Doctors from Sechenov University treated an unusual patient who turned out to have a range of pulmonary issues. Some of them were ‘one in a million’, while other ones could be diagnosed only after surgery.

Formation of abnormal air-filled cavities, or bullae, in the lung, is an unpleasant process most commonly caused by the chronic obstructive pulmonary disease (COPD). At the same time, lung cysts — epithelial-lined cavities — are observed in some people, predominantly in older age. But a combination of giant bullae and multiple cysts is extremely rare. Doctors from Sechenov University have encountered a patient with such a condition and successfully treated him. The case report has been published in the journal Respiratory Medicine Case Reports.

The 50-year-old patient, a smoker, was admitted to hospital with chest pain, cough with purulent sputum, dyspnoea (difficult breathing), and fever. He received conservative treatment but to no avail, and then the patient was referred to a specialised thoracic surgery clinic.

The X-ray examination and computed tomography (CT) scan of the chest revealed giant bullae in the upper parts of the lungs, namely 2/3 of the left hemithorax and 1/2 of the right hemithorax, and some bullae in the right lung contained fluid. Tuberculin tests were negative, while the spirometry parameters were worse than normal.

The team of medics initially suspected bullous lung disease or vanishing lung syndrome, complicated by chronic infection. Surgery was chosen as the only possible option in this case. The patient underwent a thoracoscopic lobectomy of the right upper lobe, and six weeks later, a trisegmentectomy of the left upper lobe.

Based on the histology analysis post-surgery, the final diagnosis was established — bullous disease type I (vanishing lung syndrome) complicated by suppuration (Streptococcus viridans), polycystic lung with vascular malformation of the lung parenchyma, and small focal pulmonary tuberculosis. Antibiotic therapy was administered for three weeks.

Three months after surgery, the patient was in a good condition, and the signs of respiratory failure subsided. Ten years later, a chest X-ray did not show the formation of new bullae, and the spirometry parameters had improved.

The authors of the paper conclude that in this clinical case, the role of vascular malformation remains unclear, while tuberculosis could be diagnosed only by histology. A combination of giant bullae and cysts in one patient is extremely rare, and the authors hope that their description of such a case would be very important for pulmonologists.

The report was made by the Department of Phthisiopulmonology and Thoracic Surgery (Sechenov University) and Central Scientific Research Institute for Tuberculosis (Moscow).

Read more: Giller DB, et al. Surgical treatment of giant bullae on the background of cystic lesion and vascular malformation. Case report. Respir Med Case Rep (2020).

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