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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 60-63

Subsegmental consolidation masquerading as extralobar bronchopulmonary sequestration presenting as pyrexia of unknown origin


Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission03-May-2017
Date of Acceptance20-May-2017
Date of Web Publication12-Jul-2017

Correspondence Address:
Nayyar Iqbal
Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_18_17

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  Abstract 

Acinetobacter baumannii infection is common among inpatients and is a major cause of hospital-acquired or ventilator-associated pneumonia. It is rare for this pathogen to cause community-acquired pneumonia. Eighty percent of the patients with community-acquired Acinetobacter present with lobar consolidation. Bronchopulmonary sequestration is a rare congenital disorder with incidence of 1 in 10,000–35,000 live births. Intralobar sequestration is more common than extralobar. Affected individual generally presents with respiratory distress at an early age. Late manifestation with the lower respiratory tract infection has also been reported. We report an interesting case of subsegmental consolidation masquerading as extralobar sequestration of the lung in an adult who presented with pyrexia of unknown origin.

Keywords: Community-acquired Acinetobacter, extralobar bronchopulmonary sequestration, pyrexia of unknown origin, subsegmental consolidation


How to cite this article:
Riyazuddeen M, Mookkappan S, Iqbal N. Subsegmental consolidation masquerading as extralobar bronchopulmonary sequestration presenting as pyrexia of unknown origin. J Curr Res Sci Med 2017;3:60-3

How to cite this URL:
Riyazuddeen M, Mookkappan S, Iqbal N. Subsegmental consolidation masquerading as extralobar bronchopulmonary sequestration presenting as pyrexia of unknown origin. J Curr Res Sci Med [serial online] 2017 [cited 2020 Nov 24];3:60-3. Available from: https://www.jcrsmed.org/text.asp?2017/3/1/60/210340


  Introduction Top


Community-acquired pneumonia (CAP) is one of the most common cause of life-threatening infections and a major cause of mortality among elderly and in individuals with chronic diseases. Streptococcus pneumoniae is the most common causative agent followed by Gram-negative bacilli and Mycoplasma pneumoniae. Among Gram-negative bacilli, Klebsiella pneumoniae is frequently found in sputum culture.[1]Acinetobacter baumannii is common etiological agent among nosocomial infections. Community-acquired Acinetobacter pneumonia is rare but has been reported from Asia and Australia.[2] Lobar consolidation is common in CAP. Subsegmental consolidation is a rather rare presentation of CAP. Sequestration of the lung is a rare congenital anomaly of the lower respiratory tract. The incidence is 1 in 10,000–35,000 live births reported worldwide. It is the pathoembryologic remnant of diverticular outgrowth of the esophagus. It is nonfunctioning lung tissue without any connection with main tracheobronchial tree and it has separate arterial supply.[3] The 75%–90% of sequestrations are intralobar and rest is extralobar.[4] We report an interesting case of subsegmental consolidation masquerading as bronchopulmonary sequestration and presenting as pyrexia of unknown origin (PUO).


  Case Report Top


An 18-year-old male presented with the history of fever for the past 3 weeks with chills and dry cough with no history of breathlessness or chest pain. Fever was continuous and high-grade which subsided with tablet paracetamol. He was treated with oral antibiotics by private practitioner but symptom persisted; hence, he was admitted in our hospital.

He had history of similar episode 2 years ago for which he was treated with antibiotics and recovered. On examination, the patient was febrile with 101°F, blood pressure-110/70 mmHg, pulse-110 beats/min, respiratory rate-20 breaths/min, and SpO2 at room air was 98%. There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy, and edema. Respiratory system examination revealed decreased breath sound in the left infrascapular area. Other systemic examinations were within normal limits. On the basis of history and physical examination, the patient was admitted with a provisional diagnosis of pulmonary or extrapulmonary tuberculosis or lymphoma.

On investigation, his complete blood count showed leukocytosis with increased neutrophils [Table 1]. His blood and urine culture showed no growth. Two-dimensional echocardiography and chest X-ray were also within normal limits [Figure 1]. Since patient had continuous fever and dry cough, he was taken up for computed tomography (CT) scan of the thorax which showed a mass in posterior segment of the left lower lobe [Figure 2]. Further, his bronchoscopy was done which showed normal airways without any intraluminal lesions. His bronchoalveolar lavage (BAL) fluid analysis was negative for Gene Xpert or atypical cells. BAL fluid culture was also negative. Hence, provisional diagnosis of infected bronchopulmonary sequestration was made. His CT-guided biopsy of affected lung showed few inflammatory cells and areas of necrosis [Figure 3]. Later, tissue biopsy showed growth of Acinetobacter baumanii sensitive to injection ceftriaxone and amikacin. He was initially treated with intravenous ceftriaxone 1 g twice daily. In view of nonresolution of symptoms, injection amikacin 500 mg once daily was added. He responded to the treatment and was discharged after 2 weeks of antibiotics. He was later planned for CT angiography and excision of sequestered lung. On follow-up, his contrast-enhanced CT scan (CECT) showed complete resolution of pneumonia without aberrant blood supply to the affected area of the lung [Figure 4].
Table 1: Result of investigations

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Figure 1: Chest X-ray

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Figure 2: Computed tomography scan showing area of sequestered lung in the left lower lobe

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Figure 3: Histopathological slide of lung tissue showing area of necrosis

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Figure 4: Review computed tomography scan thorax shows resolved consolidation (arrow)

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  Discussion Top


Sequestration is the aberrant formation of segmental lung tissue that has no connection with the bronchial tree. It is of two types - extralobar and intralobar. It has 0.1% of incidence and predominantly occurs in males (male:female ratio = 4:1).[2] Extralobar sequestration usually has its own visceral pleura and arterial supply. It usually occurs between the left lower lobe and hemidiaphragm.[5],[6] Extralobar sequestrations are most commonly found in the left thorax although 10%–15% can be found in the abdomen. Males are predominantly affected by sequestration of the lung. Hemoptysis, fever, and dry cough are common clinical manifestations.[7]

Subsegmental consolidation also has similar complaints of fever and dry cough. Subsegmental atelectasis is another differential diagnosis. The etiological factor associated with subsegmental atelectasis is pulmonary embolism, foreign body, tumor, mucus plug, etc.

In our case, the patient presented with fever for more than 3 weeks and classified as PUO according to Petersdorf and Beeson definition of PUO.[8] Infections are the most common cause of PUO worldwide followed by collagen vascular diseases and malignancy.[9] Among infections, extrapulmonary tuberculosis, abdominal abscess, infective endocarditis, osteomyelitis, fungal, enteric fever, and kala azar generally present as PUO. Adult-onset Still's disease presenting as PUO is more common among connective tissue disorders. In our patient, only localizing sign was dry cough; hence, extrapulmonary tuberculosis and lymphoma were provisional diagnosis. In the most cases of infection-associated PUO, histological tissue culture helps in diagnosis.[9] In our case, also the diagnosis was reached after the tissue culture.

Diagnosis of pulmonary sequestration requires demonstration of abnormal artery feeding the sequestered segment. Spiral CT of the chest and magnetic resonance imaging are the key diagnostic tools.[10] The most common CT scan findings described in the literature are consolidation or soft tissue opacity, bronchiectasis, and cystic or cavitary lesion. In our case, the patient had consolidation in the left lower lobe. Bronchoscopy is generally normal in case of extralobar sequestration of the lung even in the patients with complications such as hemoptysis.[11] In our case, bronchoscopy along with BAL fluid analysis was normal, suggests that the affected area of the lung was subsegmental.

In recent literature, Polymyxin B or colistin is the mainstay of the treatment of nosocomial Acinetobacter pneumonia.[2] In a study from Northern Australia, it was found that all the isolates of Acinetobacter from CAP were sensitive to aminoglycosides and resistant to the 3rd generation cephalosporins.[12] Although, in our case, Acinetobacter was sensitive to both ceftriaxone and amikacin, patient only responded when injection amikacin was added to injection ceftriaxone. Treatment of bronchopulmonary sequestration is excision of the sequestered segment which was avoided with subsequent CECT thorax in this case.


  Conclusion Top


Subsegmental consolidation, especially of the left lower lobe, may mimic bronchopulmonary sequestration. Normal chest X-ray does not exclude the possibility of respiratory tract infection. Early intervention with CT scan and CT-guided biopsy of the affected segment may help in reaching the diagnosis early. Follow-up CECT scan may help to differentiate these two conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Peto L, Nadjm B, Horby P, Ngan TT, van Doorn R, Van Kinh N, et al. The bacterial aetiology of adult community-acquired pneumonia in Asia: A systematic review. Trans R Soc Trop Med Hyg 2014;108:326-37.  Back to cited text no. 1
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2.
Hartzell JD, Kim AS, Kortepeter MG, Moran KA. Acinetobacter pneumonia: A review. MedGenMed 2007;9:4.  Back to cited text no. 2
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3.
Durell J, Thakkar H, Gould S, Fowler D, Lakhoo K. Pathology of asymptomatic, prenatally diagnosed cystic lung malformations. J Pediatr Surg 2016;51:231-5.  Back to cited text no. 3
[PUBMED]    
4.
Van Raemdonck D, De Boeck K, Devlieger H, Demedts M, Moerman P, Coosemans W, et al. Pulmonary sequestration: A comparison between pediatric and adult patients. Eur J Cardiothorac Surg 2001;19:388-95.  Back to cited text no. 4
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5.
Polaczek M, Baranska I, Szolkowska M, Zych J, Rudzinski P, Szopinski J, et al. Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration. J Thorac Dis 2017;9:762-7.  Back to cited text no. 5
    
6.
Sun X, Xiao Y. Pulmonary sequestration in adult patients: A retrospective study. Eur J Cardiothorac Surg 2015;48:279-82.  Back to cited text no. 6
[PUBMED]    
7.
Gompelmann D, Eberhardt R, Heussel CP, Hoffmann H, Dienemann H, Schuhmann M, et al. Lung sequestration: A rare cause for pulmonary symptoms in adulthood. Respiration 2011;82:445-50.  Back to cited text no. 7
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8.
Petersdorf RG, Beeson PB. Fever of unexplained origin: Report on 100 cases. Medicine (Baltimore) 1961;40:1-30.  Back to cited text no. 8
    
9.
Bandyopadhyay D, Bandyopadhyay R, Paul R, Roy D. Etiological study of fever of unknown origin in patients admitted to medicine ward of a teaching hospital of Eastern India. J Glob Infect Dis 2011;3:329-33.  Back to cited text no. 9
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10.
Naffaa L, Tank J, Ali S, Ong C. Bronchopulmonary sequestration in a 60 year old man. J Radiol Case Rep 2014;8:32-9.  Back to cited text no. 10
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11.
Gezer S, Tastepe I, Sirmali M, Findik G, Türüt H, Kaya S, et al. Pulmonary sequestration: A single-institutional series composed of 27 cases. J Thorac Cardiovasc Surg 2007;133:955-9.  Back to cited text no. 11
    
12.
Anstey NM, Currie BJ, Withnall KM. Community-acquired Acinetobacter pneumonia in the Northern Territory of Australia. Clin Infect Dis 1992;14:83-91.  Back to cited text no. 12
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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