A 64-year old-fashioned man with a...

A 64-year old-fashioned man with a 30 pack-year history of smoking was admitted with complaints of right-sided chest pain, agitations chills, and hemoptysis during the preceding week. There was no history of surgery or trauma. He was afebrile onward admission. End-inspiratory crackles and egophony were heard through the apical portion of the right chest wall. Laboratory findings included: hemoglobin 129 g/dl; hematocrit 386 percent; and a WBC cast up of 9,300/cu mm (11 percent bands, 65 percent neutrophils, 21 percent lymphocyte 2 percent monocytes, and 1 percent eosinophils). Initial scope air arterial blood gas horizontals were: pH, 7.53; [Posub2] 47 mm Hg; and [Pcosub2] 29 mm Hg (altitude, 1380 m) Gram stain of the sputum disclosed a moderate number of WBC with no predominant organism. No acid-fast bacilli were fix on examination of the sputum

A chest roentgenogram revealed a right upper lobe (RUL) infiltrate and right sided pleural effusion (Fig 1) Thoracocentesis yielded a sanguinary exudate with 6,500 WBC/cu mm (75 percent neutrophils, 25 percent monocytes) and 35000 RBC/cu mm No pathogen was identified by means of sputum, blood, or pleural fluid agricultures Sputum cytologic study was negative. Serology for Legionella (group 1 to 6) was also negative. A pulmonary angiogram was done to evaluate embolic disease and demonstrated a slight decrease in melt to the RUL but no intravascular filling failings Treatment with oxygen and a broad-spectrum cephalosporin was begun.

following chest roentgenograms demonstrated no infiltrate of the RUL moreover did show an infiltrate in the right lower lung field and, a week later, in the right perihilar area (Fig 2) A total of five changes in the position of the infiltrate were observ during his hospitalization. Bronchoscopic examination outcomes revealed obstruction of the anterior and apical segmental bronchi of the RUL There was no distortion or inflammation of the large airways. Washings, brushings, and bronchial biopsies were negative for microbial organisms or malignancy.

A diagnostic management was performed. Diagnosis: Lobar torsion with right upper lobe collapse

A next to the first pulmonary angiogram demonstrated that the collapsed RUL had migrated inferiorly and medially (Fig 3) The lower lobe had expanded posteriorly while the middle lobe was superior to the upper lobe. We postulated that the migratory infiltrate forward roentgenogram resulted from torsion of the RUL At thoracotomy, torsion of the bronchovascular pedicle of the upper lobe was observ and the lobe appeared atelectatic, with hemorrhage and edema. A right upper lobectomy was performed and the middle lobe stapled to the lower. The inferior pulmonary ligament was not chop Pathologic examination of the excised lung showed congest vasculature and hemorrhage of the parenchyma. There was no infarction or necrosis. The patient cureed rapidly after the lobectomy.

Twenty-five cases of lung torsion have been reported.[1-4] No pattern of characteristic age, sex or area of involvement has been identified, although it not absents most commonly after the inferior pulmonary ligament has been disjoined during thoracic surgery. It is also observ with chest trauma. A single lobe or the entire lung may be affected.

Torsion unassociated with previous surgery or trauma has been described in patients with an accessory lobe,[5] diaphragmatic hernia,[6] pneumonia,[7] neoplasma,8] and spontaneous pneumothorax.[9] In our case and with pair other patients, no pathology predisposing for torsion was found[24] Several mechanisms have been postulated to explain torsion in so patients, including the suggestion that a lengthy bronchovascular pedicle with complete fissures allow the lobe to reply to intrathoracic pressure changes and lead to torsion.

The for the use of all radiographic findings of torsion include opacification of the involved tissue, inverted vascular pattern, and collapse in an abnormal position. Our patient was unique in that he had radiographic documentation of five changes in the position of an infiltrate as the torsed, collapsed right upper lobe rotated forward its pedicle.

References

[1] Moser E Jr Proto AV. Lung torsion: case report and literature review. Radiology 1987; 162:639-43

[2] Shorr RM Rodriguez A. Spontaneous pulmonary torsion. Chest 1987; 91:927-28

[3] Louis JR Daffner RH Torsion of the lung causing refractory hypoxemia. J Trauma 1987; 27:687-88

[4] Cervantes-Perez P Recognizing pulmonary torsion. Chest 1988; 93:444-46

[5] Epplen F Jacobson AL. Twisted pedicle of accessory lobe of the lung JAMA 1930; 94:1135

[6] Ransdell HT Jr Ellison RG Volvulus of a lobe of the lung as a complication of diaphragmatic hernia. J Thorac Surg 1953; 25:341-45

[7] Tsung-Yao Huang, Shao-Ru Cho Torsion of the lung without trauma. Radiology 1979; 132:25-26

[8] Meisell R Case of the spring season. Semin Roentgenol 1980; 15:115-16

[9] Berkmen YM Uncomplicated torsion of the right upper lobe secondary to spontaneous pneumothorax. Chest 1985; 87:695-97

COPYRIGHT 1989 American association of Chest Physicians

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