Síndrome del lóbulo medio: reporte de un caso / Middle lobe syndrome: a case report

El síndrome de lóbulo medio es una entidad caracterizada por colapso recurrente y crónico del lóbulo medio del pulmón derecho, dentro de esta entidad se conocen dos formas obstructiva y no obstructiva con etiologías variadas incluyendo procesos infecciosos como la tuberculosis, cáncer y otros. La fibrobroncoscopia es la herramienta más útil para realizar el diagnóstico diferencial. Se presenta el caso de un paciente de 26 años con síndrome de lóbulo medio por tuberculosis hematógena, miliar y neumónica con caverna con alta probabilidad de absceso. En relación a la etiología tuberculosa del síndrome de lóbulo medio, se han descrito casos ligados a tuberculosis endobronquial con y sin afectación parenquimatosa, esta entidad ha mostrado ser difícil de diagnosticar ya que la baciloscopia con frecuencia es negativa, requiriendo el empleo de TC de tórax, fibrobroncoscopia y sobre todo cultivo de lavado broncoalveolar y/o histopatología de muestras obtenidas.

Middle lobe syndrome is a condition characterized by recurrent and chronic collapse of the middle lobe of the right lung, within this entity obstructive and nonobstructive two forms with varied etiologies including infectious diseases such as tuberculosis, cancer and others are known. Bronchoscopy is the most useful for the differential diagnosis tool. We present the case of a patient of 26 years of middle lobe syndrome hematogenous miliary tuberculosis and pneumonic cavern with high probability of abscess is presented. Regarding the tuberculous etiology of middle lobe syndrome cases have been reported linked to endobronchial tuberculosis with and without parenchymal involvement, this entity has proven to be difficult to diagnose because the smear is often negative, requiring the use of chest CT, bronchoscopy and culture especially bronchoalveolar lavage and/or histopathology specimens obtained.

Pulmonary arteriovenous malformation: a culprit of middle lobe syndrome?

Middle lobe syndrome [MLS] refers to lobar atelectasis and bronchiectasis and is either obstructive or non-obstructive type. A 63-year-old asthmatic female patient presented with recurrent pneumonia and unrelenting cough which proved to be due to pulmonary arteriovenous malformation that led to obstructive MLS. CT scan showed right middle lobe volume loss, bronchiectasis and dilated pulmonary vessels. The patient was operated for right middle lobectomy. The pathological examination revealed pulmonary arteriovenous malformation with post obstructive changes. Pulmonary arteriovenous malformation should be part of the differential diagnosis of MLS and should prompt early referral for surgery. Middle lobe is anatomically susceptible to obstruction of the bronchus and to atelectasis due to its poor drainage and ventilation. Conservative treatment with antibiotics, bronchodilators, and chest physiotherapy are effective in 33.3 to 66.6% of patients. Lobectomy is required in a third of MLS patients who fail conservative management or have persistent symptoms that last more than 6 months or have malignant obstruction

Childhood allergic bronchopulmonary aspergillosis presenting as a middle lobe syndrome

Allergic bronchopulmonary aspergillosis (ABPA) is infrequently documented in children with asthma. Although collapse is not uncommon, middle lobe syndrome (MLS) as a presentation of ABPA is rather a rarity. A 9-year-old female child with asthma presented with increase in intensity of symptoms along with a right midzone patchy consolidation on a chest radiograph. In addition, an ill-defined opacity abutting the right cardiac border with loss of cardiac silhouette was noted. A right lateral view confirmed a MLS, which was further corroborated by high resolution computed tomography. Central bronchiectasis was also observed, which prompted a work-up for ABPA. The child met 7/8 major diagnostic criteria for ABPA. She was then initiated on oral prednisolone that resulted in a marked clinical improvement within a fortnight. Radiological clearance occurred at 3 months with inflation of the middle lobe. ABPA presenting with MLS in a child is yet to be reported. A high index of suspicion is required to establish the diagnosis of ABPA in a child presenting with MLS. This would obviate the invasive investigations usually done to ascertain the cause of MLS.

Right middle lobe syndrome caused by eosinophilic mucoid impaction in adults

Right middle lobe syndrome (RMLS) is defined as a transient or recurrent, chronic collapse of the middle lobe of the right lung by certain pathologic conditions. RMLS is a relatively uncommon condition having multiple etiologies and various clinical presentations. Two patients were referred to Hallym University Sacred Heart Hospital, one for the treatment of coughing and the other for the treatment of pneumonia. A diagnosis of RMLS was identified through X-ray and computed tomography image evaluation for each condition. Bronchoscopy revealed mucus obstruction in the right middle lobe bronchus. Biopsy of the aspirated mucus showed mucus containing many eosinophils and Charcot-Leyden crystals. After removal of impacted mucus, clinical and radiological improvements were observed in both patients. Therefore, eosinophilic mucus impaction can be considered a potential cause of RMLS, irrespective of any underlying asthmatic symptoms.

Pulmonary function of children with right lung middle lobe syndrome / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To study the changes of pulmonary function in children with right lung middle lobe syndrome before and after treatment.</p><p><b>METHODS</b>Thirty children with right lung middle lobe syndrome were classified into two age groups: < or =4 years old and >4 years old. Pulmonary function was tested by the 2600-type and the MIR-type pulmonary function spirometry in the < or =4 years and the >4 years age groups, respectively before and after treatment. Terminal flows/peak expiratory flow (25/PF) and the percentage of tidal volume to peak tidal expiratory flow (% V-PF) were measured in the <4 years age group. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF) were measured in the >4 years age group.</p><p><b>RESULTS</b>The values of 25/PF and %V-PF in the < or =4 years age group were 0.42+/-0.08 and 0.28+/-0.03, respectively before treatment. The values were improved after treatment (0.58+/-0.12 and 0.39+/-0.06 respectively) (P<0.05). The values of FVC, FEV1 and PEF were 1.75+/-0.32, 1.36+/-0.52 and 2.56+/-0.78, respectively in the >4 years age group before treatment. The values were also improved after treatment (2.37+/-0.78, 2.08+/-0.65 and 3.68+/-0.80 respectively) (P<0.05).</p><p><b>CONCLUSIONS</b>There are significant differences in the pulmonary function before and after treatment in children with right lung middle lobe syndrome. The pulmonary function can return to normal after treatment.</p>

Endobronchial Tuberculosis Presenting as Right Middle Lobe Syndrome:Clinical Characteristics and Bronchoscopic Findings in 22 Cases

PURPOSE: Endobronchial tuberculosis (EBTB) presenting as right middle lobe syndrome (RMLS) is an uncommon clinical condition. We investigated the clinical characteristics in patients with EBTB presenting as RMLS. PATIENTS and METHODS: We retrospectively reviewed the records of 22 patients with EBTB presenting as RMLS who were diagnosed at our hospital from 2003 to 2006. RESULTS: Its occurrence was more common in females than males (F, 18; M, 4). The mean age was 70.3 +/- 8.5 years, and 17 patients were above the age of 65 years. Cough with sputum was the most common manifestation and 2 patients were asymptomatic. In bronchoscopic analysis, the most common finding was edematous-type EBTB, which was found in 15 patients, followed by actively caseating type in 6 and tumorous type in 1. Acid-fast bacilli (AFB) staining for bronchial washing fluid was positive in only 5 patients: 1 with edematous type and 4 with actively caseating type. Bronchoscopic biopsy showed chronic granulomatous inflammation in 16 patients. Follow-up chest X-ray after treatment showed complete disappearance of the lesion in 2 patients, more than 50% improvement in 5, less than 50% improvement in 5, and no change of lesion in 4. CONCLUSION: Edematous-type EBTB was the most common type of EBTB presenting as RMLS, and it usually occurred in elderly patients. Culturing for mycobacterium and histologic examination by bronchoscopy are necessary for proper diagnosis in these patients.

Right lung middle lobe syndrome as the initial and sole clinical manifestation of Hodgkin's disease

The commonest presentation in Hodgkin's disease is painless cervical lymphadenopathy with or without a mediastinal mass. Uncommon presentations of Hodgkin's disease that has been so far reported include: spinal cord compression, localized poikiloderma vascularis atrophicans, unilateral lower extremity lymphedema, multifocal nodular episcleritis and scleritis, Immune thrombocytopenia and hemolytic anemia, granolomatous keratoconjunctivitis, subdiaphragmatic Hodgkin's disease. In these cases uncommon presentations were extramediastinal. In this case Hodgkin's disease presented with right lung middle lobe syndrome without hillar or mediastinal lymphadenopathy. CT guided needle biopsy of pulmonary lesion revealed Hodgkin's disease and response to chemotherapy was very good. The typical presentation of pulmonary Hodgkin's disease includes multiple, irregularly marginated pulmonary nodules in the hillar or mediastinal areas. Our case had an uncommon presentation of pulmonary Hodgkin's disease. Therefore for early diagnosis and treatment, such presentations of the disease should be taken into consideration

Causes of Right Middle Lobe Syndrome: Recent Experience in Local Tertiary Hospital for Several Years / 결핵및호흡기질환

BACKGROUND: Right middle lobe syndrome (RMLS) is defined as transient or chronic and recurrent atelectasis of the right middle lobe. Although numerous conditions are associated with RMLS, there are very few recent reports in Korea. This study evaluated the causes of RMLS in a local tertiary hospitalover a period of 42 months. METHOD: Eighty-eight patients (M:F=64:22, mean age: 67.2+/-10.3 years), who had consistent chest radiography findings and underwent bronchoscopy in Gyeongsang University Hospital from January 2003 to July 2006, were enrolled in this study. The clinical characteristics and causes of RMLS in these patients were retrospectively reviewed. RESULTS: The most common symptoms fo RMLS were cough, dyspnea and sputum. Tuberculosis was the most common cause (endobronchial tuberculosis in 22 and pulmonary tuberculosis in 1) The other causes were bronchial stenosis by benign fibrotic changes in 22 cases (25%), anthracofibrosis in 13 cases (14.8%), pneumonia in 11 cases (12.5%), lung cancer in 10 cases (11.4%), mucus impaction in 3 cases (3.4%), bronchiectasis in 2 cases (2.3%) and no demonstrable causes in 7 cases (8%). The bronchoscopy findings were mucosal edema with hyperemic changes in 38 cases (43.2%), mucosal edema with anthracotic pigmentation in 16 cases (18.2%), mucus impaction in 13 cases (14.8%), fibrotic stenosis in 13 cases (14.8%), a mass like lesion in 8 cases (9.1%), exudative necrotic material in 4 cases (4.5%), narrowing as a result of extrinsic compression in 2 cases (2.3%) and no demonstrable abnormalities in 12 cases (13.6%). CONCLUSION: Right middle lobe syndrome was observed more frequently in patients over the age of 65. The causes were mainly benign diseases with endobronchial tuberculosis being the most common.

Middle Lobe Syndrome Caused by Occult Foreign Body in the Bronchus Intermedius: A case report / 대한흉부외과학회지

Occult bronchial foreign body is that long-standing foreign body lodge in bronchial tree. A 63-year-old male was admitted our hospital complaining of a cough. Chest computerized tomography and bronchoscopy showed collapse of right middle lobe and foreign body in the bronchus intermedius. After open thoracotomy and bronchotomy, foreign body was removed and collapsed middle lobe was ventilated. Herein we report a case of middle lobe syndrome caused by occult foreign body in the bronchus intermedius.

Middle Lobe Syndrome in Children / 소아알레르기및호흡기학회지

No abstract available.

Analysis of the Etiologies, Radiologic Findings, Bronchoscopic Findings, and Clinical Courses of Right Middle Lobe Syndrome in Children / 소아알레르기및호흡기학회지

PURPOSE: Right middle lobe syndrome is defined as chronic atelectasis of the middle lobe of the right lung. The purpose of this study was to analyze the etiologies, radiologic findings, bronchoscopic findings, and clinical manifestations of right middle lobe syndrome in children. METHODS: We retrospectively reviewed the medical records of 28 children, who were admitted to the Samsung Medical Center from June 1998 to January 2003. These children had persistent atelectasis in the right middle lobe in plain chest radiography for more than a month. RESULTS: In 28 children, the most common etiology was pneumonia, followed by tuberculosis, bronchiectasis, and asthma. Most of the patients manifested nonspecific respiratory symptoms, such as coughing. The computerized tomography showed various findings including atelectasis, air bronchogram, or bronchietasis. While normal patent airway was found in 50% of the patients by bronchoscopy, narrowing of bronchus, large amount of secretion, and granulation nodules were noted in another half of the patients. In comparison with tuberculosis, atelectasis caused by pneumonia was relived more frequently by bronchoscopic therapeutic intervention (P=0.008), but there was no significant difference between them after approximately 2 years of follow-up. (P=0.232) Final outcomes in patients whose duration of atelectasis was 2 months or less tended to be better than 12 months or more, but it was not statistically significant. (P= 0.067) CONCLUSION: Common causes of right middle lobe syndrome in Korean children are pneumonia and tuberculosis. A high index of suspicion is required for early diagnosis and proper treatment which leading to better outcomes.

Síndrome do lobo médio: estudo de 10 casos atendidos no Hospital Universitário Lauro Wanderley / Middle lob disease: 10 cases assisted in the University Hospital Lauro Wanderley

Os autores fazem um estudo de 10 casos de síndrome do lobo médio (SLM), atendidos no Hospital Universitário Lauro Wanderley da Universidade Federal da Paraíba (HULW/UFPB), no período de 1986 a 1999. Enfatizam os aspectos clínicos, epidemiológicos e laboratoriais de diagnóstico, inclusive por imagem, comentando cada caso isoladamente. Ressaltam os aspectos radiográficos mais sugestivos dessa enfermidade, visando a instituição de um protocolo terapêutico cirúrgico para posterior seguimento e evolução. Chamam ainda a atenção para a instituição do tratamento tuberculostático precoce, no intuito de evitar seqüelas irreparáqveis no lobo médio, sobretudo sua forma mais temível - a síndrome do lobo médio. Concluem que o tratamento cirúrgico da SLM é considerado imprescindível no sentido não apenas de corrigir as graves deformidades da arquitetura pulmonar do lobo médio, mas também de acelerar a cura.

Detecçäo de síndrome paraneoplásica pela cintilografia óssea / Detection of paraneoplastic syndrome using bone scintigraphy

O melanoma maligno é um dos poucos tumores que podem causar hipercalcemia como síndrome paraneoplásica. Este relato demonstra a utilidade da cintilografia com MDP-99mTC no diagnóstico desta síndrome. A captaçäo difusa e acentuada do radiofármaco em partes moles, associada à presença de múltiplas metástases ósseas, levou à hipótese de hipercalcemia por síndrome paraneoplásica e, posteriormente, ao diagnóstico final de melanoma maligno

A Case of Bronchial Lipoma with Extrabronchial Growth causing Middle Lobe Syndrome and Pneumonia / 결핵

Benign pulmonary tumors are rare entities, and among them bronchial lipomas are the most uncommon. Up to date, about 80 cases have been reported in the English literature. But, the bronchial lipoma with extrabronchial growth causing middle lobe syndrome and pneumonia is extremely rare. Bronchial lipomas, mainly arising from normal fatty tissue of the proximal portion of the lobar or segmental bronchi, are histologically benign. But if diagnosis and treatments are delayed, they can produce extensive pulmonary parenchymal damage and irreversible brochiectasis distally. So whenever possible, the treatment of choice is resection by means of bronchoscopy via early diagnosis. But if endoscopic removal is not possible because the distal end of the tumor could not be visualized by fiberoptic bronchoscopy or if the nature of the tumor is unclear, surgery is necessary, with lobectomy or pneumonectomy being required in most cases due to the extensively damaged pulmonary parenchyma. We present a case of bronchial lipoma with extrabronchial growth, with a review of the literature and report of an unusual case.

A Clinical Study of Right Middle Lobe Syndrome / 소아알레르기및호흡기학회지

PURPOSE: Right middle lobe symdrome is characterized by a spectrum of disease from recurrent atelectasis and pneunomitis to brobchiectasis of the Right middle lobe symdrom. It was first reported gy Grahm describing 12 patients with middle loge atelectasis and bronchiectasis due to enlarged lymph nodes. The incidence of Right middle lobe syndome seems tobe increasing in children, byt there have been only a few studies of right middlelobe syndrome in Korea. METHODS: Twenty-five children with RMLS who had been admitted during the last 10 years were evaluated with particular attention to clinical features, laboratory results, bronchographic findings, and treatment RESULTS: All patients were symptomatic and complained of chronic cough(25), sputum(20), fever(16), dyspnea(3), vomiting(2), and foreign body in the bronchus(2). Most of the patients had recurrent pneumonia: 6 patients had Mycoplasma pneumonia, and 6 patients had ashma and allergic disorders. Only 5 out of the 25 patients showed sufficient obstruction on bronchography and 6 patients took computed tomography scans. Chest radiography, bronchography and computed tomography scans were evaluated for review in 25 patients showing consolidation(17), patchy infiltration(14), atelectasis(12), hyperinflation(5), bronchiectasis(2), and air bronchogram(2). Most patients were improved by conservative medical management and only 2 patients had closed thoracostomy. CONCLUSION: These 25 patients who had been diagnosed as Right middle lobe syndrome were improved after 2 week treatment of antibiotics and conservative management and their prognosis were good during the follow-up period.

A Case of Endobronchial Lipoma causing middle lobe syndrome / 결핵

Although lipomas are common benign tumors in humans, endobronchial lipomas are quitely rare. Up to date, about 60 cases have been reported in the English literature. But endobronchial lipomas causing middle lobe syndrome were only 4 cases. These benign slow-growing tumors generally occur in the proximal portion of the lobar or segmental bronchi and originate from fatty tissue that is normally present in the bronchial tree. Smoking or chronic inflammation may be important in the pathogenesis of these tumors. Bronchoscopy is the definite diagnostic tool but, in general, open thoracotomy is required for diagnosis and treatment. Here, we present a case of endobronchial lipoma, with a review of the literature.

Chest computerized tomographic scan and flexible fiberopticbronchoscopy in the diagnosis of middle lobe syndrome / 결핵

No abstract available.

Síndrome del lóbulo medio secundario a Mycoplasma pneumoniae: presentación de un caso / Middle lobe syndrome secondary to Mycoplasma pneumoniae: report of a case

Se muestra la historia clínica de una paciente ingresada en el Hospital Docente Clinicoquirúrgico "Joaquín Albarrán", la cual presentó en los estudios radiológicos imagen de condensación en la zona correspondiente al lóbulo medio del pulmón derecho, que en los diagnósticos diferenciales obligaba a descartar la presencia de neoplasia. Se informa que los estudios de laboratorio, radiológicos y bacteriológicos demostraron que se trataba de una atelectasia ocasionada por un tapón mucoso localizado en el bronquiotronco derecho y casi junto a la carina, que resultó secundario a la presencia de Mycoplasma pneumoniae, lo que constituyó un cuadro clínico de neumonía atípica primaria