*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.
Correspondence to: Ronald F. Grossman, MD, FCCP, Credit Valley Professional Building, Chief of Medicine, Suite 201, 2300 Eglinton Ave, West, Ontario ON, Canada L5M 2V8; e-mail: email@example.com
A 31-year-old woman is referred for investigation of a left lower lobe mass. She was well until 1 year earlier when she acquired a persistent unproductive cough. She ignored this symptom until 7 months ago when, after a respiratory tract infection with significant worsening of symptoms, she finally sought medical attention. While the systemic symptoms improved after antimicrobial therapy, her cough persisted. She received two further courses of antibiotics because of cough and an abnormality noted in the left lower lobe of the lung, which was thought to represent an infectious pneumonia.
On physical examination, the only abnormalities were decreased movement of the left chest and decreased breath sounds over the left basal posterior chest area. Chest radiographs and a CT scan are shown (Figs 123
). Flexible bronchoscopy findings were negative. Serologic findings for histoplasmosis, blastomycosis, and coccidioidomycosis were negative. The results of a fine-needle aspiration biopsy are shown in Figure 4
; the finding on fluorescent stain for acid-fast bacilli was negative. At this point, which of the following courses of action should you recommend?
A. CT aortogram
B. Video-assisted thoracoscopic biopsy
C. Pulmonary arteriogram
D. Left lower lobe resection
E. Initiate treatment with isoniazid, rifampin, and pyrazinamide
The chest radiographs demonstrate a retrocardiac density, and the CT scan confirms a very large lobulated parenchymal density with a smaller, more superior component to it. The lung biopsy shows fragments of inflamed granulation tissue, aggregates of foamy macrophages, a lymphoid aggregate, and portions of a foreign body granulomatous reaction with prominent cholesterol clefts. The findings are in keeping with an acute and chronic inflammatory process with a foreign body-type granulomatous reaction. Given the persistent nature and the inflammatory characteristics of the density, a developmental abnormality such as a sequestration must be considered. While the biopsy is suggestive of the correct diagnosis, under most circumstances, a lung biopsy would not be required to make this diagnosis.
Of the options offered, a CT aortogram is the simplest noninvasive method to rule in sequestration. The procedure was performed, and a vascular reconstruction is shown (Fig 5
). A large feeding vessel originating from the inferior descending thoracic aorta and branching into the density can be clearly identified (closed arrowhead). Veins can also be seen draining to the left inferior pulmonary vein, making this an intralobar type of sequestration (open arrowhead). The presence of chronic inflammation in the biopsy suggests a bronchial communication in keeping with an intralobar sequestration.
A thoracic arteriogram also would have demonstrated the lesion, but this procedure is invasive and carries with it a small but identifiable risk of spinal cord injury. A pulmonary arteriogram is not indicated, and a video-assisted thoracoscopic biopsy would not have provided the diagnosis. While left lower lobe resection ultimately is the treatment of choice of the sequestration, it should not be attempted without a prior understanding of the blood supply to the lesion. There is no evidence of tuberculosis, and triple antituberculosis therapy is not indicated.
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