Pulmonary torsion is a rare complication of thoracic operations and trauma, but lobar torsion owing to a lung abscess has not been reported. We present a case of lung abscess in the right upper lobe without pleural adhesion, which caused lobar torsion upon a change in posture, resulting in stenosis of the right main bronchus.
An 82-year-old man visited our hospital with complaints of cough and wheeze. Chest x-ray performed in upright position revealed right hilar/midlung infiltrate (Fig. 1A). Interestingly, computed tomography revealed right upper lobe occupied by a mass with calcification (Fig. 2); the middle lung field was free of any mass or infiltrates. As the mass shadow showed upward movement on chest x-ray films when the patient was supine (Fig. 1B), we suspected that the right upper lobe had postural mobility. Bronchoscopy failed to visualize the right upper lobe bronchus, and the right main bronchus was stenotic (Fig. 3A); however, it became fully patent when the patient was asked to assume sitting posture (Fig. 3B). It was apparent that the right upper lobe shifted antero-inferiorly when the patient was in upright position, but moved cephalad when he was in supine position, and pulled the right main bronchus postero-superiorly, leading to its stenosis. A brushing sample obtained from the lateral wall of the right main bronchus revealed no acid-fast bacilli or malignant cells. At thoracotomy, there were no pleural adhesions, the interlobar fissure was complete, and the right upper lobe was found to contain accumulated secretion. The right upper bronchus seemed normal and there was no malformation of the pulmonary vessels. A right upper lobectomy was performed and a polycystic mass with viscous and necrotic contents was observed in the resected lung. The pathologic diagnosis was lung abscess with pulmonary tuberculosis and endobronchial tuberculosis. The patient made an uneventful recovery and received additional chemotherapy for tuberculosis. Bronchoscopy after the operation showed that the right main bronchus was fully patent, similar to the situation before surgery when the patient was in a sitting position (Fig. 3C).
Pulmonary lobar torsion is a rare complication of thoracic operations and trauma, and the most common type is the torsion of the right middle lobe after upper lobectomy.1,2 Other reported cases have been associated with lung transplantation,3 foreign body,4 and atelectasis after pneumothorax.5 In the present case, the torsion was caused by a lung abscess, and the shape of the right main bronchus changed according to the posture of the patient. The right upper lobe filled by the abscess had no pleural adhesion and a complete interlobar fissure and showed postural mobility. Therefore, the right upper lobe was shifted upward when the patient was supine, and pulled the right main bronchus postero-superiorly, making it stenotic. As a pyogenic lung usually has pleural adhesion, it rarely moves in the thoracic cavity when the patient's posture changes. As the orifice of the right upper bronchus was closed, sequestration or congenital cystic disease with bronchial atresia was suspected. However, these diseases are very rare in elderly patients. Suemitsu and colleagues reported a case of asymptomatic atresia of the right lower bronchus,6 which they speculated was related to tuberculosis, although Mycobacterium tuberculosis was not detected. In our patient, the right upper bronchus seemed normal at surgery, and M. tuberculosis was detected in the resected lung and bronchus. Therefore, we considered that atelectasis caused by endobronchial tuberculosis had developed into a lung abscess, which caused the affected lobe to show postural mobility in the absence of pleural adhesion. This type of bronchial torsion has not been reported previously. The present case was treated successfully by lobectomy.
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