SESSION TYPE: Bronchology Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Bronchial Atresia is a congenital anomaly of great significance for its varied observations and its semblance to acquired pathological conditions. The co-existence of mucoid impaction and lobar emphysema due to bronchial atresia and bronchogenic cyst is exceedingly rare, and—as outlined in our case—can represent a major diagnostic dilemma.
CASE PRESENTATION: A 45-year-old female with a history of endometriosis presented to clinic for evaluation of four-months of dyspnea and cough. She had previously received several courses of antibiotics—for presumed respiratory tract infections—to no avail. Physical examination was notable for decreased breath sounds in the left upper lung field. Laboratory testing, including extensive infectious work-up, was negative. Chest roentography showed left-sided perihilar prominence and increased lucency in the left upper lung field. Chest computerized tomography (CT) was remarkable for a non-enhancing tubular mass extending cephalad from the left hilum, representing dilatation of multiple central left upper lobe (LUL) bronchi with associated mucoid impaction, and surrounding hypoattenuation indicative of localized hyperinflation. Additionally, there was a 4.5 x 1.5 x 2.7 cm non-enhancing, well-circumscribed, low-density lesion in the posterior mediastinum. Pulmonary function testing was normal. Fiberoptic bronchoscopy revealed a compressed LUL apicoposterior segment and absence of the anterior segment. Infectious work-up and cytological analysis, including those from transbronchial needle aspiration (TBNA) and bronchoalveolar lavage (BAL), were negative. Transesophageal endoscopic ultrasound-guided needle aspiration of the posterior mediastinal lesion revealed benign respiratory mucosa. Positron emission tomography (PET) showed no evidence of abnormal tracer activity. Further imaging confirmed the mediastinal mass to be consistent with a bronchogenic cyst; additionally, there was no interval change in the size or morphology of the aforementioned abnormalities.
DISCUSSION: Bronchial atresia is a congenital anomaly of unknown etiology in which a segmental bronchus does not communicate with the central airway. Most commonly found in the apicoposterior segment of the LUL, it appears as a branching tubular area of increased opacity that extends from the hilum with surrounding hyperlucency. The hyperlucency is thought to result from unidirectional flow through collateral airways. Consequently, the intervening segments of bronchi between the atretic regions form bronchocoeles due to retained secretions leading to mucoid impaction.
CONCLUSIONS: Bronchial atresia has been hypothesized to result from intrauterine ischemia after the 15th week of gestation. However, our case—which highlights the co-existence of a bronchogenic cyst—supports the theory that this anomaly occurs at an earlier period of development.
1) Rappaport,Herman.Congenital bronchopulmonary diseases in adults.American Journal of Roetgenology,1994;162.
DISCLOSURE: The following authors have nothing to disclose: Yasmeen Kabir, Jasper Ip, Nader Kamangar, Nikhil Barot
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