Presentation
A long history of fever and persistent right middle lobe consolidation.
Patient Data
That is partially defined rounded radiopacity with few internal cystic areas seen in the right lower lung zone. The lateral chest x-ray confirms the site of this opacity in the right middle lung lobe with bulging of the horizental fissure seen.
There are linear interstitial opacities underneath the above mentioned lesion in the right lower lung zone, mostly reactional.
Area of cavitatory consolidation and air bronchograms seen in the lateral segment of the right medial lung lobe.
The area has partially cystic and partially solid components with peripheral mesh-like interconnected tiny blood vessels.
The lesion is feeded by small systemic artery from the celiac trunk and drained by small vein into the pulmonary veins.
Surrounding mild bronchiectatic and groundglass opacities are also present.
Mild bronchiectatic changes with surrounding atelectatic bands are also seen in the anterior segment of the left upper lung lobe.
Maximum intensity projection (MIP) and 3D CT reconstruction of the arterial system better visualized the feeding artery arising from the celiac trunk and ascending to supply the area of sequestration.
Case Discussion
This patient had a long history of fever, chest pain and cough. CT scan was done 3 months earlier and the diagnosis of a cavitatory pneumonia was presumed. Bronchoscopy and pus culture were done which showed very high Echinococcus granulosus, raising the possibility of pulmonary hydatid.
The diagnosis of sequestration was not established until after 3 months when the patient came back with the same clinical picture. A new CT scan showed almost the exact finding as the previous images.
Considering the age of the patient and the persistence of consolidation over this period, one should also consider sequestration, and a careful look for a feeding artery should have been done. In this case, the feeding artery was arising from the celiac trunk, and the draining veins were toward the pulmonary veins, such scenario is typical for intralobar sequestration.
Intraoperatively, there was dense adhesions between the parietal and visceral pleura, destruction of parts of the right middle lobe with aberrant blood vessel entering the chest cavity through the tendinous part of the right hemidiaphragm. The pathology was resected.
Pathological exam of the resected lesion showed cystic lesion with white membranous structure in keeping with hydatid cyst.