Ten years old female presented with a complaint of intermittent wet cough of 5 weeks' duration associated with low grade intermittent fever, shortness of breath, easy fatigability and loss of appetite. She had frequent similar complaints for the last 4 years for which she visited different hospitals and was given antibiotics for the diagnosis of pneumonia. She had 6-8 acute exacerbations annually but wasn't admitted to hospital. She had no contact history with known pulmonary tuberculosis patients and she is fully vaccinated. She has no history of drug allergy, self or family history of relevant medical or surgical illness. On presentation her vital signs were; PR = 96beat/minute, RR = 28breath/minute and oxygen saturation was 90% with 3 L of intranasal oxygen support. She had decreased air entry over her left posterior lower third lung field and digital clubbing. Otherwise, there was no remarkable finding on other systems evaluation.
Her complete blood count, renal function test and serum electrolytes were in the normal range. Chest computerized tomography (Chest CT) showed collapsed left lung with fluid filled lobar and segmental bronchi (Fig. 1). There was significant cardio-mediastinal shift to the left and compensatory hyperinflation of the right lung with herniation of the right upper and middle lobe in to the left chest. Bronchoscopic evaluation revealed destroyed left bronchial wall starting from the carina and filled with extensive purulent secretion. Bronchoscopic suctioning of the purulent fluid was attempted but it was very thick and was difficult for further evacuation. Culture from the bronchial aspirate revealed staphylococcus aureus growth which was resistant for penicillin, cloxacillin and cephalosporin's, and sensitive for gentamicin.
With an impression of left lung collapse secondary to extensive diffuse bronchiectasis with recurrent infection, the patient was started on Intravenous antibiotics and continued on intranasal oxygen. The surgical team decided for surgical intervention and the patient was operated through left posterolateral thoracotomy after getting informed written consent from the patient's family. The intraoperative finding was hyper inflated right lung filling two-third of left the hemi-thorax and completely collapsed, bronchiectatic left lung (Fig. 2). With these findings left pneumonectomy was done, left tube thoracostomy inserted and thoracotomy wound was closed in layers.
Post procedure, she was transferred to pediatric intensive care unit; and put on oxygen support and continued on intravenous antibiotics and analgesics. Subsequently, she had smooth recovery and was transferred to surgical ward. The chest tube output was insignificant and control chest x ray taken on her 4th post op day showed no evidence of collection for which the chest tube was removed.
Histopathologic study of the excised lung showed prominently dilated bronchial airways lined by flattened respiratory epithelial cells. There was extensive peribronchial inflammatory infiltrates and, extensive fibrosis and hyalinization of blood vessels with perivascular inflammatory infiltrates, the final impression being diffuse bronchiectasis (Fig. 3).
Subsequently, the patient showed a remarkable improvement and was discharged from the hospital in a stable condition.
Chest CT scan showing collapsed left lung with thickened, dilated prominent bronchi. There is also significant herniation of right upper and middle lobe into the left thoracic cavity.