Middle lobe syndrome revealing Broncholithiasis: A Case Report.

Middle lobe syndrome is a rare but important clinical entity worth investigating in local obstructive or inflammatory cause. One of its rare etiologies is broncholithiasis. We report the observation of a young female patient who presented with recurrent hemoptysis. Chest CT scan showed atelectasis of the middle lobe and suggested the diagnosis of broncholithiasis by objectifying, within the collapsed lobe, a calcification located in the bronchial lumen. Bronchial fibroscopy was of little help. Recurrent hemoptysis and doubt about pulmonary neoplasia led to a diagnostic and therapeutic lobectomy. In front of MLS, broncholithiasis should be suspected in the presence of calcifications on imaging. Surgery may be required in case of uncertain cases to not ignore an underlying tumor.

Síndrome del lóbulo medio: presentación de un caso / Middle lobe syndrome: a case report

Fundamento: el síndrome de lóbulo medio en la actualidad se considera un síndrome clínico radiológico de curso crónico caracterizado por atelectasia o diversos grados de neumonitis, bronquiectasia recurrente o crónica, secundario a obstrucción o compresión por ganglios linfáticos del bronquio del lóbulo medio de origen infeccioso o neoplásico.Objetivo: describir un caso clínico de un paciente con el diagnóstico de síndrome del lóbulo medio causado por un linfoma no Hodgkin endobronquial.Caso clínico: paciente masculino de 19 años de edad, con antecedentes patológicos de asma bronquial. El motivo de ingreso fue malestar general, dolor en punta de costado derecha, disnea a los pequeños esfuerzos, fiebre de 38 grados centígrados con expectoración hemoptoica. Al examen físico se constató palidez cutánea mucosa, disminución del murmullo vesicular, presencia de estertores roncos y sibilantes en el campo pulmonar derecho. El diagnóstico se realizó por los estudios imaginológicos, y broncoscopia con la biopsia de la tumoración endobronquial.Conclusiones: el síndrome del lóbulo medio causado por un linfoma no Hodgkin endobronquial es un diagnóstico poco frecuente por lo cual se decidió presentar el caso(AU)

Background: middle lobe syndrome is currently considered a radiologic clinical syndrome characterized by atelectasis chronic course or varying degrees of pneumonitis and bronchiectasis, recurrent or chronic, secondary to obstruction or compression by lymph nodes of the infectious or neoplastic origin middle lobe bronchus.Objective: to describe a clinical case of a patient with the diagnosis of syndrome of the middle lobe caused by endobronchial non-Hodgkin's lymphoma.Clinical case: a 19-year-old male patient with a pathological history of bronchial asthma. The reason for entry was general discomfort, pain in right side end, dyspnea to small efforts, fever of 38 degrees Celsius, hemoptoic sputum. Physical examination found mucous skin pallor, decrease of the vesicular murmur, presence of grunting and hissing crackles in right lung field. The diagnosis was made by the imaging studio, and bronchoscopy with endobronchial tumor biopsy.Conclusions: the average caused by Lymphoma endobronchial lobe syndrome is a rare diagnosis; therefore it was decided to present this case(AU)

Middle lobe syndrome: an intriguing presentation of tracheobronchial amyloidosis.

Pulmonary involvement in amyloidosis is a distinct rarity. This clinical entity usually presents as tracheobronchial amyloidosis (TBA). A 32-year-old, never-smoker man presented with episodic dyspnoea and wheezing along with cough and mucoid sputum. The chest radiograph was suggestive of a middle lobe syndrome (MLS). High-resolution CT (HRCT) of the chest confirmed the presence of MLS. In addition, HRCT showed circumferential thickening of the trachea and the main bronchi, with thickening of the posterior membranous wall of trachea. Fibrebronchoscopy, done to evaluate MLS, visualised multiple small polypoidal lesions in the lower part of trachea and carina. Endobronchial biopsies showed homogeneous, acellular amorphous deposit in the subepithelial region, which was congophilic in nature. A diagnosis of TBA presenting as MLS was made. To the best of our knowledge, this is the first detailed report of MLS as a presentation of TBA in the English literature.

Ten years' experience in surgical treatment of right middle lobe syndrome.

PURPOSE: In this study we present the clinical, radiological, pathological, bronchoscopic and surgical results of 40 patients with diagnosis of middle lobe syndrome who were referred to our thoracic surgery unit for surgical intervention in a 10 years period. METHODS: Forty patients with obstructive and non-obstructive causes of middle lobe syndrome referred to our thoracic surgery unit. Clinical data were collected from the patients' records in a ten years period. This study evaluates diagnostic approaches and surgical treatments in right middle lobe syndrome. RESULTS: We studied 23 females (57.5%) and 17 males (42.5%) with a mean age of 31.7. Clinical findings were cough 95%, sputum 80% and intermittent hemoptysis in 50% of patients. Middle lobe collapse was seen in CT scan of all patients. Bronchiectasis was the most common pathologic finding (55%). Tuberculosis was not rare and was final pathology in 20% of patients. In three patients ruptured hydatid cyst was final finding. Surgery was done without mortality and with only minor complications. CONCLUSION: Lobectomy of right middle lobe is a good therapeutic option in these patients. Due to high prevalence of tuberculosis and hydatid cyst in Middle Eastern countries these two must be considered as causes of middle lobe syndrome.

Síndrome de Lady Windermere: afectación del lóbulo medio y língula por Mycobacterium avium complex / Lady Windermere syndrome: involvement of the middle lobe and lingula by Mycobacterium avium complex

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Middle lobe syndrome associated with major haemoptysis.

A 60-year-old Indian woman who was suffering from recurrent pneumonia presented with major haemoptysis and a right-sided pleuritic chest pain. Initially the patient required resuscitation to optimise her haemodynamic parameters while oxygenation remained satisfactory. An urgent computed tomography pulmonary angiogram revealed right middle lobe syndrome which constitutes chronic collapse of the middle lobe accompanied by bronchiectatic changes. Angiography identified an abnormal bronchial artery and venous shunting which was embolised satisfactorily. Subsequently she underwent bronchoscopy which was unremarkable. Her post-operative course was uneventful and patient was discharged home. During the post-operative follow-up patient remained stable and was discharged from out-patient clinic after two years.

Síndrome del lóbulo medio y tuberculosis endobronquial. Aportación de la fibrobroncoscopia / Middle lobe syndrome and endobronchial tuberculosis. Contribution of fiberoptic bronchoscopy

El síndrome del lóbulo medio es una patología frecuente en el niño, sobre todo en relación con el asma y/o la hiperreactividad bronquial, aunque existen otras muchas causas, como los cuerpos extraños, la tuberculosis endobronquial, etc. Presentamos el caso de un niño de 5 años de edad, con atelectasia persistente en la base derecha con participación del lóbulo medio, que se diagnosticó de tuberculosis. La tomografía computarizada confirmó la lesión y, ante una prueba de la tuberculina positiva, se realizó una fibrobroncoscopia para descartar una tuberculosis endobronquial, que demostró la presencia de una lesión polipoidea en el bronquio intermediario a la entrada del lóbulo medio. Se describen las diversas formas de tuberculosis endobronquial, así como el tratamiento con corticoides sistémicos. Se aconseja la realización de una fibrobroncoscopia en los casos de tuberculosis pulmonar con alteraciones radiológicas persistentes (atelectasia, atrapamiento aéreo, etc.) y/o falta de mejoría clínica pese al tratamiento adecuado(AU)

Middle lobe syndrome is a common condition in children, mainly related to asthma and/or bronchial hyperresponsiveness, although there are many other causes, such as foreign bodies, endobronchial tuberculosis, etc. We report a 5-year-old child with persistent atelectasis involving the right middle lobe, and diagnosed with tuberculosis. Computed tomography confirmed the injury and after a positive tuberculin skin test, fiberoptic bronchoscopy is performed to rule out endobronchial tuberculosis showing a polypoid lesion in the bronchus intermedius at the entrance of the middle lobe. It describes the various forms of endobronchial tuberculosis, and treatment with systemic corticosteroids. Fiberoptic bronchoscopy is recommended in cases of pulmonary tuberculosis with persistent radiographic abnormalities (atelectasis, air trapping, etc.) and/or a lack of clinical improvement with an adequate treatment(AU)

Chyloptysis with right middle lobe syndrome complicated postoperatively by chylothorax: an unusual cause of right middle lobe syndrome.

Chyloptysis, in the context of middle lobe syndrome, and chylothorax are rare clinical entities. They are reported in the medical literature mostly as case reports, but never together in the same patient. The present report describes the case of a 34-year-old woman who presented with chyloptysis associated with recurrent right middle lobe syndrome since she was 20 years of age, and eventually underwent right middle lobectomy. A few weeks postoperatively, she developed a right-sided chylothorax, which was refractory to medical therapy, and was successfully treated with thoracic duct ligation. She has been symptom-free for two years postsurgery.

Lung cancer arising in association with middle lobe syndrome.

Middle lobe syndrome, caused mainly by benign inflammatory diseases, such as chronic bronchitis and bronchiectasis, is manifested clinically as a chronic cough with sputum production. The prognosis associated with this syndrome is considered good in most cases which are caused by chronic inflammatory diseases. A patient who developed lung cancer in the course of long-term treatment for right middle lobe syndrome is described. A 63-year-old woman was admitted to our hospital with complaints of right iliac bone pain. She had been treated for chronic bronchitis and bronchiectasis associated with middle lobe syndrome for 16 years before admission. Work-up of a lung adenocarcinoma originating from the right middle lobe disclosed bone metastasis to the illium. Tumorigenesis in association with middle lobe syndrome has not yet been reported, but this first reported case suggests the need to be alert to the possibility.

The role of timely intervention in middle lobe syndrome in children.

STUDY OBJECTIVES: Middle lobe syndrome (MLS) in children is characterized by a spectrum of clinical and radiographic presentations, from persistent or recurrent atelectasis to pneumonitis and bronchiectasis of the right middle lobe (RML) and/or lingula. This study was undertaken to evaluate the effect of early intervention, including fiberoptic bronchoscopy (FOB), in the development of bronchiectasis in MLS. DESIGN: Children with atelectasis of the RML and/or lingula persisting for > 1 month or recurring two or more times despite conventional treatment underwent high-resolution CT (HRCT) scanning and FOB. Appropriate treatment and follow-up were provided, and the effect of the duration of symptoms on clinical outcome and the development of bronchiectasis was investigated. The patient cohort was retrospectively reviewed. PATIENTS: We evaluated 55 children with MLS. The median age at diagnosis, duration of symptoms, and duration of clinical deterioration before diagnosis were 5.5 years (range, 3 months to 12 years), 14.5 months (range, 3 to 48 months), and 8 months (range, 3 to 36 months), respectively. MEASUREMENTS AND RESULTS: FOB revealed marked obstruction in two children (ie, a foreign body and an endobronchial tumor) and positive findings for a culture of BAL fluid in 49.1% of patients. The remaining 53 patients were followed up for a median duration of 24 months (range, 5 to 96 months). The clinical outcome was "cure" in 60.4% of patients, "improvement" in 32.1% of patients, and "no change" in the remaining patients. Bronchiectasis was documented prior to FOB by HRCT scan in 15 patients (27.3%). The duration of the deterioration of symptoms prior to presentation positively correlated with the development of bronchiectasis (p = 0.03) and an unfavorable clinical outcome (ie, improvement or no change) [p = 0.02]; a positive correlation was also found between the duration of symptoms and the development of bronchiectasis (p = 0.04). CONCLUSIONS: Timely medical intervention in patients with MLS that includes FOB with BAL prevents bronchiectasis that may be responsible for an ultimately unfavorable outcome.

[Analysis of patients with middle lobe and lingular syndrome complicated with nontuberculous mycobacterosis, chronic sinusitis, or bronchopulmonary tuberculosis].

The clinical characteristics and chest CT scan findings in 77 cases of middle lobe and lingular syndrome, many of which were complicated with nontuberculous mycobacteriosis (21 cases, 27.3%), chronic sinusitis (16, 20.8%), or bronchopulmonary tuberculosis (11, 14.3%) are reported. Sixteen (76.2%) cases complicated with nontuberculous mycobacteriosis and 14 (87.5%) cases complicated with chronic sinusitis had granular shadows with dilated bronchi of both middle lobe and lingular in their chest CT scans. Granular shadows with a thickening of the bronchial wall or dilated bronchi were common characteristics of the chest CT scans of the patients with nontuberculous mycobacteriosis. However, cicatrization atelectasis of either middle lobe or lingular was the most common finding in patients with bronchopulmonary tuberculosis.

Síndrome de discinesia ciliar primaria / Primary ciliary dyskinesis syndrome

El síndrome de discinesia ciliar primaria (SDCP) y su variante el Síndrome de Kartagener, son una causa infrecuente de patología neumológica recurrente en el niño. El diagnóstico se basa en la sospecha clínica ante un cuadro de sinusitis y/o neumonías recurrentes, confirmándose el mismo mediante el estudio del aclaramiento mucociliar y la biopsia nasal. Presentamos 3 casos de SDCP y S. de Kartagener en los cuales el diagnóstico de sospecha se confirmó mediante la biopsia nasal, la cual, realizada con la técnica adecuada, es rápida, inocua y de fácil realización (AU)

Outcome after right middle lobe syndrome.

The long-term pulmonary consequences of right middle lobe syndrome (RMLS) in childhood are not known. Therefore, outcome was evaluated in 17 children with RMLS diagnosed in early childhood (mean age, 3.3 years; SD, 1.1 year). Mean age at follow-up was 10.1 years (SD, 2.6 years). RMLS was defined as atelectasis of the right middle lobe (RML) of at least 1 month's duration and visible on the lateral view of the chest radiograph as a wedge-shaped density extending from the hilum anteriorly and downward. Seventeen children without personal history of allergy or respiratory tract disease were studied as control group. Five of 17 study group children had ongoing respiratory problems: symptoms of asthma were present in 4 patients, and cylindrical bronchiectasis was present in one patient. Chest radiograph at follow-up was abnormal in six patients. Pulmonary function tests, including mean and SEM for vital capacity (VC) (82% of predicted +/- 7 vs 94% predicted +/- 3), FEV1 (77% of predicted +/- 12 vs 96% of predicted +/- 4) and their ratio (75 +/- 5 vs 85 +/- 3) were significantly lower in patients with ongoing respiratory symptoms than in the control children. The provocative dose causing a 20% decrease in FEV1 (PD20) of methacholine was significantly lower in patients with ongoing symptoms at follow-up than in control children and in patients without symptoms at follow-up (2.8[2.2 to 3.1] vs 4.5[2.2 to 8.8] and 9.2[2.3 to 24] mg/mL; median and P25-75, p < 0.05). Age at initial diagnosis tended to be younger in patients with ongoing symptoms at follow-up (2.3 +/- 0.7 years vs 3.8 +/- 0.4 years; p < 0.08).

Allergic bronchopulmonary aspergillosis with middle lobe syndrome and allergic Aspergillus sinusitis.

A 55 year old male, who had a 12 yr history of rhinorrhoea and nasal blockage, presented with a middle lobe syndrome. Evaluation of the patient led to the diagnosis of concomitant allergic bronchopulmonary aspergillosis with allergic Aspergillus sinusitis, a rarely reported association.