INTRODUCTION: Pulmonary hamartomas are the most common benign lung tumors. The majority of these lesions are found within the pulmonary parenchyma and are asymptomatic at the time of discovery. Endobronchial hamartomas are far less common; however, they should be considered in patients with recurrent pulmonary infections (1). We present the unusual case of a young man with an endobronchial hamartoma as the nidus for recurrent episodes of necrotizing pneumonia.
CASE PRESENTATION: A 45 year old African-American male with Type II diabetes mellitus, hypertension, and previous episodes of pneumonia presented with complaints of fever and fatigue for twenty-four hours. The patient was tachypneic, tachycardic, and hypoxemic on initial evaluation. Imaging revealed left lower lobe consolidation with air bronchograms and focal areas of cavitation. The patient was admitted to the inpatient ward and initiated on broad spectrum antibiotics and supplemental oxygen. Pulmonary consultation uncovered a past medical history of numerous episodes of left lower lobe pneumonia during the preceding year, including one episode complicated by septic shock and prolonged hospitalization. During that particular hospitalization, attempted surgical drainage of an empyema was abandoned due to cardiac arrest during induction of anesthesia, and the patient was ultimately managed with thoracostomy tube placement alone. Given the history of recurrent infections in a young, immunocompetent host, consideration of a potential endobronchial lesion prompted fiberoptic bronchoscopy shortly after admission. Bronchoscopy demonstrated a smooth, polypoid lesion obstructing the orifice of the left lower lobe divisions. The lesion was biopsied, and pathology demonstrated inflammation only. Due to unremitting sepsis and a need for source control, the patient was prepared for removal of necrotic material from the left hemithorax and resection of the offending lesion. Left thoracotomy was undertaken, and intraoperative findings included near-complete destruction of the left lower lobe and a lobulated mass at the orifice of the left lower lobe. Microscopic evaluation of the tumor revealed mature chondroid and adipocytic tissue with trapped benign epithelium, consistent with a diagnosis of hamartoma. Postoperatively, the patient was extubated without complication and subsequently made a full recovery.
DISCUSSION: This case illustrates the uncommon occurrence of an endobronchial hamartoma; furthermore, it details the unusual association of an endobronchial hamartoma with necrotizing pneumonia requiring definitive treatment with thoracotomy and left lower lobectomy.
CONCLUSIONS: The evaluation of individuals with recurrent pulmonary infections isolated to one bronchopulmonary segment should involve prompt bronchoscopy to identify a culprit endobronchial lesion. Though nonsurgical removal techniques are possible in clinically stable patients, removal of obstructing lesions in the critically ill may necessitate surgical intervention.
Reference #1 Cosío BG, Villena V, Echave-Sustaeta J, de Miguel E, Alfaro J, Hernandez L, Sotelo T. Endobronchial hamartoma. Chest. 2002 Jul;122(1):202-5.
DISCLOSURE: The following authors have nothing to disclose: Ann Long, Christopher Thomas, Michael Sanchez, Robert Thurston, Hollis O'Neal
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