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Case 326

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Female patient, 3 years and 6 months old, presenting dry cough, paroxysmal, associated with dyspnea on medium exertion and abdominal pain two months ago. She was medicated with salbutamol and beclomethasone, without improvement. She developed persistent fever (38.5ºC) and nasal congestion and received amoxicillin for 14 days. In a new clinical reassessment, the persistence of respiratory symptoms and worsening abdominal pain were observed. She was referred for hospitalization and, after a chest X-ray, amoxicillin associated with potassium clavulanate was started. On the 4th day of hospitalization, an alternative diagnosis was suspected, and chest computed tomography was requested.

Considering the clinical history and the presented images, which one is the most likely diagnosis?

a) Congenital thymic cyst

25%

b) Infected intrapulmonary bronchogenic cyst

25%

c) Bronchopulmonary intralobar sequestration

25%

d) Pneumonia

25%
   

Images analysis

Image 1: Chest radiograph, orthostatic position. Opacity occupying a large part of the right hemithorax (red circle), with tiny gaseous accumulations of permeation, causing indefinition of the pulmonary hips and ipsilateral heart.

 

Image 2: Computed tomography (CT), axial scan, carina level, after intravenous injection of iodinated contrast, mediastinal window. Expansive lesion with liquid density (red arrow) and gaseous accumulations of permeation showing parietal enhancement by the contrast medium, occupying a large part of the right hemithorax and causing a small contralateral deviation of the adjacent mediastinal structures.

 

Image 3: Computed tomography (CT), axial scan, carina level, after intravenous injection of iodinated contrast, lung window. Expansive lesion (red arrow), with regular contours, with small gaseous accumulations of permeation, occupying a large part of the right hemithorax and causing a small contralateral deviation of the adjacent mediastinal structures.

 

Image 4: Computed tomography (CT) of the thorax, coronal reconstruction, level of the vertebral bodies, after intravenous injection of iodinated contrast, mediastinal window. Expansive lesion with liquid density (red circle), with gaseous accumulations of permeation showing parietal and septal enhancement by the contrast medium, occupying a large part of the right hemithorax.

Highlights

- Bronchogenic cyst is a relatively uncommon congenital anomaly originated from the abnormal development of the tracheobronchial tree;
- The clinical presentation varies with the age of the patient and the location of the cyst: signs of respiratory discomfort (in the 1st year of life) and recurrent respiratory infections (after the 1st year of life);                        
- The simple chest X-ray in two incidences is the main and the first examination to be requested;
- Treatment is surgical in symptomatic patients;
- Requires long-term follow-up for the chance of recurrence, in case of partial resection.

References

- Oermann, CM. (2018). UpToDate. [online] Uptodate.com. Available at: https://www.uptodate.com/contents/congenital-anomalies-of-the-intrathoracic-airways-and-tracheoesophagealfistula?search=bronchogenic%20cist&source=search_result&selectedTitle=1~28&usage_type=default&display_rank=1 [Accessed 29 Mar. 2018].

- M Oermann, C. (2018). UpToDate. [online] Uptodate.com. Available at: https://www.uptodate.com/contents/congenital-anomalies-of-the-intrathoracic-airways-and-tracheoesophagealfistula?search=bronchogenic%20cist&source=search_result&selectedTitle=1~28&usage_type=default&display_rank=1 [Accessed 29 Mar. 2018].

- Cataletto, M. (2018). Pediatric Bronchogenic Cyst: Background, Pathophysiology, Epidemiology. [online] Emedicine.medscape.com. Available at: https://emedicine.medscape.com/article/1005440-overview [Accessed 29 Mar. 2018].

- Pêgo-Fernandes PM, Freire CH, Jatene FB, Beyruti R, Suso FV, Oliveira AS. Pulmonary sequestration: a series of nine cases operated. (J Pneumol 2002; 28 (4): 175-179).

- Pêgo-Fernandes PM, Ebaid GX, Galizia MS, Marchiori P, Suso FV, Jatene FB. Thymoma: discussion of treatment and prognosis. (J Pneumol 2001; 27 (6): 289-294).

- Silva CIS, Müller NL, et al. Thorax - Brazilian College of Radiology and Imaging Diagnostic Series. 2nd Edition. Rio de Janeiro: Elsevier, 2017.

Authors

Ariádna Andrade Saldanha da Silva, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: ariadna.andrade[at]hotmail.com

Izabella Barreto, General and Trauma Surgeon, Resident in Pediatric Surgery at Hospital das Clínicas, UFMG.

E-mail: izabrs [at] yahoo.com.br

 

 

Supervisors

Eliane Viana Mancuzo, Pneumologist, PhD in Adult Health at UFMG. Preceptor of the Residency of Pneumology at HC-UFMG. Adjunct Professor, Department of Clinical Medicine at Medical School at UFMG.

E-mail: elianevmancuzo4[at]gmail.com

 

Júlio Guerra Domingues, Substitute Professor, Department of Anatomy and Image at Medical School at UFMG.

E-mail: jgdjulio[ay]gmail.com

Reviewers

Bernardo Finotti, Bruno Campos, Prof. José Nelson M. Vieira, Profa. Viviane Santuari Parisotto Marino

Translater                                                                                                                     

Izabella Costa Neves Silva, 5th year medical student at Universidade Federal de Minas Gerais. Mail:izabellacosta15[arroba]hotmail.com

Test question

(2008-TEP / PEDIATRIC SPECIALIST TITLE) A four-year-old female with a low-grade fever a month ago is taken to the health clinic. Physical examination: pallid + / 4 +. Laboratory tests: Ht: 29%, VHS: 85 mm / hour, VCM: 85fl. Chest radiography: massive mass in the posterior mediastinum of irregular contours, with calcifications. This clinical presentation is suggestive of:

a) Lymphoma

25%

b) Pneumonia

25%

c) Neuroblastoma

25%

d) Bronchogenic cyst

25%

e) Lymph node tuberculosis

25%
   

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