Bronchoscopy for management and identification of etiology of right middle lobe syndrome: Analysis of 66 cases.

BACKGROUND: Right middle lobe (RML) syndrome is a recurrent or chronic obstruction of the RML causing atelectasis of the right middle lobe due to mechanical and nonmechanical etiologies. The consequences of untreated RML syndrome range from chronic cough to post-obstructive pneumonia and bronchiectasis. We report here our bronchoscopy experience in patients with RML syndrome. METHODS: We conducted a retrospective study of adult patients who underwent bronchoscopy for RML syndrome at Rabin Medical Center from 2008 through 2022. Demographic data and medical history, bronchoscopy findings and procedures, and follow-up results were collected. RESULTS: A total of 66 patients (57.6% male, mean age 63 ± 13 years) underwent bronchoscopy for RML syndrome during the study period. Bronchoscopy revealed a mechanical etiology in 49 (74.2%) cases, including endobronchial mass (21, 31.8%) and external compression (7, 10.6%). Malignancy was identified in 20 (30.3%) cases. In 62 patients (93.9%), the bronchoscopy resulted in partial or complete reopening of the RML bronchus. The therapeutic bronchoscopic procedures were balloon dilatation (19), laser ablation (17), mechanical debridement (12), endobronchial stent insertion (11), and cryoablation (6). CONCLUSIONS: Malignancy was identified as the etiology of RML syndrome in approximately 25% of cases, suggesting bronchoscopy should be performed in every case of RML atelectasis. To our knowledge, this is the first reported series of endobronchial stenting of the RML bronchus in the context of RML syndrome.

Case Report: Middle lobe syndrome: a rare presentation in eosinophilic granulomatosis with polyangiitis.

Background: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of disorders characterized by necrotizing inflammation of small- and medium-sized blood vessels and the presence of circulating ANCA. Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic ANCA-associated vasculitis, characterized by peripheral eosinophilia, neuropathy, palpable purpuras or petechiae, renal and cardiac involvement, sinusitis, asthma, and transient pulmonary infiltrates. Middle lobe syndrome (MLS) is defined as recurrent or chronic atelectasis of the right middle lobe of the lung, and it is a potential complication of asthma. Case presentation: Herein, we describe a case of MLS in a 51-year-old woman, never-smoker, affected by EGPA, presenting exclusively with leukocytosis and elevated concentrations of acute-phase proteins, without any respiratory symptom, cough, or hemoptysis. Chest computed tomography (CT) imaging documented complete atelectasis of the middle lobe, together with complete obstruction of lobar bronchial branch origin. Fiberoptic bronchoscopy (FOB) revealed complete stenosis of the middle lobar bronchus origin, thus confirming the diagnosis of MLS, along with distal left main bronchus stenosis. Bronchoalveolar lavage (BAL) did not detect any infection. Bronchial biopsies included plasma cells, neutrophil infiltrates, only isolated eosinophils, and no granulomas, providing the hypothesis of vasculitic acute involvement less likely. First-line agents directed towards optimizing pulmonary function (mucolytics, bronchodilators, and antibiotic course) were therefore employed. However, the patient did not respond to conservative treatment; hence, endoscopic management of airway obstruction was performed, with chest CT documenting resolution of middle lobe atelectasis. Conclusion: To the best of our knowledge, this is the first detailed description of MLS in EGPA completely resolved through FOB. Identification of MLS in EGPA appears essential as prognosis, longitudinal management, and treatment options may differ from other pulmonary involvement in AAV patients.

Right middle lobe syndrome after upper lobectomy: Role of the bronchial angle.

BACKGROUND: Right middle lobe syndrome is part of a spectrum of relatively rare but serious conditions that may occur following right upper lobectomy. We aimed to assess whether the preoperative middle lobe bronchial angle on CT predicted patients at risk of developing middle lobe syndrome. METHOD: All patients who had a complete upper lobectomy over 4 years were retrospectively reviewed for clinical and imaging findings of middle lobe syndrome. Patients with previous lung surgery, preoperative chemo- or radiation therapy, or more extensive surgical resection were excluded. Patient demographics and symptoms, the surgical, pathologic and bronchoscopy reports, and pre- and post-operative chest imaging, to include 3D CT reconstructions and measurements of the middle lobe angles in a subset of patients, were retrospectively reviewed. RESULT: One hundred and twenty-eight patients met inclusion criteria. Ten (8%) had middle lobe syndrome based on symptoms and imaging features. Eight had severe middle lobe consolidation. Two had postoperative onset of wheezing, with middle lobe bronchial abnormality on CT. The pre- and postoperative middle lobe bronchial angles of 14 patients without middle lobe syndrome were compared to 10 patients with middle lobe syndrome. The middle lobe bronchus was completely obliterated postoperatively and could not be determined in 1 patient. There was no significant difference between the pre- and postoperative angles in patients with or without middle lobe syndrome. CONCLUSION: Middle lobe syndrome occurred in 8% of patients with right upper lobectomy. The preoperative middle lobe bronchial angle did not predict patients at risk for developing middle lobe syndrome.

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.

Immune reconstitution inflammatory syndrome in non-HIV patients with tuberculosis. A case series.

Tuberculosis associated Immune reconstitution inflammatory syndrome (IRIS) in a HIV negative patient can present with a multitude of clinic-radiological presentations that are often confused with drug resistance/treatment failure. Being a diagnosis of exclusion, this clinical entity is often prone to under-diagnosis. We present a series of 5 patients who presented with varied but uncommon IRIS manifestations. High index of suspicion coupled with clinical reasoning and judicious use of phenotypic and genotypic culture methods helped in their timely detection and successful treatment.

Assessing the efficacy of an ambulatory peripheral blood hematopoietic stem cell transplant program using reduced intensity conditioning in a low-middle-income country.

Efficacy of an ambulatory hematopoietic stem cell transplant (HSCT) program with a reduced intensity conditioning regimen (RIC) in malignant hematological diseases was assessed. We analyzed 217 patients who underwent HSCT from August 2013 to July 2017. There were 78 (35.9%) HLA-identical, 56 (25.8%) haploidentical, and 83 (38.2%) autologous transplants. Two-year transplant-related mortality (TRM) for HLA-identical, haploidentical, and auto grafts were 20%, 25%, and 2.5%; relapse/progression was 44%, 60%, and 55%; overall survival (OS) was 61%, 44.8%, and 78.0%; and disease-free survival (DFS) was 36.8%, 26.5%, and 43.5%, respectively. Factors associated with a high risk of TRM were male sex (HR = 2.62, P = 0.031), fever and neutropenia (HR = 3.30, P = 0.023), and cell dose < 5 × 106 CD34 +/kg (HR = 4.24, P = 0.001); cGVHD was a protective factor for TRM (HR = 0.29, P = 0.022). Transfusion was associated with increased risk of relapse/progression in univariate and multivariate analysis (HR = 3.10, P = 0.001 and HR = 3.30, P = 0.004); cGVHD was a protective factor (HR = 0.18, P = 0.001 and HR = 0.17, P = 0.002). In a multivariate analysis for allo-HSCT, infections were associated with high risk of mortality (HR = 3.90, P = 0.016) and transfusion with reduced DFS (HR = 2.76, P = 0.029); for haplo-HSCT, CD34 + < 5 × 106/kg was a risk factor for mortality and lower DFS (HR = 5.41, P = 0.001 and HR = 3.93, P = 0.001). Outcomes of our RIC-based outpatient transplant program are comparable to excellence centers in high-income countries.

68Ga-PSMA Uptake in Middle Lobe Syndrome.

Prostate cancer cells have abundant expression of the cell surface protein prostate-specific membrane antigen (PSMA). In recent years, PET radioligands detecting this protein has therefore gained substantial interest in prostate cancer staging. It turned out that PSMA expression can be evident in both malignant and benign lesions, and we have previously reported that pulmonary opacities and bronchiectasis can be avid on Ga-PSMA PET/CT. Here, we present a case with Ga-PSMA accumulation in nonobstructive middle lobe syndrome, which further indicate that benign changes in the lungs may be falsely interpreted as malignant disease.

Tuberculosis and Other Granulomatous Diseases of the Airway.

Granulomatous diseases of the airway are challenging lesions to diagnose and effectively manage not only because they are uncommon but also because they can occur in different forms, each with unique clinical and radiological characteristics. Most such lesions can be effectively managed conservatively with repeated airway dilatation, use of intraluminal stents, and specific antimicrobial treatment. The only exception is those lesions presenting with localized airway obstruction wherein surgical resection may be indicated and beneficial.

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)

Tracheobronchopathia osteochondroplastica - a 61-year-old female with middle lobe syndrome.

The authors present a case of a 61-year-old female patient suffering from tracheobronchopathia osteochondroplastica (TBO). Etiology of this unit is uncertain. TBO is characterised by presence of multiple nodules of various size, situated in the submucosa of the trachea and major bronchi. The course is usually benign, until lesion obstructs the bronchial lumen. In the presented case, occluded middle lobe bronchi resulted in peripheral atelectasis of the lung.

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.

Infectious Causes of Right Middle Lobe Syndrome.

Right middle lobe (RML) syndrome is defined as recurrent or chronic obstruction or infection of the middle lobe of the right lung. Nonobstructive causes of middle lobe syndrome include inflammatory processes and defects in the bronchial anatomy and collateral ventilation. We report on 2 case patients with RML syndrome, one due to infection with Mycobacterium avium complex followed by M asiaticum infection and the other due to allergic bronchopulmonary aspergillosis. A history of atopy, asthma, or chronic obstructive pulmonary disease has been reported in up to one-half of those with RML. The diagnosis can be made by plain radiography, computed tomography, and bronchoscopy. Medical treatment consists of bronchodilators, mucolytics, and antimicrobials. Patients whose disease is unresponsive to treatment and those with obstructive RML syndrome can be offered surgical treatment.

A Comparative Study of Video-Assisted Thoracic Surgery with Thoracotomy for Middle Lobe Syndrome.

OBJECTIVES: The aim of this study is to evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) for the treatment of middle lobe syndrome (MLS) through comparison with thoracotomy during the same period. METHODS: We retrospectively reviewed all consecutive patients with MLS who underwent lobectomy or lingular segmentectomy between December 2005 and November 2015 in a single institute. Thirty patients were enrolled and divided into two groups: VATS group (n = 19) and thoracotomy group (n = 11). Data regarding the patients' demographics, medical history were collected and statistically compared. RESULTS: All patients received successful middle lobe resection or lingular segmentectomy. In terms of operation time, blood transfusion, chest drainage amount, duration of chest drainage and postoperative complications, no significant differences were found between the two groups (p > 0.05). The mean intraoperative blood loss of VATS group was less than thoracotomy group (79.0 ± 63.9 vs. 165 ± 94.9 ml, p = 0.04). In VATS group, the mean length of postoperative hospital stay was 6.0 ± 2.4 days, shorter than that in group thoracotomy (9.0 ± 3.5 days, p = 0.01). CONCLUSIONS: VATS was a feasible and safe method for the surgical treatment of MLS in selected patients when no severe calcified lymph nodes surrounding hilus pulmonis was observed by preoperative chest CT scan.

Middle lobe syndrome: An exceptional presentation of concomitant lepidic adenocarcinoma and bronchial anthracofibrosis.

Lepidic adenocarcinoma previously known as bronchioloalveolar carcinoma (BAC) is a non-small cell lung cancer with an indolent presentation. Bronchial anthracofibrosis (BAF) is caused by long-standing exposure to biomass fuel smoke often in poorly ventilated kitchen. Middle lobe syndrome (MLS) due to BAF is not uncommon however, lepidic adenocarcinoma then known as BAC, presenting as MLS has been documented only once before in the Polish literature. A 68-year-old never-smoker female with biomass fuel smoke exposure presented with cough and breathlessness. Imaging revealed MLS. Fiberoptic bronchoscopy visualised bluish-black hyperpigmentation with narrowing and distortion of right middle lobe bronchus suggestive of BAF. Transbronchial biopsy confirmed presence of lepidic adenocarcinoma. To our knowledge, this is the first detailed description of lepidic adenocarcinoma and BAF presenting as MLS.

The Clinical Significance of Collateral Ventilation.

Oxygen delivery and carbon dioxide removal being critical to cell survival, mammals have developed collateral vascular and ventilation systems to ensure tissue viability. Collateral ventilation, defined as ventilation of alveoli via pathways that bypass normal airways, is present in humans and many other species. The presence of collateral ventilation can be beneficial in certain disease states, whereas its relative absence can predispose to other diseases. These well defined anatomical pathways contribute little to ventilation in normal humans, but modulate ventilation perfusion imbalance in a variety of diseases, including obstructive diseases, such as asthma and emphysema. These pathways can be affected by pharmaceuticals and inhaled gas compositions. The middle lobe and lingula, constrained by their isolated, segmental anatomy, have reduced collateral ventilation, which predisposes them to disease. Recently, attempts to improve the quality of life of patients with emphysema, by performing nonsurgical lung volume reduction via use of endobronchial valves, have led to mixed results, because the role of collateral ventilation in the success or failure of the procedure was not initially appreciated. This review describes the anatomical pathways of collateral ventilation, their physiology and relationship to disease states, their modulatory effects on gas exchange, treatment considerations, and their effect on diagnostic procedures.

Síndrome de lóbulo medio / Middle lobe síndrome

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