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Combined therapies for composite graft infection after Bentall’s procedure
564
CASE REPORT TAKANO ET AL COMPOSITE GRAFT INFECTION
lus is credited to Davis, who in 1834 described a case of a young boy struck with a wooden missile fragment that migrated to his right ventricle [1]. Rich and associates [2] examined 7,500 cases of vascular injury during the Vietnam war and could find only 22 cases (0.3%) of missile emboli. Reports of embolization of shotgun pellets are more scarce than for larger projectiles. In a recent review, only 28 cases of shotgun pellet emboli have been described since 1960 [1]. Even more unusual than the above is the situation where a projectile embolizes paradoxically from the venous to the arterial circulation. This may occur via one of three routes. The first involves erosion of the missile across the interatrial or interventricular septum in a patient with a direct projectile injury to the heart [3]. A second route of paradoxical embolization occurs when the projectile erodes across blood vessels from the venous to the arterial circulation [4]. A third possible route for paradoxical embolization occurs when the projectile passes across a congenital cardiac defect. The first such description came from Specht in 1917 [5]. Since that time, only 3 more cases of paradoxical embolus by this mechanism have been reported, and in only 1 of these [6] was a patent foramen ovale actually demonstrated. The present report documents the fifth case in the past 80 years of embolism of a projectile from a venous site across an intracardiac defect to the arterial circulation, and is unusual in that the projectile was a shotgun pellet. Perhaps the most unusual aspect of this case relates to the retention of the shotgun pellet in the noncoronary sinus of the aortic valve. The pellet, encased in a small amount of soft tissue, was not held fixed within the sinus, and yet it did not embolize distally. This occurrence undoubtedly reflects containment of the pellet by the flow vortex created within the sinus of Valsalva during systole. Although the turbulent flow patterns within the aortic valve sinuses have been well studied [7], there is little information on prevention of distal embolism of particulate matter by these phenomena. In addition, it was indeed fortunate for the patient that the pellet was not contained within the right or left coronary sinus, with its attendant risk of embolization down a coronary artery [8]. Paradoxical bullet embolus is a very rare occurrence, which can be associated with considerable diagnostic confusion. A careful evaluation of the patient’s injuries and a high level of suspicion are required for the successful identification and management of this condition.
References 1. Yoshioka H, Seibel RW, Pillai K, Luchette FA. Shotgun wounds and pellet emboli: case reports and review of the literature. J Trauma 1995;39:596 – 601. 2. Rich NM, Collins GJ, Andersen CA, McDonald PT, Kozloff L, Ricotta JJ. Missile emboli. J Trauma 1978;18:236–9. 3. Neerken AJ, Clement FL. Air-rifle wound of the heart with embolization. JAMA 1964;189:579– 80. 4. Lam CR, McIntyre R. Air-pistol injury of pulmonary artery and aorta. J Thorac Cardiovasc Surg 1970;59:729–32. 5. Specht VO. Granatsplitter im linken Ventrikel nach Verletzung der Vena femoralis. Munch Med Wochenschr 1917;27: 892– 4. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;66:564 – 6
6. Schurr M, McCord S, Croce M. Paradoxical bullet embolism: case report and literature review. J Trauma 1996;40:1034– 6. 7. Peacock JA. An in vitro study of the onset of turbulence in the sinus of Valsalva. Circ Res 1990;67:448– 60. 8. Hopkins HR, Pecirep DP. Bullet embolization to a coronary artery. Ann Thorac Surg 1993;56:370–2.
Combined Therapies for Composite Graft Infection After Bentall’s Procedure Tamaki Takano, MD, Yukio Fukaya, MD, Hirofumi Nakano, MD, Hideo Kuroda, MD, and Jun Amano, MD Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis. (Ann Thorac Surg 1998;66:564 – 6) © 1998 by The Society of Thoracic Surgeons
C
omposite graft infection is one of the fatal complications that can occur after Bentall’s procedure has been performed. As we have no single decisive therapy for this complication at present, combined therapies are necessary. The purpose of this report is to highlight the combined therapies for composite graft infection. The patient was a 49-year-old man. At the age of 35 years, he underwent Bentall’s procedure with a composite graft (composed of a Bjo¨rk-Shiley valve and a woven Dacron graft) for annuloaortic ectasia. At the age of 45 years, he underwent graft replacement of the aortic arch for Stanford A type acute aortic dissection. He was admitted to our hospital because of sudden fever and left hemiplegia. Cerebrospinal fluid examination and computed tomography of the head revealed a brain abscess in the right frontal lobe. Ultrasonic cardiography showed a vegetation on the prosthetic valve (Fig 1). Blood cultures showed colonies of Staphylococcus aureus. Benzylpenicillin potassium and gentamycin sulfate were given for 2 weeks intravenously and cefazolin sodium was given for 1 week intravenously. Computed tomography of the chest revealed an aortic root abscess 1 month after the onset of fever (Fig 2). Accepted for publication March 2, 1998. Address reprint requests to Dr Takano, Department of Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto 390, Japan.
0003-4975/98/$19.00 PII S0003-4975(98)00510-4
Ann Thorac Surg 1998;66:564 – 6
The infected composite graft and the arch graft were replaced with a new composite graft after debridment of the surrounding infected tissues and part of the aortic annulus. The right and left coronary arteries were anastomosed to the Dacron graft with aortic buttons during the first Bentall’s operation. These were resected from the infected graft and reanastomosed to the new Dacron graft by Cabroll’s procedure. Continuous irrigation of the mediastinum with normal saline solution containing 0.1% povidone-iodine (250 mL/h for 4 hours) and 0.2% cefazolin sodium (500 mL/h for 1 hour) was started just after the operation. After irrigation for 3 days, the pedicle of the omentum was brought up to the mediastinum and wrapped around the new composite graft. Vancomycin hydrochloride and cefazolin sodium were given intravenously for 2 months after the operation. Then cefaclor was orally administered for 2 weeks. The postoperative course was uneventful. The patient’s white blood cell count and C-reactive protein level gradually decreased and were within the normal range 3 months after the operation. The patient was discharged and returned to full-time work as a house painter. Neither clinical signs nor laboratory data of infection have been observed for 2 years of follow-up.
Comment Cases of composite graft infection are occasionally reported [1, 2]. A composite graft infection often becomes a fatal complication after reconstruction of the aortic root. Composite graft infection leads to sepsis, systemic embolism, and heart failure as a result of prosthetic valve malfunction or disruption of the suture lines. Surgical treatment should be carried out immediately after the onset of composite graft infection [1, 3]. However, in this case, computed tomography of the brain revealed an abscess and 1 month later the operation was performed after the brain abscess was encapsulated. Recommendations for the treatment of mediastinitis
CASE REPORT TAKANO ET AL COMPOSITE GRAFT INFECTION
565
Fig 2. Chest computed tomogram (contrast enhancement) shows a low-density area around the ascending aorta and the aortic arch.
involving the vascular prosthesis include open exploration and debridment of infected tissue [1], continuous mediastinal irrigation with a solution containing povidone-iodine and antibiotics [4, 5], and transposition of muscle and the omentum [1, 2]. Composite graft infections were successfully treated without replacing the infected grafts by Se´guin and Loisance [1]. On the other hand, Miller and Johnson [2] reported 2 cases in which they replaced the infected grafts. In our case, we elected to replace the infected composite graft because we observed both a brain abscess and vegetation on the prosthetic valve. After the infected composite graft has been replaced, there remains a possibility of infection in the new composite graft with the same organism that infected the original composite graft. To prevent the new composite graft from becoming infected, we continuously irrigated the mediastinum with a solution containing povidoneiodine and normal saline solution containing cefazolin sodium. After irrigation for 3 days, the transposition of the greater omentum was performed. Glick and colleagues [5] reported toxicity of iodine caused by povidone-iodine irrigation. They stated that iodine is rapidly absorbed across the epithelium of the mediastinum during continuous mediastinal irrigation, which leads to high serum iodine levels. This could lead to metabolic acidosis, hyperosmolarity, renal failure, or hepatic failure. In this case, we used 0.1% povidone-iodine for mediastinal irrigation and did not observe hepatic failure, renal failure, or any other similar symptoms. In case of composite graft infection, continuous mediastinal irrigation and omental transposition after replacement of the infected composite graft should be considered to prevent the new composite graft from becoming infected.
References Fig 1. Ultrasonic cardiography shows vegetation on the aortic curtain. (LA 5 left atrium, LV 5 left ventricle.)
1. Se´guin JR, Loisance DY. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest 1985;88:684– 6. 2. Miller DW Jr, Johnson DD. Omental pedicle graft in the
566
CASE REPORT ELIA ET AL TUBERCULOSIS COMPLICATING A SEQUESTRATION
management of infected ascending aortic prosthesis. Ann Thorac Surg 1987;44:614–7. 3. Abe T, Tsukamoto M, Komatsu S. Surgical treatment of active infective endocarditis: early and late results of active native and prosthetic valve endocarditis. Jpn Circ J 1993;57:1080– 8. 4. Schumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86: 384–7. 5. Glick PL, Guglielmo BJ, Tranbaugh RF, Turley K. Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478– 80.
Infection With Mycobacterium tuberculosis Complicating a Pulmonary Sequestration Stefano Elia, MD, Marco Alifano, MD, Maria Gentile, MD, Pasquale Somma, MD, Francesco P. D’Armiento, MD, and Giovanni Ferrante, MD Departments of Thoracic Surgery and Pathology, University “Federico II”, Naples, Italy
Pulmonary sequestration is a relatively rare malformation. Infection with common pyogenes is a frequent feature in the evolution of this disease. We report a case of intralobar sequestration infected with Mycobacterium tuberculosis in the absence of any other site of tuberculous infection. The patient underwent surgical removal of the affected lobe and subsequent antituberculous chemotherapy. At 1-year follow-up his clinical status is excellent. (Ann Thorac Surg 1998;66:566 –7) © 1998 by The Society of Thoracic Surgeons
P
ulmonary sequestration is a relatively uncommon congenital disease. Although respiratory distress (especially in the newborn or the infant), intrapleural hemorrhage, or congestive heart failure secondary to left-to-right shunt may represent the revealing symptoms [1–3], repeated bacterial infections are the most frequent modality of presentation of the disease. We report herein a case of intralobar sequestration complicated by infection with Mycobacterium tuberculosis.
Ann Thorac Surg 1998;66:566 –7
murmur at the left basal area. There was neither cyanosis nor digital clubbing. With the patient breathing room air, arterial blood-gas analysis showed a pH of 7.40, an arterial carbon dioxide tension of 37 mm Hg, and an arterial oxygen tension of 77 mm Hg. Blood laboratory studies disclosed no further abnormalities. Results of human immunodeficiency virus testing were negative. Chest radiography and computed tomographic scanning revealed a left-sided basal gross opacity (Fig 1). A computed tomography-guided fine-needle aspiration was nondiagnostic. Although the presence of a pulmonary sequestration was hypothesized because of the topography of the lesion, aortography was not performed because it was unavailable at that time. The patient underwent open thoracotomy. At exploration a gross mass was found in the left lower lobe. Careful separation of adhesions between the lobe and the diaphragm allowed the identification of an aberrant vessel of subdiaphragmatic origin. This vessel was divided. A left lower lobectomy was performed without further difficulty. Histopathologic study revealed chronic inflammation and fibrosis with obliterative changes of blood vessels; the alveolar spaces were filled by large mononuclear cells. Caseating granulomata and Langhans’ giant cells were also observed (Fig 2). Detection of antibodies against the mycobacterial antigens A60 [4] and P-90 [5] on a blood sample obtained on the 4th postoperative day was positive (anti-A60 immunoglobulin G:5.3 international units; anti-A60 immunoglobulin A, 6.2 IU; anti-P90 immunoglobulin A, 4.8 IU; normal values, ,3 IU). Cultures of samples from the surgical specimen grew fully drug susceptible M tuberculosis. Although sputum cultures were repeatedly negative and no other sites of tuberculous infection were recognized, the patient received a 6-month course of antituberculous chemotherapy (isoniazid, ethambutol, and rifampin). At 1-year follow-up he remains asymptomatic, with no radiographic signs of disease. He has also regained his body weight. Detection of antibodies against A60 and P-90 antigens is now negative.
A 61-year-old man presented with a 3-week history of cough, malaise, and fever (.38°C). Moderate (4 kg) weight loss was also reported. He was a current heavy smoker (40 packs/year). His past medical history included only a peptic ulcer treated with anti-H2 drugs. On admission he had no respiratory distress. Pulse was regular at 78 beats/min and blood pressure was 140/80 mm Hg. Physical examination revealed attenuation of respiratory Accepted for publication March 3, 1998. Address reprint requests to Dr Alifano, Via Roma 60, I-81024 Maddaloni, Italy.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Computed tomographic scan of the thorax showing a gross opacity in the left lower lobe. 0003-4975/98/$19.00 PII S0003-4975(98)00476-7
CASE REPORT TAKANO ET AL COMPOSITE GRAFT INFECTION
lus is credited to Davis, who in 1834 described a case of a young boy struck with a wooden missile fragment that migrated to his right ventricle [1]. Rich and associates [2] examined 7,500 cases of vascular injury during the Vietnam war and could find only 22 cases (0.3%) of missile emboli. Reports of embolization of shotgun pellets are more scarce than for larger projectiles. In a recent review, only 28 cases of shotgun pellet emboli have been described since 1960 [1]. Even more unusual than the above is the situation where a projectile embolizes paradoxically from the venous to the arterial circulation. This may occur via one of three routes. The first involves erosion of the missile across the interatrial or interventricular septum in a patient with a direct projectile injury to the heart [3]. A second route of paradoxical embolization occurs when the projectile erodes across blood vessels from the venous to the arterial circulation [4]. A third possible route for paradoxical embolization occurs when the projectile passes across a congenital cardiac defect. The first such description came from Specht in 1917 [5]. Since that time, only 3 more cases of paradoxical embolus by this mechanism have been reported, and in only 1 of these [6] was a patent foramen ovale actually demonstrated. The present report documents the fifth case in the past 80 years of embolism of a projectile from a venous site across an intracardiac defect to the arterial circulation, and is unusual in that the projectile was a shotgun pellet. Perhaps the most unusual aspect of this case relates to the retention of the shotgun pellet in the noncoronary sinus of the aortic valve. The pellet, encased in a small amount of soft tissue, was not held fixed within the sinus, and yet it did not embolize distally. This occurrence undoubtedly reflects containment of the pellet by the flow vortex created within the sinus of Valsalva during systole. Although the turbulent flow patterns within the aortic valve sinuses have been well studied [7], there is little information on prevention of distal embolism of particulate matter by these phenomena. In addition, it was indeed fortunate for the patient that the pellet was not contained within the right or left coronary sinus, with its attendant risk of embolization down a coronary artery [8]. Paradoxical bullet embolus is a very rare occurrence, which can be associated with considerable diagnostic confusion. A careful evaluation of the patient’s injuries and a high level of suspicion are required for the successful identification and management of this condition.
References 1. Yoshioka H, Seibel RW, Pillai K, Luchette FA. Shotgun wounds and pellet emboli: case reports and review of the literature. J Trauma 1995;39:596 – 601. 2. Rich NM, Collins GJ, Andersen CA, McDonald PT, Kozloff L, Ricotta JJ. Missile emboli. J Trauma 1978;18:236–9. 3. Neerken AJ, Clement FL. Air-rifle wound of the heart with embolization. JAMA 1964;189:579– 80. 4. Lam CR, McIntyre R. Air-pistol injury of pulmonary artery and aorta. J Thorac Cardiovasc Surg 1970;59:729–32. 5. Specht VO. Granatsplitter im linken Ventrikel nach Verletzung der Vena femoralis. Munch Med Wochenschr 1917;27: 892– 4. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;66:564 – 6
6. Schurr M, McCord S, Croce M. Paradoxical bullet embolism: case report and literature review. J Trauma 1996;40:1034– 6. 7. Peacock JA. An in vitro study of the onset of turbulence in the sinus of Valsalva. Circ Res 1990;67:448– 60. 8. Hopkins HR, Pecirep DP. Bullet embolization to a coronary artery. Ann Thorac Surg 1993;56:370–2.
Combined Therapies for Composite Graft Infection After Bentall’s Procedure Tamaki Takano, MD, Yukio Fukaya, MD, Hirofumi Nakano, MD, Hideo Kuroda, MD, and Jun Amano, MD Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis. (Ann Thorac Surg 1998;66:564 – 6) © 1998 by The Society of Thoracic Surgeons
C
omposite graft infection is one of the fatal complications that can occur after Bentall’s procedure has been performed. As we have no single decisive therapy for this complication at present, combined therapies are necessary. The purpose of this report is to highlight the combined therapies for composite graft infection. The patient was a 49-year-old man. At the age of 35 years, he underwent Bentall’s procedure with a composite graft (composed of a Bjo¨rk-Shiley valve and a woven Dacron graft) for annuloaortic ectasia. At the age of 45 years, he underwent graft replacement of the aortic arch for Stanford A type acute aortic dissection. He was admitted to our hospital because of sudden fever and left hemiplegia. Cerebrospinal fluid examination and computed tomography of the head revealed a brain abscess in the right frontal lobe. Ultrasonic cardiography showed a vegetation on the prosthetic valve (Fig 1). Blood cultures showed colonies of Staphylococcus aureus. Benzylpenicillin potassium and gentamycin sulfate were given for 2 weeks intravenously and cefazolin sodium was given for 1 week intravenously. Computed tomography of the chest revealed an aortic root abscess 1 month after the onset of fever (Fig 2). Accepted for publication March 2, 1998. Address reprint requests to Dr Takano, Department of Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto 390, Japan.
0003-4975/98/$19.00 PII S0003-4975(98)00510-4
Ann Thorac Surg 1998;66:564 – 6
The infected composite graft and the arch graft were replaced with a new composite graft after debridment of the surrounding infected tissues and part of the aortic annulus. The right and left coronary arteries were anastomosed to the Dacron graft with aortic buttons during the first Bentall’s operation. These were resected from the infected graft and reanastomosed to the new Dacron graft by Cabroll’s procedure. Continuous irrigation of the mediastinum with normal saline solution containing 0.1% povidone-iodine (250 mL/h for 4 hours) and 0.2% cefazolin sodium (500 mL/h for 1 hour) was started just after the operation. After irrigation for 3 days, the pedicle of the omentum was brought up to the mediastinum and wrapped around the new composite graft. Vancomycin hydrochloride and cefazolin sodium were given intravenously for 2 months after the operation. Then cefaclor was orally administered for 2 weeks. The postoperative course was uneventful. The patient’s white blood cell count and C-reactive protein level gradually decreased and were within the normal range 3 months after the operation. The patient was discharged and returned to full-time work as a house painter. Neither clinical signs nor laboratory data of infection have been observed for 2 years of follow-up.
Comment Cases of composite graft infection are occasionally reported [1, 2]. A composite graft infection often becomes a fatal complication after reconstruction of the aortic root. Composite graft infection leads to sepsis, systemic embolism, and heart failure as a result of prosthetic valve malfunction or disruption of the suture lines. Surgical treatment should be carried out immediately after the onset of composite graft infection [1, 3]. However, in this case, computed tomography of the brain revealed an abscess and 1 month later the operation was performed after the brain abscess was encapsulated. Recommendations for the treatment of mediastinitis
CASE REPORT TAKANO ET AL COMPOSITE GRAFT INFECTION
565
Fig 2. Chest computed tomogram (contrast enhancement) shows a low-density area around the ascending aorta and the aortic arch.
involving the vascular prosthesis include open exploration and debridment of infected tissue [1], continuous mediastinal irrigation with a solution containing povidone-iodine and antibiotics [4, 5], and transposition of muscle and the omentum [1, 2]. Composite graft infections were successfully treated without replacing the infected grafts by Se´guin and Loisance [1]. On the other hand, Miller and Johnson [2] reported 2 cases in which they replaced the infected grafts. In our case, we elected to replace the infected composite graft because we observed both a brain abscess and vegetation on the prosthetic valve. After the infected composite graft has been replaced, there remains a possibility of infection in the new composite graft with the same organism that infected the original composite graft. To prevent the new composite graft from becoming infected, we continuously irrigated the mediastinum with a solution containing povidoneiodine and normal saline solution containing cefazolin sodium. After irrigation for 3 days, the transposition of the greater omentum was performed. Glick and colleagues [5] reported toxicity of iodine caused by povidone-iodine irrigation. They stated that iodine is rapidly absorbed across the epithelium of the mediastinum during continuous mediastinal irrigation, which leads to high serum iodine levels. This could lead to metabolic acidosis, hyperosmolarity, renal failure, or hepatic failure. In this case, we used 0.1% povidone-iodine for mediastinal irrigation and did not observe hepatic failure, renal failure, or any other similar symptoms. In case of composite graft infection, continuous mediastinal irrigation and omental transposition after replacement of the infected composite graft should be considered to prevent the new composite graft from becoming infected.
References Fig 1. Ultrasonic cardiography shows vegetation on the aortic curtain. (LA 5 left atrium, LV 5 left ventricle.)
1. Se´guin JR, Loisance DY. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest 1985;88:684– 6. 2. Miller DW Jr, Johnson DD. Omental pedicle graft in the
566
CASE REPORT ELIA ET AL TUBERCULOSIS COMPLICATING A SEQUESTRATION
management of infected ascending aortic prosthesis. Ann Thorac Surg 1987;44:614–7. 3. Abe T, Tsukamoto M, Komatsu S. Surgical treatment of active infective endocarditis: early and late results of active native and prosthetic valve endocarditis. Jpn Circ J 1993;57:1080– 8. 4. Schumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86: 384–7. 5. Glick PL, Guglielmo BJ, Tranbaugh RF, Turley K. Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478– 80.
Infection With Mycobacterium tuberculosis Complicating a Pulmonary Sequestration Stefano Elia, MD, Marco Alifano, MD, Maria Gentile, MD, Pasquale Somma, MD, Francesco P. D’Armiento, MD, and Giovanni Ferrante, MD Departments of Thoracic Surgery and Pathology, University “Federico II”, Naples, Italy
Pulmonary sequestration is a relatively rare malformation. Infection with common pyogenes is a frequent feature in the evolution of this disease. We report a case of intralobar sequestration infected with Mycobacterium tuberculosis in the absence of any other site of tuberculous infection. The patient underwent surgical removal of the affected lobe and subsequent antituberculous chemotherapy. At 1-year follow-up his clinical status is excellent. (Ann Thorac Surg 1998;66:566 –7) © 1998 by The Society of Thoracic Surgeons
P
ulmonary sequestration is a relatively uncommon congenital disease. Although respiratory distress (especially in the newborn or the infant), intrapleural hemorrhage, or congestive heart failure secondary to left-to-right shunt may represent the revealing symptoms [1–3], repeated bacterial infections are the most frequent modality of presentation of the disease. We report herein a case of intralobar sequestration complicated by infection with Mycobacterium tuberculosis.
Ann Thorac Surg 1998;66:566 –7
murmur at the left basal area. There was neither cyanosis nor digital clubbing. With the patient breathing room air, arterial blood-gas analysis showed a pH of 7.40, an arterial carbon dioxide tension of 37 mm Hg, and an arterial oxygen tension of 77 mm Hg. Blood laboratory studies disclosed no further abnormalities. Results of human immunodeficiency virus testing were negative. Chest radiography and computed tomographic scanning revealed a left-sided basal gross opacity (Fig 1). A computed tomography-guided fine-needle aspiration was nondiagnostic. Although the presence of a pulmonary sequestration was hypothesized because of the topography of the lesion, aortography was not performed because it was unavailable at that time. The patient underwent open thoracotomy. At exploration a gross mass was found in the left lower lobe. Careful separation of adhesions between the lobe and the diaphragm allowed the identification of an aberrant vessel of subdiaphragmatic origin. This vessel was divided. A left lower lobectomy was performed without further difficulty. Histopathologic study revealed chronic inflammation and fibrosis with obliterative changes of blood vessels; the alveolar spaces were filled by large mononuclear cells. Caseating granulomata and Langhans’ giant cells were also observed (Fig 2). Detection of antibodies against the mycobacterial antigens A60 [4] and P-90 [5] on a blood sample obtained on the 4th postoperative day was positive (anti-A60 immunoglobulin G:5.3 international units; anti-A60 immunoglobulin A, 6.2 IU; anti-P90 immunoglobulin A, 4.8 IU; normal values, ,3 IU). Cultures of samples from the surgical specimen grew fully drug susceptible M tuberculosis. Although sputum cultures were repeatedly negative and no other sites of tuberculous infection were recognized, the patient received a 6-month course of antituberculous chemotherapy (isoniazid, ethambutol, and rifampin). At 1-year follow-up he remains asymptomatic, with no radiographic signs of disease. He has also regained his body weight. Detection of antibodies against A60 and P-90 antigens is now negative.
A 61-year-old man presented with a 3-week history of cough, malaise, and fever (.38°C). Moderate (4 kg) weight loss was also reported. He was a current heavy smoker (40 packs/year). His past medical history included only a peptic ulcer treated with anti-H2 drugs. On admission he had no respiratory distress. Pulse was regular at 78 beats/min and blood pressure was 140/80 mm Hg. Physical examination revealed attenuation of respiratory Accepted for publication March 3, 1998. Address reprint requests to Dr Alifano, Via Roma 60, I-81024 Maddaloni, Italy.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Computed tomographic scan of the thorax showing a gross opacity in the left lower lobe. 0003-4975/98/$19.00 PII S0003-4975(98)00476-7