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CASE REPORT
275
Address for correspondence:
Address for correspondence:
Address for correspondence:
Address for correspondence:
Address for correspondence: Mirosław Trzciński MD, Oddział Pulmonologiczny SSZZOZ im. T. Dunina w Rudce, Al. T. Dunina 1, Rudka, 05–320 Mrozy tel.: +48 (25) 75 74 170, fax: +48 (25) 75 74 343, e-mail:urea@mp.pl
Manuscript received on: 8.08.2011 r.
Copyright © 2012 Via Medica ISSN 0867–7077
Mirosław Trzciński1, Krystyna Folcik1, Barbara Burakowska², Katarzyna Błasińska², Elżbieta Wiatr3
1Branch of Lung Diseases, Rudka Hospital Ordynator: MD K. Folcik
²Radiology Facility, National
Tuberculosis and Lung Diseases Institute, Warsaw, Poland Head: MD, PhD I. Bestry
3III Department of of the National
Tuberculosis and Lung Diseases Institute, Warsaw, Poland Head: Prof. K. Roszkowski-Śliż MD, PhD
The bleeding into the emphysematosus bulla imitating lung tumor
Krwawienie do pęcherza rozedmowego imitujące guz płuca
No financial support declared by the authors of this publication.
Abstract
Bleeding into the lung parenchyma is a rare phenomenon that usually occurs as a result of chest trauma, other causes are anticoagulant therapy, and infections. The following case presents a patient admitted to the hospital due to haemoptysis, which was a symptom of bleeding into the emphysematosus bulla caused by anticoagulation therapy.
The decisive diagnostic examination was chest magnetic resonance. This imaging method allows the precise differentiation of tissues. Using modern imaging techniques can often dispense with invasive diagnostic methods.
Key words: lung tumor, emphysematosus bulla, hematoma, magnetic resonance imaging
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Introduction
A round opacification on chest X-ray in a pa- tient with chronic obstructive pulmonary disease (COPD) raises suspicion of a neoplasm.
Differential diagnosis should include prima- ry lung tumours, metastases, inflammatory proces- ses like tuberculosis or abscess related to other infections, pneumatocele, lung infarction, encap- sulated pleural fluid, congenital abnormalities, changes in the course of interstitial diseases like Wegener’s granulomatosis, or sarcoidosis.
Below we report a case of a patient referred to the hospital in Rudka, Poland with haemoptysis and suspicion of lung cancer on the basis of chest imaging.
Case report
A sixty-five-year-old man, a retired lock- smith, on disability pension at the time of presen- tation, ex-smoker for 10 years, with severe chro- nic obstructive pulmonary disease (COPD) was admitted to the hospital urgently due to intensive breathlessness, cough, and haemoptysis.
The patient was treated for bacteriological- ly confirmed pulmonary tuberculosis in 1987. He underwent spontaneous right and left sided pneumothoraces in 1991, 1994, and 1999, for which he had been treated with suction draina- ge in the surgical departments. In 2004 he was hospitalized in Rudka Hospital due to pulmona- ry embolism, and since then he had been treated
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with acenocumarol and seen on a regular basis by a chest physician.
On admission to the hospital the patient was in serious general condition, complaining of short- ness of breath on minimal exertion and cough with haemoptysis. Physical examination revealed a bar- rel chest, vesicular resonance and breathing so- unds, prolonged expiration time and bilateral rhon- chi, and crackles.
His heart rate was regular at 80 bpm and blo- od pressure was 140/80 mm Hg. There were no ab- normalities in the full blood count or biochemical analyses. The international normalized ratio (INR) and prothrombin ratio were abnormal: 6.16 and 14%, respectively. Chest X-ray revealed round le- sion in the peripheral region of the lower zone of the right lung, measuring 35 × 50 mm, emphyse- ma, features of chronic bronchitis, pulmonary fi- brosis with bronchiectasis in the upper right zone, and small parenchymal opacifications, most like- ly inflammatory in nature, in the lower zone of the left lung (fig. 1). Bronchoscopy showed a rusty se- cretion in the bronchi of the right lung. No other abnormalities were present. The bronchial secre- tion was taken for cultures and cytological exami- nation. Sputum sample and bronchial washings were negative for acid-fast bacilli.
Spirometry indicated airway obstruction of severe degree: FEV1 (forced expiratory volume in one second) — 1.13 L (32% of predicted value), VC (vi- tal capacity) — 4.11 L (87% of predicted value), and FEV1%VC — 27.48 (36% of predicted value). Capil- lary blood gases examination showed: oxygen par- tial pressure — 60.9 mm Hg, carbon dioxide partial pressure — 36.2 mm Hg, saturation — 92.2%.
Sputum and bronchial lavage cultures showed growth of Streptococcus spp. and Neisseria spp.
Cytological examination revealed the presence of granulocytes and macrophages. Next, contrast en- hanced computer tomography of the chest was performed. The scan showed advanced emphyse- ma with large thin-walled bullae in the peripheral areas of the lungs; the largest ones at the base of lower right lobe, with fluid levels in them visible
— likely infected. Besides that, fibrotic upper ri- ght lobe, bronchiectasis, and focal lesion 40 × 35 mm in the 9th segment of the right lung were seen.
Radiologists could not exclude neoplastic aetiology of the described lesion. There was no thromboembolic material in the pulmonary arte- ries. The biopsy of the lesion was done under USG guidance. However, a sample for microscopic exa- mination was not obtained. The procedure was complicated by pneumothorax requiring a drain in- sertion. Lung expansion was achieved (fig. 2, 3).
Figure 1. Chest X-ray, PA. Emphysema. Fibrosis of the right upper lobe. Oval lesion in the lower zone of the right lung. Small consoli- dation in the lower zone of the left lung
Figure 2. Chest CT, lung window, axial images. Multiple emphyse- matous bullae. Rounded, well-defined lesion in the 9th segment of the right lower lobe. Drain in the right pleura
Figure 3. Chest CT, mediastinal window, axial images. Multiple emphysematous bullae. Rounded, well-defined lesion in the 9th seg- ment of the right lower lobe. Drain in the right pleura
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At that point the decision was made to per- form contrast enhanced magnetic resonance ima- ging (MRI) before continuing with the invasive diagnostic process. The study showed a 32 × 33 × 47 mm, hyperintense, not enhancing in T2 weigh- ted scans, lesion with smooth contours in the ri- ght lower lobe. In T1 weighted scans of medium signal intensity, hyperintense rim characteristic for haemoglobin metabolites was described (fig. 4–6).
The performed investigations indicated the presence of haematoma formed in the emphysema- tous bulla, so surgical intervention was not under- taken. Antibiotics, mucolytics, bronchodilators, and positioning drainage were applied. This led to an improvement in the patient’s condition and re- gression of dyspnoea and haemoptysis. The anti- coagulant was stopped. The patient was dischar- ged for further follow up in an outpatient setting.
Discussion
Bleedings into lung parenchyma are usually caused by chest trauma, which happens especial- ly in young men. In such cases the blood extrava- sation is a result of rupture or thrombosis of a bron- chial artery branch, which leads to necrosis of the fragment of the lung and bleeding into the area sup- plied by the collateral vessels [1]. Another cause of bleeding into lung parenchyma is a complica- tion of treatment with an anticoagulant [1–3].
In some of patients, bleedings are related to bullous emphysema. Haemorrhage into emphyse- matous bullae can be caused by an infection that leads to necrosis of blood vessels [2]. Routine chest imaging shows intrapulmonary haematoma as consolidations or round lesions [1–4]. A round lesion in chest X-ray of the patient presenting to hospital with haemoptysis required, most of all, exclusion of neoplastic disease. In addition, the patient was a cigarette smoker, used to work in a polluted environment, and had COPD [5]. Lung cancer had to be included in the differential dia- gnosis.
The results of the performed studies, including the picture of the airway tree seen at bronchosco- py and cytological examination of bronchial secre- tion, prompted the investigation to be broadened.
In the reported case, haemorrhage to the em- physematous bulla was caused by anticoagulant overdose and probably coexisting infection of the respiratory tract.
The crucial point in the investigation that also allowed the patient to be saved from thoracotomy was performing an MRI study. It showed a hype- Figure 4. Chest MRI,T1W VIBE, axial image. Rounded lesion in
the right lower lobe, of medium- signal intensity with hyperinten- se rim
Figure 5. Chest MRI,T2W axiaI image TSE, fat-suppressed. Roun- ded, hyperintense lesion in the right lower lobe
Figure 6. Chest MRI, T1W VIBE, contrast- enhanced, axial image with fat- suppression. No contrast-enhancement of the lesion was demonstrated
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rintense rim in T1-wieghted scans, which is cha- racteristic for underwent haemorrhage.
Magnetic resonance is the most dynamically developing and universal technique of imaging, mostly due to the physical potentialities of the method. It has the ability of specific imaging of individual tissues by obtaining specific signals from various chemical compounds containing hy- drogen and the possibility of imaging the proton density. No other imaging technique allows for such precise differentiation of tissues on the basis of the content of lipids and proteins or for identi- fication of haematoma in various stages of haemo- lysis [6]. There has been significant progress in MR imaging during recent years, resulting in wide dia- gnostic possibilities [7].
Bleeding into an emphysematous bulla is a rare phenomenon. There is a case of haematoma in emphysematous bulla in Polish bibliography from recent years, published by Chabowski et al.
[8]. In that paper the case of a patient admitted to the Department of Thoracic Surgery of the Natio- nal Tuberculosis and Lung Diseases Institute for a round lesion in the lower right lobe in chest X-ray was described.
In chest CT scan numerous emphysematous bullae of the upper and middle right lobes were re- vealed. Inside one of them, a mass 35 × 28 mm was seen. Bronchoscopy did not show any pathology.
Alpha1-antitrypsin serum concentration was normal. Due to the presence of a very big bulla (that itself was an indication for surgery) and the neces- sity of verification of the lesion’s aetiology, the patient underwent right sided thoracotomy.
The emphysematous bulla, together with a mass 3 cm in diameter inside it, was removed from the upper lobe. On histopathological examination it ap- peared to be a fragment of pulmonary parenchyma
with emphysematous changes and the presence of numerous cysts with organized haematoma inside.
Bacteriological studies, including mycobacte- rial and mycological studies, of the removed tis- sue were performed. The cultures were negative [8]. Chest MR imaging was not performed in that case due to technical aspects.
As was mentioned before, bleeding into an emphysematous bulla is not a common phenome- non. We decided to present this case to show the potentialities and necessity of using different ava- ilable chest imaging methods. This helps in ma- king a diagnosis without turning to more invasive procedures.
Conflict of interest statement
The authors have no conflict of interest to declare.
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