Giant bulla mimicking massive pneumothorax together with an accessory cardiac bronchus: the interesting case of Mr. F.

C. Caviezel, F. Gambazzi

Objective

A 39-year old male was referred to our division because of pneumothorax on the left side. Personal history was uneventful besides nicotine and cannabis abuse.
He complained about dyspnea on exertion which had been increasing during the last few months. The patients relatively good condition was not adequate for his x-ray which seemed to show a massive pneumothorax on the left side (Figure 1).

Figure 1

Methods

Because of doubts concerning the pneumothorax we performed a CT-scan of the chest where a giant bulla instead of a pneumothorax could be seen (Figure 2 + 3). Because of the almost completely nonviable left lung we decided to proceed with surgery.

Figure 2
Figure 3

Results

We performed video-assisted thoracoscopic surgery (VATS) on the left side and resected the giant bulla. The postoperative course was uneventful and the x-ray showed normal conditions (Figure 4). The patient was discharged the second postoperative day.

Figure 4

Conclusion

In cases where the clinical condition and the x-ray do not fit, bullae instead of a pneumothorax should be suspected. Especially in cases of chronic obstructive lung disease, old ages or young ages with massive nicotine or cannabis abuse there is a higher incidence of bullous disease.

Sometimes bullae can easily be differentiated from pneumothorax, sometimes they mimick one. In the latter case patients often suffer from unnecessary tube thoracostomy. In doubtful situations the treating physician should consider seeking advice from a thoracic surgeon or pulmonologist.

Giant bullae shoud be resected, preferably with minimal-invasive surgery (VATS).

As a secondary finding our patient showed a so called "accessory cardiac bronchus" (Figure 3). This anomalous bronchus arises from the medial wall of the bronchus intermedius, most often just distal to the level and opposite to the orifice of the right upper lobe. It is found in 0.09% to 0.5% of the general population. It may be only a blind stump like in our case or it has a number of rudimentary or nearly normal branches associated with lung parenchyma. Mostly the anomalous bronchus is asymptomatic but may give rise to symptoms like hemoptysis as the result of infection.