Asian Cardiovasc Thorac Ann 2006;14:244-246
© 2006 Asia Publishing EXchange Ltd
Giant Bronchogenic Cyst Mimicking Tension Pneumothorax
Sedat Demircan, MD,
I Cüneyt Kurul, MD,
Mahmut Tokur, MD,
Leyla Memis, MD1,
Ilyas Okur, MD2
Department of Thoracic Surgery
1 Department of Pathology
2 Department of Pediatrics, Gazi University Medical Faculty, Ankara, Turkey
For reprint information contact: I Cüneyt Kurul, MD Tel: 90 312 214 1000 Fax: 90 312 212 9014 Email: ckurul{at}hotmail.com, Oyak Sitesi Blok 1/20, Çankaya, Ankara 06610, Turkey.
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ABSTRACT
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An 18-month-old girl presented with high fever and vomiting. Pneumothorax and a cystic formation in the right hemithorax were found on a chest radiograph. The cyst measuring 10 x 10 x 8 cm was resected by a simple wedge resection. Histology revealed a complicated bronchogenic cyst with abscess formation.
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INTRODUCTION
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Cystic lesions of the mediastinum are uncommon, comprising 20% to 32% of all mediastinal masses. Furthermore, 50% to 60% of mediastinal cysts are bronchogenic cysts.1 Bronchogenic cysts are occasionally associated with serious complications. Among these complications, pneumothorax is a very rare entity.
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CASE REPORT
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An 18-month-old girl was brought to our hospital with a high fever (39.5°C) and vomiting, which had started suddenly the previous day. The patient was noted to have a history of neonatal hepatitis. Physical examination showed that breath sounds on the right thorax were much reduced compared to the left side. Chest radiography showed a pneumatocele lesion on the right side of the lung. The cyst covered the whole of the right thorax and caused a shift towards the left. Air-fluid levels existed at the base of the lesion. On the right side, no lung parenchyma was seen, while there was consolidation of the left lung parenchyma. On the second day of hospitalization, pneumothorax was detected on a chest radiograph which also showed a cystic formation on the right hemithorax with septations and a range of air-fluid densities. There was air in the pleural space and an amount of fluid was observed (Figure 1A
). Computed tomography of the chest revealed a cystic lesion (Figure 1B). Given the findings of pneumothorax and dyspnea, a chest tube was placed at the 2nd intercostal space on the right side to avoid placing it into the cystic cavity and to improve the child’s general condition. After day 1, very limited regression of the symptoms was seen and the huge cyst continued to press against the right lung and heart, thus a decision to operate became inevitable. The operation was started with rigid bronchoscopy and no pathology was detected. The thoracic cavity was opened by a right posterolateral thoracotomy through the 5th intercostal space. A cystic lesion measuring 10 x 10 x 8 cm with an abundance of vascularization was observed. Stalk connections between the posterior segment of the upper and middle lobes were identified. These connections were simply divided by gentle traction and blunt dissection, and the cyst was excised by a simple wedge resection. Morphologically, the cystic content was of a liquid nature. The fluid was yellow and pus-like. Histological examination revealed a complicated bronchogenic cyst with abscess formation. The patient’s postoperative course was uneventful and she left the hospital on the 7th postoperative day (Figure 2).
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Figure 1. (A) Chest radiograph showing a well-defined cystic lesion on the right thorax and an appearance of pneumothorax.
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DISCUSSION
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A congenital cystic lesion in the lung of a child is uncommon but potentially life-threatening, so urgent diagnostic work-up is required. The 4 major congenital cystic lesions of the lung are pulmonary sequestration, congenital cystic adenomatoid malformation, congenital lobar emphysema, and bronchogenic pulmonary cysts. Bronchogenic cysts are the most common of these.2 They result from a developmental malformation of the embryonic foregut.1–5 They can be either extrapulmonary or intrapulmonary. Most occur within the middle or posterior mediastinum around the tracheobronchial tree, and up to 30% occur within the pulmonary parenchyma.1,4
Clinical findings and plain chest radiographs are often sufficient for diagnosis. However, there are no specific clinical signs or symptoms of bronchogenic cysts. The most frequent symptoms are pain, cough, fever and dyspnea. Serious complications due to bronchogenic cysts have been reported, of which infection is the most common.1,5 It is usually caused by communication with the tracheobronchial tree. Other symptoms occur due to compression, such as arrhythmias, pulmonary artery obstruction, and superior vena cava syndrome.5 The cysts often have valves which lead to enlargement, resulting in life-threatening compression. Compression is the most important complication in infants and children, and thus requires immediate treatment.5 Pneumothorax is a rarely seen but serious complication that needs urgent intervention. Another serious complication is malignant transformation.5 Computed tomography provides the diagnosis in most cases when a cystic mass is evidenced in the vicinity of the respiratory tree.1,2,5 Computed tomography of bronchogenic cysts typically shows sharply defined mediastinal masses of soft tissue or fluid attenuation.1,5
Treatment of bronchogenic cysts in pediatric patients is surgical excision. Demircan and colleagues5 advocate the surgical treatment of cysts without waiting for the occurrence of any complications or symptoms, to prevent progressive growth and subsequent mediastinal compression. Incomplete surgical excision is to be avoided since there have been numerous reports of cyst recurrence after such procedures.1–3,5 This case highlights the need for early diagnosis and urgent operation for these cysts.
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REFERENCES
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- Duranceau A, Deslauriers J. Foregut cysts of the mediastinum in adults. In: General thoracic surgery. 5th ed. Shields TW, LoCicero J, Ponn RB, editors. Philadelphia: Lippincott Williams & Wilkins 2000:2401–13.
- Takeda S, Miyoshi S, Inoue M, Omori K, Okumura M, Yoon HE, et al. Clinical spectrum of congenital cystic disease of the lung in children. Eur J Cardiothorac Surg 1999;15:11–7.[Abstract/Free Full Text]
- Barsotti P, Chatzimichalis A, Massard G, Wihlm JM. Cervical bronchogenic cyst mimicking thyroid adenoma. Eur J Cardiothorac Surg 1998;13:612–4.
- St-Georges R, Deslauriers J, Duranceau A, Vaillancourt R, Deschamps C, Beauchamp G, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg 1991;52:6–13.[Abstract]
- Demircan S, Liman ST, Kuzucu A, Karao lano lu N, Kürkçüo lu IC, Taþtepe I, et al. Surgical approach to the mediastinal bronchogenic cystic lesions. Solunum Hastaliklari 1996;7:431–8.
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ABSTRACT
INTRODUCTION
