A case of ruptured descending thoracic aortic aneurysm into the right pleural cavity: importance of preoperative drainage of the right pleural cavity

We present an unusual case of a ruptured descending thoracic aortic aneurysm into the right pleural cavity of a patient with pectus carinatum. The presence of pectus carinatum played an important role in the development of the aneurysm at the atypical site and the rupture into the right pleural cavity. A small amount of right pleural bleeding on admission can increase and develop to massive hemothorax until emergency operation. Massive bleeding in the right pleural cavity where the dependent lung is located causes atelectasis and increased shunt fraction under one lung ventilation. Therefore, continuous drainage of the right pleural cavity is essential to prevent serious hypoxia during graft replacement in a case of ruptured descending thoracic aneurysm into the right hemithorax.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

Pneumothorax complicating bronchiolitis in an infant

Pneumothorax is an uncommon complication of bronchiolitis. The case illustrates an unusual pattern of atelectasis of the right lung with pleural air surrounding the right upper lobe and the remainder of the lung expanded. It is thought that the hyperinflated lung is unable to collapse as a result of the 'ball valve' effect of air trapping.     

A case of pleural involvement followed by idiopathic retroperitoneal fibrosis

We report a rare case of pleural involvement followed by idiopathic retroperitoneal fibrosis in a 55-year-old man. He complained of right chest pain and his chest radiogram showed pleural thickening and calcification. Chest X-ray computed tomogram (CT) also showed a mass-like pleural thickening and a soft tissue density lesion surrounding the thoracic aorta, suggesting fibrosis. By open pleural biopsy, the mass-like pleural lesion was diagnosed as chronic pleuritis. Three years later, the patient experienced difficulty in urination, and bilateral hydronephrosis which was probably due to a retroperitoneal lesion was detected. Abdominal X-ray CT revealed a retroperitoneal lesion of soft tissue density comprised of a smooth and clearly delineated mass which encased the large vessels and ureters, compatible with retroperitoneal fibrosis. Although it was not possible to biopsy the retroperitoneal lesion, the lesion was clinically and radiologically thought to be retroperitoneal fibrosis. We could not determine the etiology of these findings, but such a case of pleural involvement followed by idiopathic retroperitoneal fibrosis was considered to be very rare.     

Local resection of pulmonary lesions by Nd-YAG laser without suturing

Local excision of 67 pulmonary lesions in 5 patients was performed with the Nd-YAG laser. There were 2 women and 3 men with an average age of 68 years. The patients consisted of three cases of metastatic lung cancer (65 lesions), one hamartoma (One lesion) and one organized pneumonitis (one lesion). The lesion was first enucleated by a contact method using an Nd-YAG laser scalpel, then the crater of the resected lesion in the normal lung tissue was coagulated with a defocused laser beam. The craters of 52 of the 67 resected lesions which were shallow seated in the lung were left open, but the other 15 resected lesions were closed with sutures. Total blood loss was less than 100 ml. There was no bleeding or air leakage (30 cm water pressure) during the post operative days in 4 of the 5 patients, but one patients (one lesion) had to be treated by bronchoscopic endobronchial embolization against a persistent air leak. This lesion was 2.5 cm in diameter and 4 cm deep in the lung on CT. The other lesions were also measured by CT. The tumor size was 1.4 +/- 0.7 cm and the depth was 2.4 +/- 1.0 cm. The Nd-YAG laser is very suitable for local resection of peripheral lung lesions without suturing.     

Doppler grid surface scanning applications for pulmonary subsurface parenchymal perfusion assessment

Subsurface perfusion to lung parenchyma underlying the pleura is difficult to assess in live ventilated animals. The purpose of this study was to assess applicability of a newly developed laser Doppler grid scanning imaging technology that measures perfusion of pleural subsurface lung regions in intact normal and abnormal animal lungs. Eighty-six Doppler grid perfusion measurements were performed in five New Zealand White Rabbits (3-5 kg); four with unilateral bullous lung disease, one normal control. Left upper lobe lung surface was exposed to 10 1-sec spot Nd:YAG exposures (70 W/cm2). One week following laser exposure, all rabbits underwent sequential bilateral open thoracotomy. Unaffected left lower lobes in these animals and all four lobes of a previously untreated rabbit were used as controls. Pleural subsurface perfusion measurements were recorded over a contiguous 900-pixel square surface grid using quantitative noncontact laser Doppler imaging during open thoracotomy procedures. Scans were obtained in a normal volume ventilation mode, at 30 cm of inspiratory hold airway pressure, and postinflation. A perfusion-pressure response curve was obtained in normal lung at 10-, 20-, and 30-cm static airway pressure. Post mortem measurements were used as 0 flow controls. Normal lung tissue was found to have relatively high pleural subsurface perfusion (1362 +/- 328 corrected units on a scale of 0-4095). Areas of atelectasis had decreased perfusion (659 +/- 512 U., 48.4 +/- 12.5% compared to normal lung, p < 0.02), but returned to normal levels after inflation of the lung (1253 +/- 363 U., p = 0.21 compared to normal). Pleural subsurface perfusion decreased uniformly and progressively as lung inflation pressure increased (p < 0.0001). Perfusion increased immediately to supranormal values following release of high inspiratory inflation pressure holds (1603 +/- 626 U., 117 +/- 18% compared to normal lung, p = 0.03). Bullae had markedly decreased perfusion (541 +/- 68 U.) that was not further reduced by increased inflation pressures. Noncontact laser Doppler grid perfusion imaging appears to provide a new tool for measuring pleural subsurface perfusion over a large area of lung surface in clinical experimental settings. Results are rapid, reproducible, and consistent. Sampling errors inherent in current point sampling Doppler flow techniques are reduced by the multiple contiguous measurements. We have used this technique to demonstrate inspiratory pressure-related reduction in pleural subsurface perfusion in normal lung, reversible decreased perfusion in atelectatic regions, and reduced perfusion in bullous and laser-treated lung regions.     

Improvement of the merthiolate-iodine-formalin (MIF) fecal technique for hookworm, Trichuris trichiura, and Ascaris lumbricoides eggs

A patient with a history of total thyroidectomy for papillary carcinoma showed a solitary hot spot in the chest on post-therapy radioiodine imaging. Subsequent evaluation demonstrated that this lesion was a primary squamous-cell lung cancer. Our case illustrates a rare but important differential diagnosis from lung metastasis of thyroid cancer in 131I scintigraphy. Alternatively, this "aberrant uptake" might be a rather common phenomenon for lung neoplasms, although the underlying mechanism is not yet known. Future experimental studies might lead to a new application of radioiodine imaging in pulmonary oncology.     

Measurement of lung expansion with computed tomography and comparison with quantitative histology

The total and regional lung volumes were estimated from computed tomography (CT), and the pleural pressure gradient was determined by using the milliliters of gas per gram of tissue estimated from the X-ray attenuation values and the pressure-volume curve of the lung. The data show that CT accurately estimated the volume of the resected lobe but overestimated its weight by 24 +/- 19%. The volume of gas per gram of tissue was less in the gravity-dependent regions due to a pleural pressure gradient of 0.24 +/- 0.08 cmH2O/cm of descent in the thorax. The proportion of tissue to air obtained with CT was similar to that obtained by quantitative histology. We conclude that the CT scan can be used to estimate total and regional lung volumes and that measurements of the proportions of tissue and air within the thorax by CT can be used in conjunction with quantitative histology to evaluate lung structure.     

Bronchiolitis obliterans organizing pneumonia

Idiopathic BOOP is a clinicopathological entity defined histopathologically by the presence of granulation tissue in bronchioles, alveolar ducts and alveoli. 2 men and 6 women (mean age 47.2 years, range 22-66) with idiopathic BOOP have been observed, the mean period of observation being 31.1 months. In 7 cases the disease started with fever, cough and in 6 with progressive dyspnea. The interval between the onset of symptoms and the beginning of treatment ranged from 2 to 10 months. One woman was asymptomatic. The initial findings were: tachypnoea (6), crackles (7), decreased VC (6), reduced diffusing capacity (6), raised erythrocyte sedimentation rate (7). In 6 cases chest radiographs showed multiple alveolar patchy opacities of various size predominantly in the middle and lower lung zones. HRCT demonstrates peripheral distribution of changes. In one case diffuse reticulonodular infiltrates and in one case solitary tumor-like opacity with cavitation were observed. Seven subjects were given prednisone. Three subjects recovered completely, in 1 clinical and radiological improvement was observed. In 3 cases relapse occurred. The woman with the solitary tumor-like opacity was cured by surgical excision of the lesion.     

A case report of pneumonia due to Chlamydia trachomatis with pleural effusion

A 64-year-old male consulted our hospital with a 6-day history of malaise, body temperature to 38 degrees C, anorexia, and light headedness. The chest radiograph showed consolidation in the left lower lung area. Chest CT and ultrasonography revealed left pleural fluid. The pleural fluid was exudative (yellowish in color, protein 3.0 g/dl, Rivalta reaction positive, adenosine deaminase 19.4 U/L), and had a total cell count of 4.7 x 10(6)/ml with 45% lymphocytes, 40% histiocytes, and 15% polymorphonuclear leukocytes. He had kept a budgerigar, but we could not isolate Chlamydia from the pleural fluid or the pet bird. Transbronchial lung biopsy from left S10 revealed an increase of mononuclear leukocytes within the interstitial spaces, and the alveolar spaces contained polymorphonuclear leukocytes, fibrin, and organized alveolar exudate. Bronchoalveolar lavage cellular constituents were 50% lymphocytes, 27% neutrophils, and 23% macrophages. Serologic studies demonstrated C. trachomatis specific IgM antibody titers at 1:20 in a serum sample and at 1:10 in pleural fluid. We report a case of community-acquired pneumonia caused by C. trachomatis diagnosed by serologic studies.     

Complications of thoracoscopy

BACKGROUND: The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery. METHODS: A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed. RESULTS: Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy. CONCLUSIONS: Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.     

Intrapulmonary cystic lymphangioma: report of a case

We describe herein the case of a 52-year-old man found to have a solitary pulmonary lymphangioma. Computed tomography (CT) scan demonstrated a nodule with homogeneous density and a well-defined border in the lower lobe of the right lung. T2-Weighted magnetic resonance imaging (MRI) revealed a nodule with homogeneously high signal intensity. The tumor was removed by partial resection, and pathologic examination confirmed a diagnosis of primary lymphangioma of the lung.     

Epidemiologic survey of pleural plaques among inhabitants of Matsubase exposed to asbestos

A high prevalence of pleural plaques (41.5%, 148/357) was found during a mass screening for lung cancer in Matsubase town in 1988. The inhabitants of this town were carefully studied each year from 1988 to 1993. The vast majority (81.2%) of inhabitants over the age of 20 years underwent chest roentgenography at least once during this period. Pleural plaques were detected by CT in 938 subjects, which is 17.3% of those studied and 4.1% of the total population. A total of 89 had an occupational history of asbestos exposure, 64 (71.9%) of whom had pleural plaques. However, these subjects with occupational exposure accounted for only 6.8% of the 938 subjects, and therefore most of the pleural plaques seemed to have been caused by general environmental exposure. The incidence of plaques was greater in older subjects: among those in the seventh decade of life it was more than eight times higher than among those in the fourth decade of life. Anthophyllite was detected in the main asbestos mill. The concentrations of asbestos fibers in the air and water near the old asbestos mills and factories were not high. The death rates and the adjusted mortality rates due to lung cancer in Matsubase were lower than in surrounding towns and lower than in Kumamoto prefecture as a whole. These results indicate that there is now no environmental contamination by asbestos fibers in Matsubase town. No cases of malignant mesothelioma have been confirmed in this town during the past 17 years.     

Identification and genetic analysis of Schizosaccharomyces pombe cDNAs that suppress deletion of IRA1 in Saccharomyces cerevisiae

OBJECTIVE: To determine the etiology, pregnancy complications, and outcome of isolated fetal pleural effusion diagnosed antenatally and to evaluate the benefits of prenatal fetal interventions. DATA SOURCES: A literature search of MEDLINE was performed for relevant English language publications between 1985-1991. In addition, reference lists of articles were used to identify reported cases of isolated fetal pleural effusion. METHODS OF STUDY SELECTION: Our search uncovered 31 papers published in peer review journals. From these reports, 82 cases met our selection criteria: All fetuses were diagnosed antenatally with pleural effusion and had no other signs of hydrops at initial diagnosis. DATA EXTRACTION AND SYNTHESIS: The etiology of isolated fetal pleural effusion was unknown in most cases. Possible causes included congenital chylothorax, goiter, lung tumors, and infection. Cardiac defects (4.9%), Down syndrome (4.9%), and polydactyly (1.2%) may be associated with isolated fetal pleural effusion. Perinatal mortality was high (36%) and was related to the development of nonimmune hydrops, prematurity, and pulmonary hypoplasia. Early gestational age at diagnosis of isolated fetal pleural effusion (32 weeks or less) was associated with poor outcome and a neonatal death rate of 55%. In contrast, the neonatal death rate approached 31% as gestational age at diagnosis exceeded 32 weeks. Fifty-four cases were managed conservatively whereas 24 received intrauterine intervention, which included either pleuroamniotic shunt or repeated thoracenteses. Neonatal death rates were 37 and 33%, respectively. CONCLUSION: Not enough data exist to support either the conservative approach or intrauterine pleural drainage in cases of isolated fetal pleural effusion diagnosed antenatally.     

A case of successful resection of pulmonary arteriovenous fistula with a high shunt ratio

We report on a 25-year-old cyanotic man who was diagnosed as having a pulmonary arteriovenous fistula. His chief complaint had been shortness of breath since childhood. Polycythemia (Hb 21.4 g/dl) was detected during a health checkup at his company. A chest X-ray showed an abnormal mass in the left lung. Blood gas analysis showed severe hypoxia with PaO2 of 38.6 mmHg at room air. Angio-CT showed a large aneurysmal lesion at S6 of the left lung with a large feeding artery and vein. Oxygen saturation was 75.2% in the radial artery and 62.5% in the right atrium. The right-to-left shunt ratio was therefore calculated as 62%. The aneurysmal lesion was resected by segmentectomy of the left S6 following division of A6 and V6. After a successful operation, the patient no longer had shortness of breath or cyanosis and blood gas analysis showed PaO2 as 84.3 mmHg at room air. Pulmonary angiography showed no residual shunt lesion.     

Actinomyces meyeri cutaneous actinomycosis with pulmonary localization

Infections due to Actinomycosis species are located in the cervico-facial region in 50 to 65 percent of the cases. Extra-cervical cutaneous lesions are exceptional. The most frequently encountered germ is Actinomyces israeli, observed in 85 percent of the cases. We report the case of an Actinomyces meyeri infection which presented as a leg abscess and a pulmonary lesion. There was no cervico-facial localization. There was however a chronic parodontitis. A second germ, Capnocytophaga sp. was isolated from the abscess. This case is of particular interest because of the extracervical localization and the rare species isolated (17 other cases of Actinomyces meyeri infection have been reported). The mechanism of the infection can be better understood in light of pulmonary lesions in the lower right lobe due to inhalation and the coexistence of a buccodental germ in the culture of the leg abscess: buccodental origin of the germ, pulmonary lesion secondary to inhalation, septicaemic dissemination with cutaneous metastases.     

Role of endogenous opioids in syncope induced by head-up tilt test and its relationship with isoproterenol-dependent and isoproterenol-independent neurally-mediated syncope

Pleural dissemination in lung cancer was prospectively evaluated by helical computed tomography (CT), and the usefulness of thick-section CT (10-mm collimation; pitch 1) and thin-section CT (2-mm collimation; pitch 1) were compared. The study included 54 patients with pulmonary adenocarcinoma in whom plain chest radiographs showed no evidence of pleural effusion and in whom the primary lesion was seen to be contiguous with the pleural surface on thick-section CT. Thin-section CT was performed for evaluation of the costal, mediastinal, interlobar, and diaphragmatic pleural surfaces. Pathologic examination revealed pleural dissemination in 20 patients (8 resected, 12 nonresected). Pleural dissemination was diagnosed in 12 patients on thick-section CT, and in 20 patients on thin-section CT. False negatives occurred in ten and two patients, respectively. The same two patients were false positives by both methods. Accuracy was 78% for thick-section CT and 93% for thin-section CT, and sensitivity was 50% and 90%, respectively. Thin-section CT provided more useful information than thick-section CT for the evaluation of pleural dissemination in lung cancer.     

Rounded atelectasis: another pulmonary pseudotumor

Rounded atelectasis or Blesovsky's syndrome (also called pleuroma, folded lung or shrinking pleuritis with atelectasis) is the association of plaque-like pleural fibrosis with a folding visceral pleura and nodular atelectasis of the underlying lung. It can mimic a peripheral lung tumor or a mesothelioma. Radiography and computed tomography (CT) show a characteristic opacity with a comet-tail sign. The pathogenesis in some of the cases is considered to be secondary to pleural effusions and in others to a contraction of a focus of pleural fibrosis, not associated with effusion. In many cases, there was a history of asbestos exposure. We report the case of a 44-year-old, man who had smoked and worked with materials containing asbestos. He referred thoracic pain of 6 months duration and dyspnea. An X-ray of the chest (Fig. 1, 2) and a CT scan (Fig. 3) revealed a round peripheral mass in the left lower lobe. A fine needle aspiration biopsy of the lung was performed revealing clusters of large atypical cells with abundant cytoplasm. A thoracotomy was decided upon and no frozen section was requested. Gross examination of the resected lobe (Fig. 4) demonstrated a 2.5 cm white, irregular, firm and retracting pleural plaque. On sectioning, a peculiar folding of the visceral pleura delimited by anthracotic pigmentation was noted below the fibrotic plaque. The folding extended perpendicularly deep into the parenchyma. It was possible to separate the folding and liberate the underlying parenchyma, which was firm, fibrotic and atelectatic. No tumor was found anywhere within the lobe.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preoperative diagnosis with video-assisted thoracoscopy with miniaturized endoscopes in general thoracic surgery: a preliminary study

Video-assisted thoracoscopy using a miniaturized endoscope (mini-VAT) was applied for preoperative diagnosis in general thoracic surgery. Thirty-one patients, including 27 with indeterminate pulmonary nodule and 4 with suspected pleural involvement of lung cancer or metastatic pleural tumor, underwent mini-VAT. As a pilot study, 14 of the former 27 patients underwent mini-VAT while receiving general anesthesia. As a prospective study, all the remaining 17 patients underwent mini-VAT while receiving local anesthesia. Solid scopes of three different sizes, 0.9, 1.9, or 4.0 mm diameter, were used. An artificial pneumothorax for scope introduction was produced by needle thoracentesis under atmospheric pressure. Automatic cutting needle biopsy was used for tissue sampling. In the pilot study group, mini-VAT with a 4.0-mm scope provided excellent visibility and diagnostic sensitivity of 100%. This study group showed the diagnostic sensitivity of needle biopsy for pulmonary nodule to be 100%. Hemorrhages and air leaks at biopsy sites were sealed with blood coagulation in a short time. In the prospective study group, mini-VAT with a 4.0-mm scope with the patients receiving local anesthesia provided a diagnostic sensitivity of 91% for pulmonary nodule and a diagnostic accuracy of 100% for suspected pleural involvement. Causes of failure of mini-VAT with the use of local anesthesia were cough reflex during needle biopsy and incomplete lung collapse for deeply located target in two cases. The adverse effects of the mini-VAT were paradoxical respiration in two cases in which local anesthesia was used. The patients who received only local anesthesia required no chest tube drainage. Mini-VAT is a simple, minimally invasive procedure suitable as a preoperative examination technique for histologic diagnosis, evaluation of disease progression, and selection of strategy in thoracic surgery.     

Treatment of hemopneumothorax under thoracoscopic guidance: a case report

A 32-year-old man was admitted to our hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemithorax. Shock developed following drainage of 1,500 ml hemorrhagic pleural fluid. Following blood transfusion, emergency surgery was carried out. At operation under thoracoscopic guidance, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noted. The artery was successfully ligated with surgical clip, and the bulla was resected using EndoGIA. This case report indicates that hemopneumothorax can be safely operated on under thoracoscopic guidance after the patient has recovered from shock by adequate blood transfusion.