Pictorial Quiz
Unilateral hyperlucent lung: Always think ACROSS Mahesh Jansari, Vinaya Karkhanis, J. M. Joshi Department of Pulmonary Medicine, T.N. Medical College, B.Y.L. Nair Hospital, Mumbai, Maharashtra, India
Address for correspondence: Dr. J. M. Joshi, Department of Pulmonary Medicine, T.N. Medical College and B.Y.L. Nair Hospital, Mumbai - 400 008, Maharashtra, India. E-mail: [email protected]
An 11-year-old boy with no significant past medical or surgical illness was symptomatic since 10 months with recurrent respiratory tract infection. Clinical examination revealed decreased breath sounds in left hemithorax. Chest X-ray [Figure 1] showed hyperlucent left lung. High resolution computed tomography (HRCT) thorax [Figure 2] showed a distinct opacity in the left main
Figure 1: Chest X-ray showing left hyperlucent lung
bronchus. Spirometry showed a restrictive abnormality with forced vital capacity (FVC) 54% of predicted and forced expiratory volume in 1 s (FEV1) 50% of predicted.
QUESTION What is the likely diagnosis?
Figure 2: High resolution computed tomography thorax coronal view showing foreign body in the left main bronchus
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.120629
368
Lung India • Vol 30 • Issue 4 • Oct ‑ Dec 2013
Jansari, et al.: Unilateral hyperlucent lung
ANSWER Post-obstructive emphysema due to foreign body (FB) in the left main bronchus. Bronchoscopy was performed and betel nut 6 mm × 4 mm [Figure 3] was removed from the apical segment of the left lower lobe. Spirometry showed improvement FVC - 260 ml, FEV1 - 250 ml. HRCT thorax showed thickened bronchial wall and mild focal narrowing of left main bronchus. A repeat bronchoscopy revealed granulation tissue in left main bronchus with no obstruction or FB. The differential diagnosis for unilateral hyperlucent lung can be best remembered by the mnemonic ACROSSS Air (i.e., pneumothorax), A - Artery (pulmonary) absent or hypoplasia C - Chest wall – mastectomy, polio, Poland syndrome R - Rotated film O - Obstructive causes: airway obstruction, foreign body, unilateral emphysema, or large embolus S - Scoliosis S - Surrounding (i.e., increased density: for example, pleural effusion in opposite lung in a recumbent patient) S - Swyer James syndrome (Macleod’s syndrome). Tracheobronchial FB is a common cause for unilateral hyperlucent lung in children but requires high index of suspicion. Flexible fiber-optic bronchoscopy is the diagnostic investigation of choice for initial evaluation and rigid bronchoscopy is the standard for removal of foreign
Figure 3: Bronchoscopically removed betel nut
body.[1] Thoracotomy may be life-saving in endoscopically non-retrievable foreign bodies. Once identified, FB should be removed as early as possible.
REFERENCE 1.
Dixit S, Agarwal R, Kumar N, Verma R, Krishna V, Sahni JL. Management of tracheobronchial foreign bodies-experience of cardiothoracic department of cardiology institute. Indian J Thorac Cardiovasc Surg 2011;27:33-5.
How to cite this article: Jansari M, Karkhanis V, Joshi JM. Unilateral hyperlucent lung: Always think ACROSS. Lung India 2013;30:368-9. Source of Support: Nil, Conflict of Interest: None.
Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.jcasonline.com/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.jcasonline.com/rssfeed.asp as one of the feeds. Lung India • Vol 30 • Issue 4 • Oct ‑ Dec 2013 369
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Unilateral hyperlucent lung: Always think ACROSS Mahesh Jansari, Vinaya Karkhanis, J. M. Joshi Department of Pulmonary Medicine, T.N. Medical College, B.Y.L. Nair Hospital, Mumbai, Maharashtra, India
Address for correspondence: Dr. J. M. Joshi, Department of Pulmonary Medicine, T.N. Medical College and B.Y.L. Nair Hospital, Mumbai - 400 008, Maharashtra, India. E-mail: [email protected]
An 11-year-old boy with no significant past medical or surgical illness was symptomatic since 10 months with recurrent respiratory tract infection. Clinical examination revealed decreased breath sounds in left hemithorax. Chest X-ray [Figure 1] showed hyperlucent left lung. High resolution computed tomography (HRCT) thorax [Figure 2] showed a distinct opacity in the left main
Figure 1: Chest X-ray showing left hyperlucent lung
bronchus. Spirometry showed a restrictive abnormality with forced vital capacity (FVC) 54% of predicted and forced expiratory volume in 1 s (FEV1) 50% of predicted.
QUESTION What is the likely diagnosis?
Figure 2: High resolution computed tomography thorax coronal view showing foreign body in the left main bronchus
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.120629
368
Lung India • Vol 30 • Issue 4 • Oct ‑ Dec 2013
Jansari, et al.: Unilateral hyperlucent lung
ANSWER Post-obstructive emphysema due to foreign body (FB) in the left main bronchus. Bronchoscopy was performed and betel nut 6 mm × 4 mm [Figure 3] was removed from the apical segment of the left lower lobe. Spirometry showed improvement FVC - 260 ml, FEV1 - 250 ml. HRCT thorax showed thickened bronchial wall and mild focal narrowing of left main bronchus. A repeat bronchoscopy revealed granulation tissue in left main bronchus with no obstruction or FB. The differential diagnosis for unilateral hyperlucent lung can be best remembered by the mnemonic ACROSSS Air (i.e., pneumothorax), A - Artery (pulmonary) absent or hypoplasia C - Chest wall – mastectomy, polio, Poland syndrome R - Rotated film O - Obstructive causes: airway obstruction, foreign body, unilateral emphysema, or large embolus S - Scoliosis S - Surrounding (i.e., increased density: for example, pleural effusion in opposite lung in a recumbent patient) S - Swyer James syndrome (Macleod’s syndrome). Tracheobronchial FB is a common cause for unilateral hyperlucent lung in children but requires high index of suspicion. Flexible fiber-optic bronchoscopy is the diagnostic investigation of choice for initial evaluation and rigid bronchoscopy is the standard for removal of foreign
Figure 3: Bronchoscopically removed betel nut
body.[1] Thoracotomy may be life-saving in endoscopically non-retrievable foreign bodies. Once identified, FB should be removed as early as possible.
REFERENCE 1.
Dixit S, Agarwal R, Kumar N, Verma R, Krishna V, Sahni JL. Management of tracheobronchial foreign bodies-experience of cardiothoracic department of cardiology institute. Indian J Thorac Cardiovasc Surg 2011;27:33-5.
How to cite this article: Jansari M, Karkhanis V, Joshi JM. Unilateral hyperlucent lung: Always think ACROSS. Lung India 2013;30:368-9. Source of Support: Nil, Conflict of Interest: None.
Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.jcasonline.com/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.jcasonline.com/rssfeed.asp as one of the feeds. Lung India • Vol 30 • Issue 4 • Oct ‑ Dec 2013 369
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
