- Email: [email protected]
Pulmonary infarct simulating a mass pulmonary lesion in a patient being evaluated for mitral commissurotomy
Pulmonary Infarct Simulating a Mass Pulmonary Lesion in a Patient Being Evaluated for Mitral Commissurotomy LowELL L. LANE, M .D ., Cynwyd, Pennsylvania, WILLIAM L. JAMISON, M .D., Philadelphia, Pennsylvania AND FRANKLIN C . MASSEY, M .D ., Ardmore, Pennsylvania
Front the Division of Medicine, and the Division of Surgery, Habnemann Medical College, Pbiladelpbia, Pennsylvania. HE
of sputum, often blood-streaked in the morning . At no time did she experience chest pain, cyanosis, tachypnea, acute dyspnea or "attacks" of anv sort . No historical or overt evidence of paroxysmal heart action, phlebothrombosis or thrombophlebitis could be manifested . Six months before reporting to us, signs of congestive heart failure gradually developed . Despite her decreasing vital capacity, the patient not only managed her own household (physical) chores but also augmented the family income by working full-time in a factory as a "checker" of coils in a radio-condenser assembly line, a sedentary job . Three months after her visit to the Cardiac Clinic she was hospitalized because of noticeably diminished functional capacity despite maintenance digitalis and mercurial diuretic therapy . Her last pre-hospitalization period of three weeks was spent at bedrest . For one year prior to her first visit to the Cardiac Clinic the patient had been taking digitalis (digitalis folia o .i gm .) daily, with mercurial diuretic injections (exact quantity unknown) on a biweekly basis . Interrogation from the general standpoint documented an undiagnosed febrile illness at age four, frequent sore throat in childhood and frequent upper respiratory infections throughout her life . She had four successful, full-term, normal deliveries before age thirty-six . Only with the first of' these did she have any disturbance, namely, polyarthralgia of both knees . Physical examination of this average-appearing woman with a slight degree of pallor was unremarkable in all details with the exception of the cardiovascular system . Her blood pressure was i io,-'58 mm . ; Hg average in the supine position . Regular sinus rhythm at a rate of 86 minute was present .
purpose of reporting this case of mis-
T diagnosed pulmonary infarction is not
because of its rarity ; in our own experience and in the experience of physicians dealing routinely with pulmonary disease, this lesion is misappreciated frequently to a discouraging degree . Our aim here, especially in view of recent articles' , ' stressing the need for prompt thoracotomy for patients exhibiting suspicious and unexplained lung lesions, particularly if they are silent, is to emphasize the fact that pulmonary infarction may simulate numerous types of chronic lung disease . Further, the need for thorough evaluation of preoperative cases, regardless of the major complaint, is brought into proper perspective by avoiding focus on a single lesion . For example, we are not evaluating a heart, rather, a patient with a heart . Obviously, this patient did have an operable cardiac lesion, but its importance was relegated to a secondary position .' CASE REPORT
A thirty-nine year old white housewife was first seen in the Hahnemann Hospital OutPatient Department in the Cardiac Clinic, referred there by her family physician for evaluation for mitral valvular commissurotomy . Her history indicated she first knew of a heart lesion two years previously . A childhood history suggesting rheumatic infection was present only in the form of occasional "rheumatism ." The entire review otherwise was insignificant . Progressive cardiac disability developed within the past two years . I n this last period, while she was under the care of her family physician, a sporadic cough developed, productive of variable quantities 921
Misdiagnosed Pulmonary Infarction
Fic . i . Lateral and postero-anterior roentgenograms showing the pulmonary infarct (I) which simulated a mass pulmonary lesion in a patient being evaluated for mitral commissurotomy .
A sharp first sound at the apex was heard . A grade ii, harsh, high-pitched, systolic murmur was present, referred rather widely, particularly toward the base . An easily definable, low-pitched, rumbling mid-diastolic murmur with appreciable pre-systolic accentuation also was audible in the mitral area. The pulmonic second sound was accentuated two to three plus . Aortic area auscultation produced no abnormalities, although in the second or third interspace and along the upper left sternal border, the mitral murmurs were distinctly audible, although of diminished intensity . Venous pressure was not increased . Breath sounds were diminished in the right lower lobe posteriorly with no associated abnormalities. The liver was enlarged 8-io cm . below the costal margin, measured at the line extended from the right mid-clavicular . Basic laboratory studies were well within the bounds of conventional normal standards with the possible exception of the 6 per cent eosinophilia of the peripheral blood . Serologically negative blood (Kolmer and V .D .R .L .) was Rh+, A 2 in type. Serial smears and cultures of sputum and gastric washings for tubercle bacilli all were negative . Radiologic study of the heart showed two plus left atrial enlargement, also two plus enlargement of both the inflow and outflow tracts of the right ventricle . Left ventricular enlarge922
ment was absent . A large, comparatively homogeneous density was observed in the lower or middle lobes of the right lung . (Fig. i .) This same lesion had been noted on chest film studies made at the time of her only outpatient visit three months prior to hospital admission . Transient first-degree A-V heart block was seen on the electrocardiogram, along with minor, non-specific T wave and S-T segment changes in multiple leads . Intracardiac surgery was cancelled and intensive study of the pulmonary lesion begun . Serial and special projectional films were of no additional diagnostic help and the pulmonary lesion remained static . Bronchoscopic diagnostic examination was done,' showing the right main bronchus stenosed to the degree that the 7 mm . bronchoscope could not pass to the middle lobe level or into the lower lobe . There was no ulceration . Mucous membrane surfaces on the right side were inflamed . Because of these developments it was deemed wise to perform lung surgery (lobectomy or pneumonectomy) on the right, leaving mitral commissurotomy for a later date . At surgery, there was a considerable amount of thin, brownish pleural effusion . Several adhesions joined the right lower lobe and parietal pleura, as well as the right lower and right middle lobes. There was a large gray area occupying the entire basal portion of the right
Misdiagnosed Pulmonary Infarction lower lobe . This area was firm, well demarcated and solid in consistency . It was triangular in shape . The superior segment of the right lower lobe was normal and well aerated . The right middle lobe was discolored slightly, presenting a grayish orange appearance on its inferior aspect . The entire right middle lobe contained no aerated tissue. Pathologic examination of the specimen showed little other than pulmonary infarction . Details of this cytopathology are unnecessary here .
significant bronchostenotic lesions as determined by expert bronchoscopy . 3 . Total-patient appraisal rather than organoriented, myopic evaluation is mandatory if the patient is to receive appropriate therapy . REFERENCES
BERNATZ, P . E . and CLAGETT, O . T . Exploratory thoracotomy in diagnosis and management of certain pulmonary lesions . J. A . M . A ., I52 : 379, 1953 . 2 . MALONEY, W . M . Personal communication . 3 . MASSEY, F . C . and LANE, L . L . Factors Determining Operability of Candidates for Mitral Valvular Commissurotomy . In : Clinical Cardiology, by Massey, F . C . Baltimore, 1953, Williams & Wilkins Co. 4 . PERKINS, R . B . and BRADSHAw, H . H . Pulmonary infarction mistaken for bronchogenic carcinoma . J. A . M . A ., 151 : 545. 1953 . 1.
SUMMARY
i . Undiagnosed pulmonary lesions, particularly if they are silent, justify thoracotomy for diagnostic purposes . 2 . Pulmonary infarction may present confusing clinical situations, even mimicking
92 3
Front the Division of Medicine, and the Division of Surgery, Habnemann Medical College, Pbiladelpbia, Pennsylvania. HE
of sputum, often blood-streaked in the morning . At no time did she experience chest pain, cyanosis, tachypnea, acute dyspnea or "attacks" of anv sort . No historical or overt evidence of paroxysmal heart action, phlebothrombosis or thrombophlebitis could be manifested . Six months before reporting to us, signs of congestive heart failure gradually developed . Despite her decreasing vital capacity, the patient not only managed her own household (physical) chores but also augmented the family income by working full-time in a factory as a "checker" of coils in a radio-condenser assembly line, a sedentary job . Three months after her visit to the Cardiac Clinic she was hospitalized because of noticeably diminished functional capacity despite maintenance digitalis and mercurial diuretic therapy . Her last pre-hospitalization period of three weeks was spent at bedrest . For one year prior to her first visit to the Cardiac Clinic the patient had been taking digitalis (digitalis folia o .i gm .) daily, with mercurial diuretic injections (exact quantity unknown) on a biweekly basis . Interrogation from the general standpoint documented an undiagnosed febrile illness at age four, frequent sore throat in childhood and frequent upper respiratory infections throughout her life . She had four successful, full-term, normal deliveries before age thirty-six . Only with the first of' these did she have any disturbance, namely, polyarthralgia of both knees . Physical examination of this average-appearing woman with a slight degree of pallor was unremarkable in all details with the exception of the cardiovascular system . Her blood pressure was i io,-'58 mm . ; Hg average in the supine position . Regular sinus rhythm at a rate of 86 minute was present .
purpose of reporting this case of mis-
T diagnosed pulmonary infarction is not
because of its rarity ; in our own experience and in the experience of physicians dealing routinely with pulmonary disease, this lesion is misappreciated frequently to a discouraging degree . Our aim here, especially in view of recent articles' , ' stressing the need for prompt thoracotomy for patients exhibiting suspicious and unexplained lung lesions, particularly if they are silent, is to emphasize the fact that pulmonary infarction may simulate numerous types of chronic lung disease . Further, the need for thorough evaluation of preoperative cases, regardless of the major complaint, is brought into proper perspective by avoiding focus on a single lesion . For example, we are not evaluating a heart, rather, a patient with a heart . Obviously, this patient did have an operable cardiac lesion, but its importance was relegated to a secondary position .' CASE REPORT
A thirty-nine year old white housewife was first seen in the Hahnemann Hospital OutPatient Department in the Cardiac Clinic, referred there by her family physician for evaluation for mitral valvular commissurotomy . Her history indicated she first knew of a heart lesion two years previously . A childhood history suggesting rheumatic infection was present only in the form of occasional "rheumatism ." The entire review otherwise was insignificant . Progressive cardiac disability developed within the past two years . I n this last period, while she was under the care of her family physician, a sporadic cough developed, productive of variable quantities 921
Misdiagnosed Pulmonary Infarction
Fic . i . Lateral and postero-anterior roentgenograms showing the pulmonary infarct (I) which simulated a mass pulmonary lesion in a patient being evaluated for mitral commissurotomy .
A sharp first sound at the apex was heard . A grade ii, harsh, high-pitched, systolic murmur was present, referred rather widely, particularly toward the base . An easily definable, low-pitched, rumbling mid-diastolic murmur with appreciable pre-systolic accentuation also was audible in the mitral area. The pulmonic second sound was accentuated two to three plus . Aortic area auscultation produced no abnormalities, although in the second or third interspace and along the upper left sternal border, the mitral murmurs were distinctly audible, although of diminished intensity . Venous pressure was not increased . Breath sounds were diminished in the right lower lobe posteriorly with no associated abnormalities. The liver was enlarged 8-io cm . below the costal margin, measured at the line extended from the right mid-clavicular . Basic laboratory studies were well within the bounds of conventional normal standards with the possible exception of the 6 per cent eosinophilia of the peripheral blood . Serologically negative blood (Kolmer and V .D .R .L .) was Rh+, A 2 in type. Serial smears and cultures of sputum and gastric washings for tubercle bacilli all were negative . Radiologic study of the heart showed two plus left atrial enlargement, also two plus enlargement of both the inflow and outflow tracts of the right ventricle . Left ventricular enlarge922
ment was absent . A large, comparatively homogeneous density was observed in the lower or middle lobes of the right lung . (Fig. i .) This same lesion had been noted on chest film studies made at the time of her only outpatient visit three months prior to hospital admission . Transient first-degree A-V heart block was seen on the electrocardiogram, along with minor, non-specific T wave and S-T segment changes in multiple leads . Intracardiac surgery was cancelled and intensive study of the pulmonary lesion begun . Serial and special projectional films were of no additional diagnostic help and the pulmonary lesion remained static . Bronchoscopic diagnostic examination was done,' showing the right main bronchus stenosed to the degree that the 7 mm . bronchoscope could not pass to the middle lobe level or into the lower lobe . There was no ulceration . Mucous membrane surfaces on the right side were inflamed . Because of these developments it was deemed wise to perform lung surgery (lobectomy or pneumonectomy) on the right, leaving mitral commissurotomy for a later date . At surgery, there was a considerable amount of thin, brownish pleural effusion . Several adhesions joined the right lower lobe and parietal pleura, as well as the right lower and right middle lobes. There was a large gray area occupying the entire basal portion of the right
Misdiagnosed Pulmonary Infarction lower lobe . This area was firm, well demarcated and solid in consistency . It was triangular in shape . The superior segment of the right lower lobe was normal and well aerated . The right middle lobe was discolored slightly, presenting a grayish orange appearance on its inferior aspect . The entire right middle lobe contained no aerated tissue. Pathologic examination of the specimen showed little other than pulmonary infarction . Details of this cytopathology are unnecessary here .
significant bronchostenotic lesions as determined by expert bronchoscopy . 3 . Total-patient appraisal rather than organoriented, myopic evaluation is mandatory if the patient is to receive appropriate therapy . REFERENCES
BERNATZ, P . E . and CLAGETT, O . T . Exploratory thoracotomy in diagnosis and management of certain pulmonary lesions . J. A . M . A ., I52 : 379, 1953 . 2 . MALONEY, W . M . Personal communication . 3 . MASSEY, F . C . and LANE, L . L . Factors Determining Operability of Candidates for Mitral Valvular Commissurotomy . In : Clinical Cardiology, by Massey, F . C . Baltimore, 1953, Williams & Wilkins Co. 4 . PERKINS, R . B . and BRADSHAw, H . H . Pulmonary infarction mistaken for bronchogenic carcinoma . J. A . M . A ., 151 : 545. 1953 . 1.
SUMMARY
i . Undiagnosed pulmonary lesions, particularly if they are silent, justify thoracotomy for diagnostic purposes . 2 . Pulmonary infarction may present confusing clinical situations, even mimicking
92 3