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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 197-199

Lung cyst in a toddler: Congenital or infective?


Department of Pediatrics, JSS University, JSS Medical College and Hospital, Mysore, Karnataka, India

Date of Web Publication25-Oct-2013

Correspondence Address:
N Rashmi
Department of Pediatrics, JSS University, JSS Medical College and Hospital, Ramanuja Road, Agrahara, Mysore 570 009, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.120589

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  Abstract 

Cysts and cavities are commonly encountered lesions in the lung on chest radiography and chest computed tomography. They are usually of congenital origin in children. Common causes of acquired lung cysts during childhood include necrotizing pneumonias, trauma, cystic fibrosis and kerosene poisoning. We report here a toddler who presented with bronchopneumonia, was treated for the same, then found to have a left lower lobar lung cyst, which disappeared after 2 months with appropriate conservative management.

Keywords: Acquired, conservative management, lung cyst


How to cite this article:
Mahendrappa KB, Rashmi N, Mamatha S, Bandaru K. Lung cyst in a toddler: Congenital or infective? . Int J Health Allied Sci 2013;2:197-9

How to cite this URL:
Mahendrappa KB, Rashmi N, Mamatha S, Bandaru K. Lung cyst in a toddler: Congenital or infective? . Int J Health Allied Sci [serial online] 2013 [cited 2019 Sep 16];2:197-9. Available from: http://www.ijhas.in/text.asp?2013/2/3/197/120589


  Introduction Top


Lung cysts are the air spaces lined by epithelia and may be congenital or acquired. The differential diagnosis of these lesions is broad as many different processes of acquired or congenital origin can cause these abnormalities. The common congenital causes for cysts in lung diseases include central and peripheral bronchogenic cysts, intra-lobar pulmonary sequestrations, congenital cystic bronchiectasis, cystic adenomatoid malformation of lung and tracheobronchial papillomatosis. [1],[2] Acquired causes of cystic lung lesions include acute and persistent pulmonary interstitial emphysema, post-infarction peripheral cysts, post-infectious pulmonary cysts and the cystic form of pleuropulmonary blastoma. Asymptomatic cysts present a therapeutic dilemma: Surgical intervention or "conservative" observation. Hence, treatment of each case has to be individualized.


  Case Report Top


A male child aged 1-year and 4-month presented with a history of fever and cough since 6 days and hurried respiration since 1 day. There was no history of stridor or grunting. Child was apparently normal until the onset of this illness. He was born to a non-consanguineously married couple, with an uneventful birth history, with normal development and immunized to date. There was no history of similar illness in the past or any other illness requiring hospitalization. There was no contact history of tuberculosis. On examination, he was conscious, oriented, febrile, with a heart rate of 120/min, respiratory rate of 54/min, temperature of 102°F. There was pallor, but no icterus or cyanosis or lymphadenopathy. His anthropometric parameters corresponded to fifth centile on the National Center for Health Statistics growth charts. Respiratory system examination revealed tachypnea with intercostal and subcostal recessions and bilateral crackles and wheeze in all the lung areas. Examination of other systems was unremarkable. His initial investigations revealed microcytic hypochromic anemia with thrombocytosis, neutrophilic leukocytosis and an elevated erythrocyte sedimentation rate. Chest X-ray showed bilateral non-homogenous opacities, more intensely on the left lower lung zones. He was started on broad spectrum intravenous antibiotics with other supportive care. He started clinically responding after 2 days of treatment, with no respiratory distress and was afebrile later. The repeat chest X-ray after 7 days of antibiotic showed resolution of pneumonia, but presence of a ring lesion in the left lower lobe [Figure 1]a. Child was asymptomatic however and it was thought to be an incidentally detected congenital cyst. Hence, a high resolution computed tomography (HRCT) thorax [Figure 2]a was done, which clearly demonstrated a small thin walled (3.5 mm) irregular cystic lesion involving the lateral basal segments of left lower lobe with a thin adjacent pleural effusion. These features were most probably suggestive of an infective process. Hence, child was continued on an appropriate anti-staphylococcal antibiotic for another 14 days (total antibiotic duration of 21 days). On follow-up after 2 months, the repeat chest X-ray and HRCT thorax [Figure 1]b and [Figure 2]b, both showed complete resolution of the cyst. Hence, it was retrospectively concluded that it was an infective cyst and not a congenital one and hence surgery could be avoided.
Figure 1: (a) The left lung cyst (arrow), (b) cyst's disappearance after conservative management

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Figure 2: (a) High resolution computed tomography thorax showing the cyst (arrow), (b) cyst's subsequent disappearance

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  Discussion Top


Cysts and cavities are seen as foci of decreased lung density with definable walls. [3] The term cyst is means a clearly defined air containing space surrounded by a relatively thin (≤4 mm) wall. In contrast, the term cavity refers to an air-containing lesion with a relatively thick (>4 mm) wall or within an area of a surrounding infiltrate or mass. [4],[5] Pulmonary cysts may occur as an isolated abnormality, but may also be present in a multifocal distribution or even involve the lung parenchyma diffusely.

They are the air spaces lined by epithelia, which usually have the characteristics of bronchial epithelia. A variety of lung diseases can cause or mimic thin-walled air-containing cysts in the lung [Table 1]. They may be congenital or acquired as in conditions such as histiocytosis-X, bullous emphysema, pneumatocoeles and post-infectious states. Some of the common infectious causes of lung cysts include bacteria such as Staphylococcus aureus, Gram-negative bacteria, pneumococcus, mycobacteria and anaerobes, fungi such as histoplasmosis, coccidiodomycosis, pneumocystis carinii, cryptococcosis and parasitic infestations like hydatid disease. In child presented here, S. aureus infection seems to be the most likely cause of the cyst as it disappeared with the appropriate antibiotic treatment given for an adequate duration.
Table 1: Imaging clues to help differentiate pulmonary cysts and other lesions mimicking them


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Lack of mural inflammation and presence of cartilaginous element is a discriminating feature between congenital and acquired cysts but recurring infections lead to chronic inflammation with destruction of cartilage, making it impossible to differentiate between the congenital and the acquired variety of cysts in most cases. [6]

The duration of lung cysts in childhood is very variable. Many last only a few days or weeks.

Others appear thick-walled, yet a bout of infection produces complete resolution. Some persist unchanged through several bouts of infection and show little inclination to clear. When a large cyst is found in a child who has a history of pulmonary infection, it is probable that the cyst was caused by bronchial inflammation and obstruction. Cases are, however, seen without any history of an acute fever or chest disease, which may have initiated the cysts. [7] A correct diagnosis can be made by using a multi-disciplinary approach taking into account the patient's clinical history, physical examination and the radiologic appearance; certain clinical and radiographic features may eliminate the need for surgical lung biopsy. This approach is evident in our case, as conservative treatment was tried before contemplating for surgery.

The chest radiograph is not a sensitive imaging modality for patients with pulmonary cysts, as the discrete cysts are usually not visible through radiography. [8] Chest HRCT scan is the imaging modality of choice both to detect and differentiate among the different causes of cystic lung disease.

Most of the acquired lung cysts are infective in origin and hence respond to conservative treatment with a broad spectrum antibiotics. Rare cases, however, will require excision or aspiration as in case of hydatid cysts. Hence, it is more important to diagnose an acquired etiology for a lung cyst and differentiate it from a congenital one, based on history, clinical and radiological features. This usually avoids an invasive procedure and the resultant morbidity.

 
  References Top

1.Godwin JD, Webb WR, Savoca CJ, Gamsu G, Goodman PC. Multiple, thin-walled cystic lesions of the lung. AJR Am J Roentgenol 1980;135:593-604.  Back to cited text no. 1
    
2.Takeda S, Miyoshi S, Inoue M, Omori K, Okumura M, Yoon HE, et al. Clinical spectrum of congenital cystic disease of the lung in children. Eur J Cardiothorac Surg 1999;15:11-7.  Back to cited text no. 2
    
3.Austin JH, Müller NL, Friedman PJ, Hansell DM, Naidich DP, Remy-Jardin M, et al. Glossary of terms for CT of the lungs: Recommendations of the Nomenclature Committee of the fleischner society. Radiology 1996;200:327-31.  Back to cited text no. 3
    
4.Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: Focal and diffuse. Mayo Clin Proc 2003;78:744-52.  Back to cited text no. 4
    
5.Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246:697-722.  Back to cited text no. 5
    
6.Vishak Acharya K, Anand R. Lung cysts in tuberculosis. Journal, Indian Academy of Clinical Medicine 2004;5:202-4.  Back to cited text no. 6
    
7.Conway DJ. The origin of lung cysts in childhood. Arch Dis Child 1951;26:504-29.  Back to cited text no. 7
    
8.Lee KH, Lee JS, Lynch DA, Song KS, Lim TH. The radiologic differential diagnosis of diffuse lung diseases characterized by multiple cysts or cavities. J Comput Assist Tomogr 2002;26:5-12.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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