Medical Image of the Week: Bronchopulmonary Sequestration

Figure 1. A) Chest x-ray PA view demonstrating an oblong soft tissue density in the retrocardiac region overlying the medical aspect of the left hemidiaphragm. B) Chest x-ray lateral view demonstrating the same opacity anterior to a lower thoracic vertebral body, suspicious for a lung mass.

Figure 2. Chest computed tomography A) axial and B) coronal sections demonstrating a lobulated, cystic structure within the left lower lobe with a feeding artery off the aorta, consistent with a pulmonary sequestration.

A 49-year-old woman was incidentally found to have a lung mass on a pre-operative chest x-ray done prior to an elective cholecystectomy (Figure 1). Chest computed tomography, ordered to further characterize this mass revealed a left lower lobe lobulated, cystic opacity with a feeding artery from the aorta, consistent with bronchopulmonary sequestration (BPS) (Figure 2). Given that she has not had any complications of BPS we elected to manage her conservatively with observation.

BPS is a rare congenital malformation of the lower airways characterized by abnormal lung tissue that does not communicate with the tracheobronchial tree and receives its blood supply from the systemic circulation (1). Our patient’s BPS was intralobar in location, occurring within a normal lobe but lacking its own visceral pleura. The posterior basal left lower lobe is the most common intralobar location. Among cases that escape clinical detection in infancy, BPS comes to light in childhood or adulthood as either an incidental radiographic finding or as a symptomatic presentation of a lung infection. While surgical resection is generally considered to be the treatment of choice given the risk of developing infection, hemorrhage or malignancy (2), some asymptomatic adults with BPS may be managed conservatively with observation with serial imaging (3).

Udit Chaddha MD¹, Niusha Damaghi MD¹, Ashley Prosper MD², and Ching-Fei Chang MD¹

¹Division of Pulmonary, Critical Care and Sleep Medicine and ²Department of Radiology

Keck School of Medicine

University of Southern California

Los Angeles, CA USA

References

1. Biyyam DR, Chapman T, Ferguson MR, Deutsch G, Dighe MK. Congenital lung abnormalities: embryologic features, prenatal diagnosis, and postnatal radiologic-pathologic correlation. Radiographics. 2010 Oct;30(6):1721-38. [CrossRef] [PubMed]
2. Azizkhan RG, Crombleholme TM. Congenital cystic lung disease: contemporary antenatal and postnatal management. Pediatr Surg Int. 2008 Jun;24(6):643-57. [CrossRef] [PubMed]
3. Stanton M, Njere I, Ade-Ajayi N, Patel S, Davenport M. Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg. 2009 May;44(5):1027-33. [CrossRef] [PubMed]

Cite as: Chaddha U, Damaghi N, Prosper A, Cha C-F. Medical image of the week: bronchopulmonary sequestration. Southwest J Pulm Crit Care. 2017;14(4):168-9. doi: https://doi.org/10.13175/swjpcc036-17 PDF

Medical Image of the Week: Wolff-Parkinson-White Syndrome

Figure 1. Presenting EKG with supraventricular tachycardia at rate of 232.

Figure 2. Post-conversion EKG demonstrating a short PR interval, slurring of the initial QRS upslope (delta wave), widened QRS, and ST-T repolarization change; characteristic of Wolff-Parkinson-White Syndrome.

A 38-year-old man developed sustained rapid heart rate while rock climbing. The patient reported that he had experienced rare bouts of self-limited palpitations in the past. Blood pressure on arrival to the emergency department was 112/ 65 mm Hg. The patient’s initial EKG demonstrated a regular, narrow complex supraventricular tachycardia, with a rate of 232 (Figure 1). Intravenous adenosine was administered with no change in his rate or rhythm. The patient then received amiodarone by intravenous bolus, with subsequent conversion to sinus rhythm (Figure 2).

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac condition present in approximately 0.15% of the general population. WPW is characterized by the abnormal presence of conduction tissue that creates an accessory atrioventricular pathway and thus potentiates reentrant tachycardia (1). The classic resting EKG findings in WPW are: a shortened PR interval (less than 0.12 seconds), an indistinct initial upslope of the QRS complex (known as the delta wave), a widened QRS complex (0.12 seconds or greater), and ST-T repolarization changes (2). In WPW presenting as a narrow complex tachycardia without hypotension, the initial treatment is adenosine or a calcium channel blocker, followed by amiodarone if unsuccessful. If the presenting rhythm is atrial fibrillation, atrial flutter, or an undefined wide complex tachycardia without hypotension, amiodarone is used. A hemodynamically unstable rhythm warrants immediate electrical cardioversion. Definitive evaluation and treatment of WPW requires electrophysiologic mapping and subsequent ablation of the accessory pathway.

Charles Van Hook MD, Cristina Demian MD, Douglas Tangel MD, Jennifer Blair MD, and Lisa Patel MD

Avista Adventist Hospital

Louisville, Colorado USA

References

1. Katritsis DG, Camm AJ. Atrioventricular nodal reentrant tachycardia. Circulation. 2010 Aug 24;122(8):831-40. [CrossRef] [PubMed]
2. Mark DG, Brady WJ, Pines JM. Preexcitation syndromes: diagnostic consideration in the ED. Am J Emerg Med. 2009 Sep;27(7):878-88. [CrossRef] [PubMed]
3. Khairy P, Van Hare GF, Balaji S, et al. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease. Heart Rhythm. 2014 Oct;11(10):e102-65. [CrossRef] [PubMed]

Cite as: Van Hook C, Demian C, Tangel D, Blair J, Patel L. Medical image of the week: Wolff-Parkinson-White syndrome. Southwest J Pulm Crit Care. 2017;14(4):164-5. doi: https://doi.org/10.13175/swjpcc046-17 PDF