Endoscopic aspects of Middle Lobe Syndrome

Bushev, Jane and Buklioska Ilievska, Daniela and Jovevska, Svetlana and Kochovska-Kamchevska, Nade and Baloski, Marjan and Poposki, Bozidar and Trajkovska, Vanche (2024) Endoscopic aspects of Middle Lobe Syndrome. In: Drugi kongres bronhologa Srbije, 16-18 May 2024, Belgrade, Serbia.

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Abstract

INTRODUCTION Middle lobe syndrome is a term used in pulmonology to denote a number of pathological conditions accompanied by atelectasis and a decrease in the volume of the middle lobe. According to different authors, middle lobe syndrome occurs in 0.33-6% of lung patients, and in men it is found about twice as often. Middle lobe syndrome is a preliminary clinical and radiological diagnosis that requires further clarification of the cause of this pathological process. It is suggested to exclude cases of atelectasis caused by tumoral obstruction of the bronchus from this concept. In practice, until the diagnosis is differentiated and the etiology determined, this term can be hidden and include bronchogenic carcinoma. Different variants of middle lobe syndrome should be distinguished from central lung cancer, tuberculosis and interlobar pleurisy. Rarer differential diagnostic causes can be pericardial cyst and abdominal mediastinal lipoma. Th e isolation of this syndrome is a consequence of the relatively high incidence of damage to this area of the right lung, which is related to anatomical characteristics. In comparison with other lobar bronchi, the middle lobar bronchus has the narrowest diameter and the longest length, moreover, when it separates from the intermediate bronchus it forms an acute angle of about 30°. In the immediate vicinity of the bronchus of the middle lobe, there is a large number of bronchopulmonary lymph nodes whose hyperplasia causes external compression of the bronchial wall. Due to these characteristics, hypoventilation of the middle section occurs more easily. The aim of the work is the analysis, assessment and comparison of bronchoscopy findings in cases where the indications for endoscopic examination were radiographically observed changes (on posteroanterior and lateral view) in the area of the anatomical projection of the middle section (code according to ICD R91 - “abnormal findings in diagnostic imaging of the lungs regardless of the manifestation of clinical symptoms. CASE REPORT Case 1. AM, a 48-year-old woman, with a history of non-specific complaints that manifested themselves a few days before appearing for an examination: light chest pain and a rare dry cough predominate. No data was obtained for elevated temperature or fever. Non-smoker, no comorbidities, negative personal and family history. Standard laboratory analyzes and tumor markers were within reference values. X-ray showed the finding of infiltration in the mid-section projection. Chest CT showed a conglomeration of lymph glands in the mediastinum, a consolidation zone in the right hilus with Antero basal propagation, and a positive air bronchogram. Bronchoscopy examination confirmed mild stenosis of the mouth of the median incision, submucosal and mucosal infiltration with stenosis of the lumen, and complete impermeability of the lumen distal to the infiltrating mass with hyperemic mucous membrane. Diff use edema of the mucosa (morphological subtype edematous, hyperemic, fibro sthenic) was also observed. Histological findings confirmed granulomatous inflammation with many epithelioid granulomas, some with central necrosis, around which accumulations of lymphocytes were seen. Th e definitive histological diagnosis was Inflammation chronica granulomatosis, which confirmed the clinical diagnosis of endobronchial tuberculosis. The microbiological findings of broncho aspirate and sputum did not reveal the presence of acid-resistant bacilli (in the direct preparation and with the immunofluorescence technique, cultures according to Levenstein-Jensen and Bactec remained negative). A positive molecular test result (GeneXpert) was obtained. Antituberculosis therapy was carried out with a 9-month regime (due to prolonged clinical symptoms and prolonged radiological findings of infiltrative changes, which pointed to prolonged disease activity and slowed tissue regeneration, as a result, a temporary oral steroid regime was also carried out, aft er which moderate radiological resolution (in the future, the formation of residual and secondary bronchiectasis changes in the middle section will be monitored, which will most likely manifest clinically as part of the “second section syndrome”). condition, but there are occasional symptoms in the form of a poorly productive cough, chest tightness, occasional feeling of chest discomfort and general discomfort, and frequent “colds”, while laboratory parameters and lung function are within normal limits submucosal infiltration, especially in the lingula bronchus (in the biopsy, fibro collagenous and hyaline changes were found, the pathologist’s answer was “fibrosis”). Th e mouth of the median incision is passable, stenosis of the bronchial lumen is observed distally, and segmental orifices cannot be visualized (compared to the findings before the INTRODUCTION of therapy, the reduction of changes in the orifice of the median incision is monitored, which is now passable, while the changes in the lingula are almost identical in appearance). The overall appearance points to post-tuberculosis sequelae (in the further course of the multi-year follow-up, it will be evaluated in terms of definite residues as well as the manifestation of symptoms as part of the “middle cut syndrome”). Case 2. JV, aged 72, was referred to a pulmonologist due to general symptoms: a feeling of weakness, loss of appetite and weight loss, prolonged cough with expectoration of thick secretions, and pain all over the body, especially in the back (lumbar and sacral region of the spine), pain in the chest on the right side. The problems have been going on for 6 months. Paraneoplastic syndrome was previously suspected due to symptoms of paraparesis. The patient was hospitalized at the Neurological Clinic, where a CT scan of the LS region was performed, and osteolytic changes were seen with a decrease in the diameter of individual vertebral bodies. From personal history: long-term smoker. Auscultatory findings on the lungs show a weakened respiratory sound on the front side of the right hemithorax, there are no enlarged lymph glands. Laboratory analyzes are not characteristic. Radiography showed a solid homogeneous change of elongated triangular shape in the mid-section projection (lobar atelectasis). Th e bronchoscopy finding was typical – a tumor mass with a smooth grayish-white surface protrudes from the mouth of the median incision, which completely obturates the mouth of the bronchus with the involvement of the interlobar carina, which cannot be recognized as tumor infiltration – the endoscopic diagnosis was Infiltration et obturation bronchi lobe media, Infiltration carinae interlobaris. Pathohistological findings from the biopsy showed small cell carcinoma (histological and immunohistochemical differentiation of the subtype was not performed). During the staging, metastases in the liver and lumbar vertebrae were found. Due to general poor condition (Karnofsky 50), the patient was not treated oncological. CONCLUSION Th e presented cases are unequivocal in terms of diagnosis. Th e examination algorithm for radiologically observed changes in the mid-section projection should unconditionally include an endoscopic examination. A detailed bronchoscopy examination is inevitable as a simple, reliable and accurate diagnostic procedure. In presented cases, the endoscopic finding correlated with the radiological and CT findings, which also helped to establish the diagnosis, and the outcome of the treatment itself complemented the diagnosis.
KEYWORDS
Middle lobe, middle lobe syndrome, bronchoscopy, endobronchial tuberculosis

Item Type:	Conference or Workshop Item (Poster)
Subjects:	Medical and Health Sciences > Clinical medicine
Divisions:	Faculty of Medical Science
Depositing User:	Daniela Buklioska Ilievska
Date Deposited:	11 Dec 2024 09:10
Last Modified:	11 Dec 2024 09:10
URI:	https://eprints.ugd.edu.mk/id/eprint/35182

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