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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 22

Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology

Case 22

Michael P. D'Alessandro, M.D.,
Steven J. Fishman, M.D.,
Deborah E. Schofield, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Thirty month old male with progressive respiratory distress.

Clinical History:
This is a two and a half year old male admitted to the hospital with a two day history of cough, rhinorrhea, and increasing respiratory distress. There was no history of foreign body aspiration. He was found to be positive for RSV. A chest film taken at that time showed over inflation of the right upper lobe. The patient showed initial improvement, but then decompensated one day later, suddenly developing severe retractions and hypercarbia.

Clinical Physical Exam:
The chest had diffuse wheezes and occasional rales. The right chest was hyperexpanded.

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Clinical Labs:
Non-contributory

Clinical Differential Diagnosis:
Congenital lobar emphysema, airway foreign body

Imaging Findings:
A chest film from the day of admission showed hyperinflation of the right upper lobe. A repeat chest film from one day later showed probable increasing hyperinflation of the right upper lobe.

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Imaging Differential Diagnosis:
Congenital lobar emphysema, airway foreign body.

Operative Findings:
The patient was taken emergently to the operating room after his respiratory decompensation. A rigid bronchoscopy was performed to rule out the presence of a foreign body before a thoracotomy was performed for congenital lobar emphysema. No airway foreign body was seen on bronchoscopy. Mucosal edema and thin white secretions were seen throughout the airway. A thoracotomy was then performed through a standard right posterolateral thoracotomy incision. Upon opening the chest, a very large right upper lobe was encountered and was allowed to herniate out through the incision, thus decompressing the other intrathoracic structures. The patient's respiratory status improved immediately. The right upper lobe was then resected.

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Pathological Findings:
Examination of the surgical specimen revealed a lobe of lung with focal hemorrhage and subpleural bullae. Emphysematous change, bronchiolitis with proliferation of bronchiolar epithelium, and patchy interstitial pneumonitis was seen.

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Final Diagnosis:
Congenital Lobar Emphysema

Follow-up and Prognosis:
The patient had an uncomplicated post-operative course.

Similar Cases:
Case 17

References:

Title Page


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