Presentation
Patient with rheumatoid arthritis presented with chronic cough for 5 months. No hemoptysis or shortness of breath.
Patient Data
Biapical fibrosis. Bilateral subpleural and peribronchovascular reticulations with bronchiolectasis are noted in right upper, right middle and and bilateral lower lobes. No straight edge sign. No honeycombing. Few small lung cysts at right upper and right lower lobes. A small calcified granuloma at posterobasal segment of right lower lobe. No pleural effusion bilaterally.
Trachea is central. Focal soft tissue thickening seen within right anterior trachea.
Incidental finding of dilated subsegmental left pulmonary artery at the lingular segment of left upper lobe with dilated pulmonary vein. Pulmonary trunk is not dilated. No cardiomegaly. Coronary artery calcification with thoracic aortic atherosclerotic disease noted,
No enlarged mediastinal lymphadenopathy.
Segment VII hypodense liver may represent liver cyst.
CTPA confirmed a nidus of pulmonary arteriovenous malformation (PAVM) in the lingular segment of the left upper lobe, measuring approximately 1.5 x 1.3 x 1.0cm (AP x W x CC). It is fed by a single enlarged branch from the pulmonary artery and drains via the left pulmonary vein into the left atrium. No evidence of pulmonary hypertension or embolism. Heart is not enlarged.
Unchanged hypodense lesion at the segment VII of the liver may represent liver cyst.
The previously seen intraluminal tracheal lesion has disappeared, indicating that this may be due to mucous plugging.
Case Discussion
This is a case of left lingular pulmonary arteriovenous malformation ( simple type) evidenced by single segmental artery feeding the malformation.
The patient initially came for HRCT thorax to look for interstitial lung disease in view of underlying rheumatoid arthritis. HRCT showed indeterminate UIP pattern and incidental finding of PAVM which was further evaluated by CTPA.
PAVMs are rare vascular abnormalities consisting of fistulous connections between dilated pulmonary arteries and dilated pulmonary veins resulting in a right-to-left shunt 1, bypassing the normal pulmonary capillary bed.
The most common association is hereditary hemorrhage telangiectasis.
Contrast-enhanced CT thorax or transthoracic contrast echocardiography (TTCE) are useful for further evaluation 1.
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