Bilateral intralobar pulmonary sequestration with horseshoe lung.

We present an unusual case of a young woman with a several-month history of bronchopulmonary infection, symptomatic on the left side, who underwent complete studies showing bilateral pulmonary sequestration with suspected bridging tunnel. A bilateral resection was performed as a single procedure through a left thoracotomy.

Exsanguinating hemoptysis.

Massive hemoptysis (600 ml in 24 hours) results in a mortality of more than 50%. We have performed 74 pulmonary resections in patients with massive hemoptysis in the last 15 years, with a mortality of 13%. The mortality correlated with the rate and the amount of recorded blood loss before the operation. From this experience, we have identified a subgroup of patients with such massive hemoptysis that life was threatened by exsanguination. Twenty-four of our patients lost more than 1,000 ml of blood, at a rate of at least 150 ml an hour, before the pulmonary resection was performed. The bleeding site was always identified by bronchoscopy. All patients were treated by resection of the bleeding lung parenchyma. Several methods were used to avoid the patient's drowning in his own blood during the operation. In five patients, a double-lumen endotracheal tube was used: Two died of suffocation during the procedure and another died of respiratory and liver failure. In four patients, single-lung ventilation with an endotracheal tube in the left main bronchus was used: All four survived. In another 10 patients a bronchial blocker (No. 9 Fogarty balloon venous catheter) was used to stop bleeding. Two patients died of renal failure and gastrointestinal bleeding, respectively, but none had aspiration problems. In five additional patients, a regular endotracheal tube was used: One patient died of massive aspiration. Our experience indicates that bleeding from the left lung and right lower lobe should be controlled by intubation of the left bronchus. Patients with exsanguinating hemoptysis should be treated, when possible, by pulmonary resection. A survival rate of 75% was obtained in our patients.

Treatment of Candida endocarditis and arteritis.

A patient suffering from Candida endocarditis presented with a gangrenous foot. In addition to arterial embolism, occult mycotic aneurysms were found by arteriography. Clinical cure was achieved with a combination of chemotherapy and valvular débridement, but viable Candida persisted in an easily removable embolus. Occult peripheral vascular lesions may be a continuing source of Candida sepsis in some patients.