac arrest upon arrival. Spontaneous circulation was restored after resuscitation with an urgent thoracic computed tomography angiogram revealed bleeding likely from the posterior basal segment of left lower lobe, with bronchiectatic changes. Urgent flexible bronchoscopy revealed airway flooding, with bleeding originating from the lingular and posterior-basal segment of the left lower lobe. Airway toileting was performed and two 7 mm Endobronchial Watanabe Spigots were plugged into the culprit bronchi. Urgent bronchial artery embolization was then attempted, but was unsuccessful. She was managed conservatively, as surgical resection was deemed high risk. The spigots were removed 4 days later uneventfully. There was no recurrence of hemoptysis, and patient remained well during 1-month follow up.ConclusionsThe utmost priority in managing life-threatening hemoptysis is to prevent airway flooding. Endobronchial embolization with Endobronchial Watanabe Spigot is useful as a temporary measure before definitive therapy, or can itself be the main therapeutic player in the hemoptysis armament for high-risk patients.

Recurrent hemoptysis: An unusual cause and novel management.

We report a rare case a 15 year old boy who presented with recurrent hemoptysis. There was past history of pancreatitis. A CT scan of thorax revealed a small collection in the region of the tail of the pancreas and a tract from it extending across the diaphragm into the posterobasal segment of left lower lobe, suggesting a pancreatico-pleuro-pulmonary fistula. The fistula was embolised by percutaneous injection of glue into the collection and fistula, which resulted in good symptom control.

Three Cases of ALCAPA with Associated Anomalies

There are several potential issues that affect the treatment and diagnostic pattern of anomalous left coronary artery arising from the pulmonary artery. We report three cases of infants who presented with anomalous left coronary artery arising from the pulmonary artery with severe left ventricular dysfunction and severe mitral regurgitation along with associated anomalies. One patient had congenital lobar emphysema of the right midde lobe. Another patient had left main stem bronchus compression, collapse of basal segments of left lower lobe and panlobular emphysema in medial basal segment of right lower lobe. The third patient had cleft lip and palate. All patients underwent successful repair. The hemodynamic stability was compromised when the infant with congenital lobar emphysema had spontaneous pneumothorax after extubation and she needed an intercostal drainage. The infant with lung collapse had to be reintubated on the second day since she became hypoxic due to recollapse of the lung once the airway positive pressure was removed. She needed chest physiotherapy, vigorous endotracheal suctioning and inhaled bronchodilator therapy. The patient who had cleft palate succumbed to aspiration pneumonitis in the postoperative period. Follow-up of other two patients after three months showed very good improvement in left ventricular systolic function.

A Case of Endobronchial Aspergilloma Associated with Foreign Body in Immunocompetent Patient without Underlying Lung Disease

Aspergillus causes a variety of clinical syndromes in the lung including tracheobronchial aspergillosis, invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, allergic bronchopulmonary aspergillosis, and aspergilloma. Aspergilloma usually results from ingrowths of colonized Aspergillus in damaged bronchial tree, pulmonary cyst or cavities of patients with underlying lung diseases. There are a few reports on endobronchial aspergilloma without underlying pulmonary lesion. We have experienced a case of endobronchial aspergilloma associated with foreign body developed in an immunocompetent patient without underlying lung diseases. A 59-year-old man is being hospitalized with recurring hemoptysis for 5 months. X-ray and computed tomography scans of chest showed a nodular opacity in superior segment of left lower lobe. Fiberoptic bronchoscopy revealed an irregular, mass-like, brownish material which totally obstructed the sub-segmental bronchus and a foreign body in superior segmental bronchus of the lower left lobe. Histopathologic examinations of biopsy specimen revealed fungal hyphae, characteristic of Aspergillus species.

完全胸腔鏡下肺底区域切除を施行した左肺底区動脈大動脈起始症の1例

完全胸腔鏡下肺底区域切除を施行した左肺底区動脈大動脈起始症の1例

Pulmonary epithelioid hemangioendothelioma: A rare pulmonary tumor in differential diagnosis of bronchogenic carcinoma

Sir, A 33-year-old female was admitted to our institute with complaints of dry cough with minimal expectoration and two episodes of hemoptysis in the last four years. She was also complaining of intermittent chest pain and loss of appetite but without any weight loss for last four months. She had no prior medical history, was a non-smoker, and denied any history of exposure to pets or birds. There was no other family history of cancer. She was average built and, on physical examination, showed no clubbing of fingers and toes, no enlarged lymph nodes. Lung examination revealed minimal inspiratory crackles at the left base without any added sounds or evidence of consolidation. Routine blood investigations were in normal limits. Sputum smears were negative for acid fast bacilli, fungal elements and malignant cells. Chest radiograph showed about 6 × 6 cms round opacity in mid zone of left lung [Figure 1]. Contrast enhanced computerized tomographic (CT) scan of thorax showed heterogeneously enhancing soft tissue density mass lesion in apical segment of left lower lobe [Figure 2]. CT guided needle aspiration cytology of mass showed atypical epithelial cells along with keratinous material and was suspicious of squamous cell carcinoma. Ultrasound abdomen was normal. No endobronchial lesions were found at fiber optic bronchoscopy. Pulmonary function tests were within normal range. Under general anesthesia, we found a 7 × 7 cms firm vascular mass, of heterogeneous consistency, cystic in between and involving major fissure with both lobes of left lung without any pleural and vascular invasion. Left sided extra pericardial pneumonectomy was done. Postoperative course was uneventful and she was discharged after a week in satisfactory condition. Biopsy of specimen diagnosed it as epithelioid hemangioendothelioma of lung. Later, immuno-histochemistry was done for confirmation of the diagnosis, vascular tumor markers CD31 (CD = cluster of differentiation- antigen class) and CD34 (CD = cluster of differentiation- antigen class) were positive. Patient survived without any morbidity and is doing well so far (postoperative three years). Due to asymptomatic nature, no additional imaging modalities were done.Figure 1: Chest radiograph shows a rounded mass lesion in the left hemithorax without any associated bony abnormalityFigure 2: Computed tomography (CT) scan shows a well defined mass in the left lung; there was no hilar or mediastinal lymphadenopathy in the mediastinal windowsThe tumor was initially described in 1975 by Dail and Liebow and named “intravascular sclerosing bronchioalveolar tumor” (IVBAT) because of the proposed bronchioalveolar origin of the neoplasm. Enzinger and Weiss (1988) first used the term hemangioendothelioma. Now it is recognized that this is the pulmonary counterpart of epithelioid hemangioendothelioma, which is sclerosing true neoplasm of vascular endothelium of low grade to borderline malignancy potential and occurring around medium to large size veins in soft tissue, occurring also in other anatomical sites.[1–3] Three quarters of patients with epithelioid hemangioendothelioma of the lung are women. The age range at presentation is wide (12 - 60 years). Half the patients are asymptomatic and are discovered on incidental chest radiography. Symptoms are uncommon and are usually include dyspnea, mild pleuritic pain, non-productive cough and rarely hemoptysis. The chest radiograph usually reveals multiple or bilateral pulmonary nodules. Pleural effusions and distant metastases are rarely seen.[1–3] Histology is diagnostic for these tumors.[13] The characteristic immunophenotype is negative for epithelial, muscular, and neural markers, and positive for vascular markers such as factor VIII, CD31 (Most specific and sensitive endothelial marker), CD34, von Willebrand's factor, and Ulex europaeus antigen (UEA-1). Ultra-structural endothelial characteristics can be confirmed by electron microscopy, which shows the presence of prominent basal lamina, pinocytotic vesicles, and Weibel-Palade bodies.[134] Because of the rarity of this condition, there is no clear standard for treatment. In most cases, the disease has a slowly progressive course. Apparently, benign lesions of hemangioendothelioma are best treated by wide local excision and apparently malignant ones by radical excision.[134] Epithelioid hemangioendothelioma is a rare pulmonary neoplasm of vascular origin with fewer than 50 cases reported in the literature.[35] We report one such case with an initial presentation mimicking bronchogenic carcinoma but proven to be pulmonary epithelioid hemangioendothelioma on histopathological and immunohistochemical examination of the surgically resected tumor. It is also unusual because of the solitary nature.

A Case of Anomalous Systemic Arterial Supply to Normal Basal Segments of Left Lower Lobe

Anomalous systemic arterial supply to the lung is a rare congenital anomaly. The lung supplied by the anomalus systemic artery has a normal bronchial tree, which is usually in the basal segment of the lung, especially in the left lung. Most of patients are asymptomatic, but the main clinical symptoms of this disease are hemoptysis and exertional dyspnea. CT is useful for the diagnosis and showed a retrocardiac nodular shadow connected to the descending aorta branching into the basal segments of the relatively normal lower lobe. Surgery is indicated for all patients. Here we report a case of anomalous systemic arterial supply to normal basal segments of left lower lobe in a patient with hemoptysis with a review of the relevant literature. (Tuberculosis and Respiratory Diseases 2004, 56:97-102)

Anomalous systemic arterial supply to normal basal segments of left lower lobe: characteristic imaging findings.

The purpose of this study was to describe the characteristic findings in each imaging modality of anomalous systemic arterial supply to normal basal segments of the left lower lobe of the lung. Five patients with anomalous systemic arterial supply to normal basal segments of the left lower lobe were retrospectively reviewed. Chest radiography, contrast-enhanced CT scan, angiography, and other imaging modalities were analyzed. The imaging findings of this anomaly were characterized by three issues as follows: an anomalous systemic artery arising from the thoracic aorta, absence of pulmonary arterial supply, and normal bronchial system as well as normal pulmonary parenchyma in the affected segments. The anomalous systemic artery was demonstrated on chest radiography, contrast-enhanced CT scan, MRI, and thoracic aortography. Absence of pulmonary arterial supply was revealed by pulmonary angiography, radiolabeled perfusion scan, and CT scan. Normal bronchial system was confirmed by radiolabeled ventilation scan, bronchography, and CT scan. CT is useful in making the correct diagnosis of this anomaly because it is the only diagnostic method that can demonstrate the anomalous systemic artery, absence of pulmonary arterial supply, and normal bronchial system in the affected segments.

Anomalous Systemic Arterial Supply to Normal Basal Segments of Left Lower Lobe: A Report of Two Cases

Two cases of an anomalous systemic arterial supply to the basal segments of the left lower lobe without pulmonary wequestration are presented. In the first case, a preoperative diagnosis was made by chest CT, and confirmed by angiograpy, in a 22-year old man who had a recurrent hemoptysis. There was systemic arterial supply that originated from the thoracic descending aorta and no pulmonary arterial supply to the basilar segment of the left lower lobe. However, the pulmonary parenchyma was normal without sequestration. Ligation of the abnormal artery and a left lower lobectomy were performed without complication. In the second case, there were characteristic features of this anomaly on chest CT and the angiogram in a 31-year-old man with symptoms of hemoptysis. The patient refused surgery.

Systemic arterial supply to normal basal segments of left lower lobe: CT findings.

The purpose of this study was to evaluate the usefulness of CT in making a diagnosis of systemic arterial supply to normal basal segments of the left lower lobe. We retrospectively reviewed chest radiography (three cases), CT (three cases), and angiography (two cases). An anomalous systemic artery arising from the descending aorta was shown as a retrocardiac density on posteroanterior radiography and as a nodular density behind the heart on lateral radiography. Contrast enhanced CT revealed the vascular nature of the density adjacent to the descending aorta. Dynamic CT in one patient demonstrated that the nodular density was composed of an anomalous systemic artery and a prominent inferior pulmonary vein. High-resolution CT showed the interlobar artery distal to the origin of the superior segmental artery to be absent. The bronchial system of the left basal segments was normal as was the pulmonary parenchyma on CT. Characteristic CT findings consist of absence of the interlobar artery distal to the origin of the superior segmental artery and origination of an anomalous artery from the descending aorta that gives off branches to normal left basal segments. With a constellation of these CT findings, angiography would be obviated for definite diagnosis of this anomaly.