A 28-month-old girl was referred to our clinic because of a persistent cough, wheeze, and increased work of breathing for the preceding three months. Despite oral antibiotics and high doses of inhaled corticosteroids prescribed by her primary physician, cough and wheeze were persistent. Parents denied any history of witnessed foreign body aspiration, and there were no feeding-related symptoms. The patient was born at term with an uneventful postnatal course. Her history was significant for episodes of cough and intermittent wheeze that begun at one year of age; these episodes were usually treated with bronchodilators and inhaled steroids. There was no history of atopy in the family.
Initial physical examination revealed normal growth parameters, a respiratory rate of 40 breaths/minute, and no retractions. Oxygen saturation ranged from 94 to 95% on room air, and she was afebrile. Lung auscultation revealed decreased air exchange in the left lung; the rest of her physical examination was normal.
A chest X-ray was performed for abnormal breath sounds and showed hyperlucency of the left lung (Figure 1). A barium swallow study was normal with no apparent external indentation or displacement of the esophagus and no evidence for GERD.
Blood work, including routine hematology and biochemistry tests, was within normal limits. Results of virology PCR for CMV, EBV, and adenovirus were negative. Acid-fast bacilli smear, culture, and TB PCR were negative.
On flexible bronchoscopy examination of her lower airways, no foreign body was seen, but significant external nonpulsatile compression over the left main bronchus was noticed; the rest of the airway anatomy was normal. This finding prompted us to undertake a detailed evaluation. Thoracic computed tomography (CT) scan and angiogram showed a soft tissue mass in the middle mediastinum, compressing the carina and proximal part of the right and left main bronchi, more pronounced on the left main bronchus (Figure 2). This mass was further delineated by magnetic resonance imaging of the thorax with contrast which revealed a lobulated cystic mass lesion (Figure 3).
These findings were in favor of the diagnosis of a bronchogenic cyst in the middle mediastinum. Therefore, the patient underwent thoracotomy and surgical removal of a cystic mass which was found during surgery to be adjacent to the posterior trachea and left main bronchus. Pathological examination of the mass showed a cystic lesion lined by the ciliated columnar epithelium surrounded by a fibromuscular wall containing the cartilage and nests of bronchial submucosal glands, confirming the probable diagnosis of a bronchogenic cyst. There was no evidence of malignancy.
The postoperative course was uneventful. The patient had been free of any respiratory symptoms and signs, including a cough and wheezing in the subsequent follow-up visits.