Intralobar pulmonary sequestration associated with anomalous pulmonary vessels: a nonentity

A strange case of pleuritic pain in the third trimester of pregnancy

Pulmonary sequestration is an uncommon congenital malformation of the lung, generally diagnosed in childhood or adolescence, corresponding to dysplastic lung tissue not communicating with the rest of vascular or bronchial lung system but receiving an arterial blood supply from systemic arteries. Currently, surgical resection is usually indicated in order to prevent or treat related symptoms or complications, although controversy exists regarding its use in asymptomatic patients and adults. We present the case of a 32-year-old pregnant woman with acute chest pain and vomiting diagnosed with intralobar sequestration at 32+2 weeks of gestation and treated with pulmonary lobectomy after giving birth by cesarean section at 33+0 weeks of gestation.

Pulmonary Sequestration Associated with Actinomycosis: A Case Report

Background: Bronchopulmonary sequestration is a rare congenital malformation of the lower respiratory tract; it consists of a nonfunctioning mass of lung tissue that is irrigated by an anomalous systemic artery. The association with Actinomyces superinfection has not been well established. Methods: We present the case of a 35-year-old woman with a history of recurrent episodes of pneumonia. Based on radiological and histopathological examination, she was diagnosed with intralobar bronchopulmonary sequestration associated with Actinomyces infection. Promoting clinical suspicion is essential to diagnose pulmonary actinomycosis in patients with recurrent pneumonia, to improve early recognition and timely management.

Anomalous Systemic Arterial Supply to the Lung: To Which Category Should This Belong?

BACKGROUND

The nomenclature of both intralobar pulmonary sequestration (ILS) and aortic origin of a pulmonary artery (AOPA) remains controversial. According to this review, both ILS and AOPA have an anomalous systemic arterial supply to all or part of the lung with venous drainage into the pulmonary veins, which leads to pulmonary hypertension, congestive heart failure, and fatal pulmonary haemorrhage. The purpose of this review was to consider whether these two rare congenital anomalies have similar anatomical, clinical and pathological characteristics.

METHODS

This review was conducted by researching relevant literature using PubMed and MEDLINE databases to January 2019. All researched literature was related to the anatomical, associated anomalies, pathophysiology and clinical features of the extralobar pulmonary sequestration (ELS), ILS, and AOPA, and the therapeutic method for ILS and AOPA.

RESULTS

Through research literature, it was found that ILS and AOPA may differ in terms of embryonic origin, but some of the anatomical, histopathological, physiological and clinical features of these two congenital malformations are similar. However, ELS and ILS have significant differences in their anatomical, histopathological, physiological, and clinical features.

CONCLUSIONS

This study proposes that ILS and AOPA could be classified as one single condition - systemic arterialisation of the lung - and further divided into three subtypes, namely: types I, II and III. This new classification nomenclature permits the appropriate change of novel surgical techniques, which obviate the need for lobectomy or segmentectomy in specific cases, thereby minimising fatal postoperative complications.

Pulmonary Sequestration: A 29 Patient Case Series and Review

INTRODUCTION

Pulmonary sequestration also known as bronchopulmonary sequestration is a rare disease, with very few case series reviewed in literature. In this study, we review the demographics, presentation, imaging and treatment of pulmonary sequestration in 29 patients from our institution, and provide comparison data from previously published series with an overview of the disease history.

MATERIALS AND METHODS

Records reviewed for all patients evaluated and treated in our institution with a pathological proven diagnosis of pulmonary sequestration from January 2004 through December 2013. Collected data included demographics, clinical presentation, diagnostic imaging, location of the lesion, type of sequestration, and subsequent treatment.

RESULTS

Of the 29 patients reviewed 8 (28%) were children 0-2 years, 1 adolescent age 17, and 20 (69%) adults 21-70 years with a mean age of 42 among adults. Systemic arterial supply to the sequestered segment was demonstrated with computed tomographic angiography (CTA) in 25 patients (86%). In 19 patients (66%), the sequestered segment was located in the left lower lobe, and 16 (55%) were intralobar.

CONCLUSION

Diagnostic delays of pulmonary sequestration were common among the adult population as the presenting symptoms often mimicked other common pulmonary diseases, such as pneumonia and asthma. These findings were consistent among previously published series. CTA was the preferred imaging modality for preoperative planning with high sensitivity and specificity in identifying the lesion.

Acquired Nonneoplastic Neonatal and Pediatric Diseases

The lung biopsy is an established procedure to procure a pathologic diagnosis in a child with a suspected pneumonic process of undetermined etiology. Improvements in pediatric anesthesia and surgery have reduced the operative complications to a minimum. A biopsy can usually be taken through a small intercostal incision when localization is not especially important in a patient with diffuse changes (see Chapter 1). The alternative method for tissue sampling is the endoscopic transbronchial biopsy. There is less risk to the patient, but the specimen is smaller and crush artifacts from the instrument are more common.

Intralobar sequestration with tuberculous infection confined to the sequestrated lung

A 22-year-old female was referred to the hospital suffering from a persistent, non-productive cough and repeated exacerbations of a right lower zone infiltrate suggestive of pulmonary sequestration. Angiography revealed an aberrant artery that originated from the left side of the descending aorta, crossed the aorta anteriorly, flowed through the right lower lobe and drained into the right inferior pulmonary vein. Right lower lobectomy was conducted by open thoracotomy. Gross examination revealed mucoid impaction of bronchi in the sequestration. Microscopy demonstrated a clear boundary between sequestrated and normal lung, as well as caseating epitheloid granulomas confined to the sequestration. As the aberrant artery fed both sequestrated and adjacent normal lung and the boundary did not involve the pleura, the lesion was classified as a Pryce's type II intralobar sequestration. No acid-fast bacilli were observed, but homogenates of the sequestration were positive for Mycobacterium tuberculosis by polymerase chain reaction. The patient was treated with isoniazid and rifampicin daily for 9 months, and 6 years later her clinical status remained excellent. Tuberculosis confined to a sequestration is extremely rare and characteristics of the aberrant artery suggested this intralobar sequestration was likely to be congenital in origin.

Pulmonary sequestration

Pulmonary sequestration refers to the situation whereby a portion of lung tissue receives its blood supply from an anomalous systemic artery. Three main variants exist: intralobar, extralobar and communicating bronchopulmonary foregut malformations. Venous drainage is typically via a systemic vein, although drainage into the pulmonary veins is well documented. Pulmonary sequestrations are the second commonest congenital lung anomaly. Affected individuals often have other anomalies which are responsible for most of the mortality associated with sequestrations. Diagnosis requires a high index of suspicion particularly in any child with a chest x-ray suggesting the presence of a mass, those with recurrent chest infections and those with other anomalies seen with the pulmonary sequestration spectrum. Surgical excision is usually advised, although embolisation of the feeding vessel has a role in selected cases.

Pulmonary intralobar sequestration in a patient with cystic fibrosis

We report a case in which pulmonary Intralobar Sequestration (ILS) was an incidental finding at autopsy in an adult with Cystic Fibrosis. Two aberrant arteries from the descending thoracic aorta supplied a bronchial cystic lesion in the right lower lobe. Termination of the segmental bronchus and scar formation proximal to the cyst suggested prior bronchial obliteration. The elastic configuration of the aberrant aortic-derived vessels of the sequestration contrasted sharply with massively hypertrophied, muscular, bronchial arteries which supplied the bronchiectatic upper lobe. Sections of inferior pulmonary ligament were studied in five additional patients with CF but without ILS. Small muscular arteries were consistently noted within the inferior pulmonary ligament. These histologic findings support the concept that the vascular portion of ILS is congenital, whereas the bronchocystic component, in some cases, may be acquired.

Haemoptysis in healthy children due to unsuspected foreign body

Haemoptysis in otherwise healthy children is an uncommon event. Two cases of massive haemoptysis, subsequently requiring lobectomy, are discussed. In each case, foreign vegetable matter was identified despite previously normal bronchoscopy and minimal changes on chest radiograph.

Simultaneous discovery of bilateral intralobar and extralobar pulmonary sequestrations

We describe the rare case of bilateral bronchopulmonary sequestrations, one intralobar and one extralobar, in a 22-year-old man. The coexistence of two forms of separated sequestrations with a common vascularization support the theory that intralobar as well as extralobar sequestrations are congenital malformations.

Acquired intralobar bronchopulmonary sequestration secondary to occluding endobronchial carcinoid tumor

We present the imaging findings of a 29-year-old man with an intralobar sequestration of the posterior segment of the left lower lung lobe, occurring distal to and sharing parasitized blood supply with a proximal occluding endobronchial carcinoid tumor. The etiology and pathogenesis of intralobar bronchopulmonary sequestration are discussed.

Intraabdominal pulmonary sequestration

A left upper quadrant fetal abdominal mass was detected at 24 weeks gestation. The mass was again confirmed in a postnatal ultrasound. Pathological analysis of the excised mass demonstrated an intraabdominal lung sequestration with Stocker type II congenital cystic adenomatoid malformation (CCAM). The sonographic characteristic of these lesions are those of a homogeneous echogenic mass with variable shape passing through or arising from the diaphragm. Surgical excision is recommended because of the uncertainty of the preoperative diagnosis and the possibility of malignant changes in CCAM.

Review of bronchopulmonary foregut malformations

The term bronchopulmonary foregut malformation (BFM) describes rare cases of pulmonary sequestrations that communicate with the upper gastrointestinal tract. An unusual type of BFM is described; it consisted of esophageal atresia, proximal and distal tracheoesophageal fistulae, and bilateral extralobar pulmonary sequestrations communicating with a common bronchial structure that replaced the distal esophagus. This case is related to other reported cases in the literature, and serves as the basis for a proposed theory of the embryonic development of BFM.

Clinical symptoms and therapy of lung separation

This paper refers to the different terminology used in so-called lung separation/sequestration and to the standpoint of the pathologist. Theories of development are discussed. Clinical symptoms, diagnosis, indications for operation and operative technique are described, and nine cases of lung separation (six with extralobar and three with intralobar forms) tabulated analysed. Among them there is a 5-month-old female infant with extralobar lung separation in the right hemithorax resulting in recurrent pleural effusions with severe respiratory insufficiency. There was evidence of aeration in the pathohistological preparation. Pleural effusion and the origin of the aeration in the separated lung are discussed.

Intralobar pulmonary sequestration (a nonentity?)

Intralobar pulmonary sequestration has generally been considered a congenital malformation in which an accessory lung bud develops, is enveloped by normal lung, and retains its systemic arterial supply. Also usually included in the "sequestration spectrum" are aberrant arteries to normal lung with either normal or anomalous venous connection. We reviewed all surgical pathology specimens and autopsies performed at Texas Children's Hospital from 1955 through 1984. There were 15 cases with an aberrant systemic artery to normal or abnormal lung. Nine were cases of structurally normal lung with an aberrant systemic artery, and five were cystic adenomatoid malformations with a systemic artery. In one older child some features of intralobar sequestration were present, but a major bronchial connection was retained. We propose that most intralobar sequestrations represent either cystic adenomatoid malformations that clinically are unrecognized until they become secondarily infected or developmentally normal lung supplied by a systemic artery.

Intralobar pulmonary sequestration: value of aortography and pulmonary arteriography

Twelve patients with plain roentgenographic findings of intralobar pulmonary sequestration were evaluated with aortography and, in most instances, pulmonary arteriography. Correlative criteria from aortography and pulmonary arteriography permit a precise diagnosis to be made. Pulmonary infections must be differentiated from intralobar pulmonary sequestration because treatment for the latter should be surgical.

Mediastinal enteric sequestration with aberrant pancreas: a formes frustes of the intralobar sequestration

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Pulmonary sequestration. A report of an unusual case and a review of the literature

A case of extralobar sequestration with findings indicating a pulmonary origin is reported. The literature has been reviewed and evidence presented that intra- and extralobar sequestration are variants of the same abnormality and that the systemic artery is an associated anomaly. From the evidence available at present the pathogenesis of this anomaly is best explained as an abnormality of bronchial and foregut budding resulting from failure of normal embryonic organizer control.

Simultaneous intra- and extrapulmonary sequestration

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