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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 70-71  

Incidental finding of pulmonary lymphangitis carcinomatosa in a patient of chest trauma


1 Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
2 Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, India
3 Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Sofia Jaswal
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_581_18

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How to cite this article:
Ahuja V, Jaswal S, Aggarwal D, Kaur H. Incidental finding of pulmonary lymphangitis carcinomatosa in a patient of chest trauma. Indian J Anaesth 2019;63:70-1

How to cite this URL:
Ahuja V, Jaswal S, Aggarwal D, Kaur H. Incidental finding of pulmonary lymphangitis carcinomatosa in a patient of chest trauma. Indian J Anaesth [serial online] 2019 [cited 2019 Jan 20];63:70-1. Available from: http://www.ijaweb.org/text.asp?2019/63/1/70/249787



Sir,

Delayed complications of blunt chest trauma often occur up to 2 weeks after discharge from the emergency department in upto 10% of patients, but there are case reports of patients presenting even after 4 weeks.[1],[2] The incidence of delayed haemothorax in blunt chest trauma ranges from 5.0% to 7.4%.[1]

Recently, a 45-year-old male patient, a chronic smoker, was referred to our hospital for management of chest pain and progressively increasing respiratory distress following blunt chest trauma 3 months back. Past history revealed that patient had two prior admissions in a local hospital before presenting to our hospital. A high-resolution computed tomography (HRCT) showed bilateral hydropneumothorax with multiple rib fractures. The patient was shifted to intensive care unit (ICU) with signs of respiratory failure. He was managed as a sequela of blunt chest trauma with bilateral chest tubes in situ, intermittent non-invasive ventilation (NIV), antibiotics, adequate analgesia and supportive management. Subsequently, chest tubes were removed after confirming minimal fluid on ultrasound chest, but dyspnoea still persisted. Repeat HRCT chest reported infective pathology (atypical pneumonia) and lesions in the apical segment of right upper lobe consistent with lymphangitis carcinomatosa [Figure 1], which needed further evaluation. During the stay of patient in ICU, arterial blood gases reported persistently high pCO2 with mild hypoxia. Patient was also then managed as a case of acute exacerbation of COPD with type 2 respiratory failure. A short course of oral steroid was started as a management of COPD. There was 20–30% improvement in dyspnoea and patient required NIV 3–4 hours/day. Echocardiography done later was found to be within normal values. Subsequently, a repeat contrast-enhanced computed tomography (CECT) lung done 2 weeks later showed a spiculated nodule in upper part of right lower lobe, multiple sclerotic lesions in vertebral body of D1 and sternum, and a lytic lesion in D11 (with pedicles) in bone window. Ultrasound abdomen showed hepatomegaly with multiple space-occupying lesions in both lobes of the liver, likely to be metastasis. Fine-needle aspiration cytology of space occupying lesion in liver reported adenocarcinoma metastasis. Chemotherapy could not be started due to poor general condition of patient. Subsequently, patient expired after 10 days of diagnosis of occult primary malignancy with pulmonary lymphangitis carcinomatosa (PLC) and liver metastasis.
Figure 1: High resolution computed tomography showing ground glass appearance with septal thickening, peribronchovascular thickening and prominence of centrilobular interstitium suggestive of pulmonary lymphangitis carcinomatosa

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In 1873, Troisier introduced the term PLC to describe diffuse infiltration of the lymphatics of bilateral lungs by malignant cells.[3] This condition is seen more commonly in younger population and affects males more than females (60:40).[3] Around 30–40% of patients with malignant disease have intra-thoracic metastasis and among those only 6–8% develop PLC.[3],[4] It may be the only manifestation of an occult malignancy.[3] PLC is a metastatic lung disease which may precede or obscure or dominate any local symptoms and present as a diagnostic problem in dyspnoea.[3] This patient was initially managed as a sequela of blunt chest trauma. But even after managing blunt chest trauma, COPD and sepsis, patient progressively deteriorated with increasing respiratory distress. Radiological picture in CECT showed nodular thickening of interlobular septa and peribronchovascular interstitium, and ground-glass appearance with septal thickening suggestive of PLC.

The primary tumours commonly associated with PLC are breast (33%), stomach (29%), lungs (17%), pancreas (4%) and prostate (3%).[4],[5] Sometimes, chest X-ray is normal in 30–50% cases.[5] It can even mimic sarcoidosis radiologically. The differentiating features of sarcoidosis are presence of nodular thickening and ground-glass attenuation mainly involving the central regions of the middle and upper lobes of the lungs.[5] The diagnosis of noncaseating granuloma in sarcoidosis should be confirmed by biopsy. However, rapid deterioration of patient's dyspnoea, predominant disease in the lower lobes of the lungs and lack of response to steroids within 2–4 weeks also should alert clinicians in favour of PLC.[5] The preferred diagnostic procedure for PLC is lung biopsy (transbronchial or open).[4]

In this patient, the clinical presentation of PLC became evident only after chest trauma and was an incidental finding. Although PLC is rare, it should be included as a differential diagnosis in a young male patient with progressively increasing respiratory failure.

Informed consent

Written informed consent is obtained from the patient for publication of radiological image in this scientific journal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yamamoto N, Sakakibara M, Murakami M, Sakaguchi K. Delayed hemothorax after conservative treatment of sternal fracture. Gen Med 2011;12:85-8.  Back to cited text no. 1
    
2.
Sato N, Sekiguchi H, Hirose Y, Yoshida S. Delayed chest wall hematoma caused by progressive displacement of rib fracture after blunt trauma. Trauma Case Reports 2016;4:1-4.  Back to cited text no. 2
    
3.
Raja A, Seshadri RA, Sundersingh S. Lymphangitis carcinomatosa: Report of a case and review of literature. Indian J Surg Oncol 2010;1:274-6.  Back to cited text no. 3
    
4.
Gilchrist FJ, Alton H, Brundler MA, Edward L, Plunkett A, Rao S. Pulmonary Lymphangitic carcinomatosis presenting as severe interstitial lung disease in a 15-year-old female. Eur Respir Rev 2011;20:208-12.  Back to cited text no. 4
    
5.
Thomas A, Lenox R. Pulmonary lymphangitic carcinomatosis as a primary manifestation of colon cancer in a young adult. Can Med Assoc J 2008;179:338-40.  Back to cited text no. 5
    


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