Finger-in-glove sign in congenital bronchial atresiaThorax 2011;66:182.Congenital bronchial atresia...

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Can Respir J Vol 22 No 5 September/October 2015 255 IMAGES IN RESPIRATORY MEDICINE ©2015 Pulsus Group Inc. All rights reserved Finger-in-glove sign in congenital bronchial atresia Miguel Ariza-Prota MD 1 , José Luis Diez Jarilla MD, Amador Prieto MD 2 , Ana Pando-Sandoval MD 1 , Pere Casan MD 1 1 Hospital Universitario Central de Asturias (HUCA). Instituto Nacional de Silicosis (INS). Área del Pulmón. Facultad de Medicina. Universidad de Oviedo. Oviedo. España; 2 Hospital Universitario Central de Asturias (HUCA). Departamento de Radiología. Oviedo, España. Correspondence: Dr Miguel Angel Ariza Prota, Instituto Nacional de Silicosis (INS), Área del Pulmón, Hospital Universitario Central de Asturias (HUCA), Facultad de Medicina, Universidad de Oviedo, Avenida Roma s/n, Oviedo, Asturias 33011, Spain. Telephone 34-69006806, e-mail [email protected] A 60-year-old woman was referred to the authors’ hospital in 2012, with a three-month history of nonproductive cough. She had no chest pain, night sweats or fever. She had no known toxic habits, nor surgical or medical background of interest. The chest x-ray showed loss of normal lung markings in the left upper lobe and a rounded, branch- ing opacity mass lesion in the area of the left hilum (finger-in-glove sign) (Figure 1A). A computed tomography scan of the chest showed mucoid impactation, segmental hyperlucency and decreased vascular- ity of the left upper lobe (Figure 1B). Three-dimensional reconstruc- tion of the bronchial tree revealed an atretic apicoposterior segmental bronchus of the left upper lobe confirming the diagnosis of congenital bronchial atresia (Figure 1C). KEY LEARNING POINTS Congenital bronchial atresia is a rare anomaly characterized by normal bronchial ramification from a central blind bronchial sac filled with mucus (mucocoele). The regional hyperinflation is due to a check valve mechanism in the collateral ventilation through the alveolar pores of Kohn, the bronchoalveolar channels of Lambert, or the interbronchiolar channels. Distal to the bronchial atresia secretions accumulate, leading to mucoid impaction surrounded by segmental hyperlucency caused by a combination of trapped air and oligaemia. The apicoposterior segmental bronchus of the left upper lobe is most commonly affected. • Sixty percent of patients are asymptomatic, their anomaly being discovered on a routine chest radiograph. • Computed tomography (with contrast if necessary) is the diagnostic test of choice. The differential diagnosis of finger-in-glove sign includes mucus impaction due to cystic fibrosis, allergic bronchopulmonary asperigillosis, broncholithiasis, foreign body aspiration and malignancies. REFERENCES 1. Nussbaumer-Ochsner Y, Kohler M. Finger-in-glove sign in bronchial atresia. Thorax 2011;66:182. 2. Jederlinic PJ, Sicilian LS, Baigelman W, Gaensler EA. Congenital bronchial atresia. A report of 4 cases and a review of the literature. Medicine 1986;65:73-83. 3. Martinez S, Heyneman L, McAdams H, et al. Mucoid impactions: Finger-in-glove sign and other CT and radiographic features. Radiographics 2008;28:1369-82. Figure 1) A Posteroanterior radiograph showing loss of normal lung markings in the left upper lobe and a rounded, branching opacity mass lesion (glove-in- finger sign) in the area of the left hilum (white arrow). B Axial computed tomography image revealing mucoid impaction, segmental hyperlucency and decreased vascularity in the left upper lobe. C Three-dimensional reconstruction of the bronchial tree. No division of the corresponding bronchi, confirming the diagnosis of left upper lobe congenital bronchial atresia (arrows) The ‘Images in Respiratory Medicine’ section of the Canadian Respiratory Journal aims to highlight the importance of visual interpretation, whether physiological, radiological, broncho- scopic, surgical/thorascopic or histological, in the diagnosis of chest diseases. Submissions should exemplify a classic, particularly dramatic or intriguing presentation of a disease while offering an important educational message to the reader (insightful diagnostic pearls or differential diagnosis, etc). This section is not intended to be a vehicle for publication of case reports (see the Clinical- Pathologic-Conferences for case-based leaning series). A B C

Transcript of Finger-in-glove sign in congenital bronchial atresiaThorax 2011;66:182.Congenital bronchial atresia...

Page 1: Finger-in-glove sign in congenital bronchial atresiaThorax 2011;66:182.Congenital bronchial atresia is a rare anomaly characterized by normal bronchial ramification from a central

Can Respir J Vol 22 No 5 September/October 2015 255

IMAGES IN RESPIRATORy MEDICINE

©2015 Pulsus Group Inc. All rights reserved

Finger-in-glove sign in congenital bronchial atresia Miguel Ariza-Prota MD1, José Luis Diez Jarilla MD, Amador Prieto MD2,

Ana Pando-Sandoval MD1, Pere Casan MD1

1Hospital Universitario Central de Asturias (HUCA). Instituto Nacional de Silicosis (INS). Área del Pulmón. Facultad de Medicina. Universidad de Oviedo. Oviedo. España; 2Hospital Universitario Central de Asturias (HUCA). Departamento de Radiología. Oviedo, España.

Correspondence: Dr Miguel Angel Ariza Prota, Instituto Nacional de Silicosis (INS), Área del Pulmón, Hospital Universitario Central de Asturias (HUCA), Facultad de Medicina, Universidad de Oviedo, Avenida Roma s/n, Oviedo, Asturias 33011, Spain. Telephone 34-69006806, e-mail [email protected]

A 60-year-old woman was referred to the authors’ hospital in 2012, with a three-month history of nonproductive cough. She had no

chest pain, night sweats or fever. She had no known toxic habits, nor surgical or medical background of interest. The chest x-ray showed loss of normal lung markings in the left upper lobe and a rounded, branch-ing opacity mass lesion in the area of the left hilum (finger-in-glove

sign) (Figure 1A). A computed tomography scan of the chest showed mucoid impactation, segmental hyperlucency and decreased vascular-ity of the left upper lobe (Figure 1B). Three-dimensional reconstruc-tion of the bronchial tree revealed an atretic apicoposterior segmental bronchus of the left upper lobe confirming the diagnosis of congenital bronchial atresia (Figure 1C).

KEY LEARNING POINTS• Congenital bronchial atresia is a rare anomaly characterized by

normal bronchial ramification from a central blind bronchial sac filled with mucus (mucocoele). The regional hyperinflation is due to a check valve mechanism in the collateral ventilation through the alveolar pores of Kohn, the bronchoalveolar channels of Lambert, or the interbronchiolar channels.

• Distal to the bronchial atresia secretions accumulate, leading to mucoid impaction surrounded by segmental hyperlucency caused by a combination of trapped air and oligaemia.

• The apicoposterior segmental bronchus of the left upper lobe is most commonly affected.

• Sixty percent of patients are asymptomatic, their anomaly being discovered on a routine chest radiograph.

• Computed tomography (with contrast if necessary) is the diagnostic test of choice.

• The differential diagnosis of finger-in-glove sign includes mucus impaction due to cystic fibrosis, allergic bronchopulmonary asperigillosis, broncholithiasis, foreign body aspiration and malignancies.

REFERENCES1. Nussbaumer-Ochsner Y, Kohler M. Finger-in-glove sign in bronchial

atresia. Thorax 2011;66:182.2. Jederlinic PJ, Sicilian LS, Baigelman W, Gaensler EA. Congenital

bronchial atresia. A report of 4 cases and a review of the literature. Medicine 1986;65:73-83.

3. Martinez S, Heyneman L, McAdams H, et al. Mucoid impactions: Finger-in-glove sign and other CT and radiographic features. Radiographics 2008;28:1369-82.

Figure 1) A Posteroanterior radiograph showing loss of normal lung markings in the left upper lobe and a rounded, branching opacity mass lesion (glove-in-finger sign) in the area of the left hilum (white arrow). B Axial computed tomography image revealing mucoid impaction, segmental hyperlucency and decreased vascularity in the left upper lobe. C Three-dimensional reconstruction of the bronchial tree. No division of the corresponding bronchi, confirming the diagnosis of left upper lobe congenital bronchial atresia (arrows)

The ‘Images in Respiratory Medicine’ section of the Canadian Respiratory Journal aims to highlight the importance of visual interpretation, whether physiological, radiological, broncho-scopic, surgical/thorascopic or histological, in the diagnosis of chest diseases. Submissions should exemplify a classic, particularly dramatic or intriguing presentation of a disease while offering an important educational message to the reader (insightful diagnostic pearls or differential diagnosis, etc). This section is not intended to be a vehicle for publication of case reports (see the Clinical-Pathologic-Conferences for case-based leaning series).

A B C

Page 2: Finger-in-glove sign in congenital bronchial atresiaThorax 2011;66:182.Congenital bronchial atresia is a rare anomaly characterized by normal bronchial ramification from a central

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