Complex Mass at Right Lung Base: Diagnosis
Intralobar sequestrations lie contiguous to normal lung parenchyma and within the same visceral pleura. Venous drainage is usually via the pulmonary veins. There is a slight left-sided predominance with the posterior basal segments most often involved. Most patients with intralobar sequestration present with recurrent respiratory infections. In about 15 percent of the patients, other congenital abnormalities are identified. These include esophagobronchial diverticulum, diaphragmatic hernia, skeletal deformities, and cardiac abnormalities. Extralobar sequestrations are enveloped by a separate pleural covering and usually have systemic venous drainage. They are related to the left hemidiaphragm in 80 percent of the cases. In 75 percent of cases, the sequestration is located between the diaphragm and the lower lobe. It may also be within or below the diaphragm. It is frequently (about 50 percent) associated with congenital abnormalities. The most common of these include diaphragmatic hernias, diaphragmatic defects, and other lung anomalies. natural breast enlargement cream
The diagnosis of bronchopulmonary sequestration should be considered with persistent or recurrent lower lobe infiltrates or masses, especially if the posterior basal segment is involved. Intralobar sequestrations are more likely to appear round or oval. Infections are more common in intralobar sequestrations and may result in communication with the airway resulting in an air-containing cystic mass. Infection may also cause enlargement or propagation of the sequestration due to the accumulation of purulent material, as was probably the case in our patient.
Extralobar sequestration is usually a pyramidalshaped homogenous mass at the left lung base. Infection is less likely because of the pleural lining separating it from adjacent lung. Extralobar sequestrations are more likely to be discovered in a child, occasionally as an asymptomatic mass associated with other congenital malformations.
Aortography is frequently performed preoperatively to establish the diagnosis and to plan surgery Fatal exsanguination has occurred when an anomalous vessel was not recognized at surgery Alternative methods of demonstrating the anomalous arterial supply have been reported using computerized tomography, ultrasound, and magnetic resonance imaging.
The differential diagnosis of this chest film would include lung abscesses, metastatic neoplasm, Boch-dalek hernia, bronchiectasis, and intrapulmonary bronchogenic cysts. Given the posterior basal location of the lesions, the chronic nature (14 years), the patients lack of symptoms, and the positive cultures on aspiration, a diagnosis of infected bronchopulmonary sequestration is the most likely consideration. The patients post-aspiration biopsy symptoms of fever and pleuritic chest pain were in part due to hemorrhage into the pleural space. In addition, aspiration biopsy may have allowed some of the previously well-contained purulent material within the sequestered lung to leak into adjacent lung parenchyma causing acute pneumonia. Aortography was performed to confirm the diagnosis and to plan surgery.