Imaging: Fellow Case Report Poster - Imaging |

A Case of Vanishing Lung Syndrome FREE TO VIEW

Sathish Kumar Krishnan, MD; Shahryar Ahmad, MD; Andrew Zane, MD
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Medical College of Wisconsin, Greenfield, WI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):654A. doi:10.1016/j.chest.2016.08.748
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SESSION TITLE: Fellow Case Report Poster - Imaging

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Vanishing lung syndrome (VLS), or giant bullous emphysema, is a distinct clinical syndrome characterized by the development of giant bullae that compress the adjacent lung parenchyma causing it to seemingly disappear.

CASE PRESENTATION: A 44 year old male presented with a 3-month history of exercise intolerance and shortness of breath, and 2-week history of left sided pleuritic chest pain. He was smoking 3 cigarettes per day for 20 years, and was smoking marijuana and cocaine up to 10 times a day for 15 years. On presentation, he was tachypneic and oxygen saturation was 86% on room air. Physical examination was significant for decreased breath sounds in the upper lung fields bilaterally. Chest X-ray was suggestive of left apical pneumothorax and bullous changes in the right upper lung field. CT chest revealed giant bullae bilaterally that spared the lower lobes. No pneumothorax was identified. His alpha 1 antitrypsin level was normal. He was diagnosed with vanishing lung syndrome and was treated with surgical bullectomy.

DISCUSSION: VLS is characterized by the coalescence of adjacent areas of paraseptal emphysema to form giant bullae with a marked predisposition for the upper lobes. Risk factors include alpha 1 antitrypsin deficiency, and tobacco, marijauana, and cocaine smoking. In patients who smoke marijauana and cocaine, the pathological changes are known to occur earlier in life, by about 20 years. Radiologically, VLS is defined by the finding of giant bullae in one or both lungs, occupying at least one third of the hemithorax and compressing the surrounding lung parenchyma. CT scan of the chest plays a key role in management. The large size and apical location of the bullae pose a challenge to differentiate from pneumothorax on chest X-ray. CT scan also shows the extent and distribution of the bullae for preoperative assessment. Treatment of VLS is usually surgical bullectomy, especially when the patient is symptomatic or develops pneumothorax.

CONCLUSIONS: Smoking marijuana and cocaine play a synergistic role in the pathogenesis of VLS. It is vital to differentiate giant bulla from pneumothorax to avoid inadvertent placement of a chest tube and creation of an iatrogenic bronchopleural fistula.

Reference #1: Tashtoush B., et al. Vanishing Lung Syndrome in a Patient with HIV Infection and Heavy Marijuana Use. Case Reports in Pulmonology. 2014;2014:285208

Reference #2: Khasawneh F., et al. Vanishing lung syndrome mistaken for bilateral spontaneous pneumothorax. BMJ Case Reports. 2013 Oct 17;2013. pii: bcr2013201016

DISCLOSURE: The following authors have nothing to disclose: Sathish Kumar Krishnan, Shahryar Ahmad, Andrew Zane

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