A 50-year-old male, smoker (50 packs/year), was diagnosed in 2000 with chronic obstructive lung disease (COPD) and was admitted to a local hospital complaining of chest pain, cough with purulent sputum up to 150 ml/day, dyspnea on excretion and fever up to 39 S. He was treated with Amoxillin, Tiotropium bromide and Salmeterol.
Due to the failure of conservative treatment, the patient was routed to the thoracic surgical clinic. A chest X-ray and CT scan revealed giant bullae in the upper parts of the lungs (2/3 of the left hemithorax and 1/2 of the right hemithorax). Some bullae in the right lung contained fluid. The lung tissue was emphysematous in the epiphrenic regions, but did not contain bullae (Fig. 1).
During further examination, tuberculin tests were negative; acid fast bacilli (AFB) were not detected in the sputum neither microscopically nor by culturing.
Spirometric parameters, the partial pressures of blood gases and 6-min walking test were decreased compared to normal (Table 1).
Taking into account the spirometry indicators' discrepancy to COPD GOLD criteria, the absence of alfa1 antitrypsin level decreasing, we initially diagnosed bullous lung disease (vanishing lung syndrome) complicated by non-specific suppuration in the right lung with sputum culture revealed Streptococcus viridans at 3 x 107. Due to chronic infection persistence, not amenable to conservative therapy, and progressive respiratory failure, then a surgical intervention was the only option for this patient.
At the first stage, the patient underwent a thoracoscopic lobectomy of the right upper lobe en-bloc with segment 6.
At the second stage, the patient underwent a trisegmentectomy of the left upper lobe six weeks later. (Fig. 2).
bullae of lung tissue with multiple cysts in the area of chronic inflammation with the presence of vascular malformation
zones of organizing hemorrhagic infarcts next to lung cysts and vascular malformations,
foci of non-specific inflammation
fibrotic tuberculosis granuloma in the area of fibrocystic modified lung
cystic change of the bronchi.
Histological examination (Fig. 3) revealed:
The histological report established the diagnosis: bullous disease type I (vanishing lung syndrome) complicated by suppuration (Streptococcus viridans). Polycystic lung with vascular malformation of the lung parenchyma. Small focal pulmonary tuberculosis.
Antibiotic therapy was carried out for 3 weeks in accordance with bacterial sensitivity data. On discharge, 3 months post-surgery, the patient's condition was satisfactory with the signs of respiratory failure having significantly decreased. At a follow-up examination, 10 years later, the patient's status condition was good. He has continued to smoke. A chest X-ray did not demonstrate new bullae (Fig. 4). Spirometric parameters were satisfactory (Table 1).
Positive dynamics of functional parameters and gas exchange was noted in comparison with previous data (Table 1).