A 42-year-old woman with diffuse pulmonary infiltrates and bilateral pneumothoraces

Spontaneous pneumothorax in diffuse cystic lung diseases

PURPOSE OF REVIEW

Diffuse cystic lung diseases (DCLDs) are a heterogeneous group of disorders with varying pathophysiologic mechanisms that are characterized by the presence of air-filled lung cysts. These cysts are prone to rupture, leading to the development of recurrent spontaneous pneumothoraces. In this article, we review the epidemiology, clinical features, and management DCLD-associated spontaneous pneumothorax, with a focus on lymphangioleiomyomatosis, Birt-Hogg-Dubé syndrome, and pulmonary Langerhans cell histiocytosis.

RECENT FINDINGS

DCLDs are responsible for approximately 10% of apparent primary spontaneous pneumothoraces. Computed tomography screening for DCLDs (Birt-Hogg-Dubé syndrome, lymphangioleiomyomatosis, and pulmonary Langerhans cell histiocytosis) following the first spontaneous pneumothorax has recently been shown to be cost-effective and can help facilitate early diagnosis of the underlying disorders. Patients with DCLD-associated spontaneous pneumothorax have a very high rate of recurrence, and thus pleurodesis should be considered following the first episode of spontaneous pneumothorax in these patients, rather than waiting for a recurrent episode. Prior pleurodesis is not a contraindication to future lung transplant.

SUMMARY

Although DCLDs are uncommon, spontaneous pneumothorax is often the sentinel event that provides an opportunity for diagnosis. By understanding the burden and implications of pneumothoraces in DCLDs, clinicians can facilitate early diagnosis and appropriate management of the underlying disorders.

[Multicystic presentation of a lepidic mucinous adenocarcinoma]

INTRODUCTION

The pneumonic form is very characteristic of lepidic pattern adenocarcinoma of the lung. However, the diagnosis and treatment of the disease when it presents in this way may be delayed by atypical radiological findings and severity of hypoxemia.

CASE REPORT

A 48-year-old female, non-smoker, asthmatic since the age of 20 years, was hospitalized for a diffuse infiltrative pneumonia complicated by severe respiratory failure. The history included chronic cough, gradually increasing dyspnoea on exertion lasting for 14 months and the onset of haemoptysis of low abundance associated with arthralgia in the previous month. She had no professional or domestic exposure to any risk factors. Chest CT scan revealed bilateral alveolar condensations, ground glass areas with thickened septa creating a crazy paving pattern, and numerous large cysts of various sizes and locations, often with irregular thin walls. Microbiological and immunological tests were negative. She required early invasive ventilation and then venovenous ECMO together with broad-spectrum empiric antibiotic therapy, but died after 39 days in intensive care. The autopsy revealed lesions consistent with mucinous lepedic adenocarcinoma with no EGFR mutation and KRAS mutation. There was also associated pulmonary suppuration.

CONCLUSION

Mucinous lepidic adenocarcinoma is an alternative diagnosis for pneumonic consolidation associated with multiple cysts.