Pulmonary Mass in a Neonate

1
Pulmonary Mass in a Neonate

• Filomena Hazel R. Villa, MD
• PL 1- Pediatrics

2
Objective

• To present a case of a neonate with pulmonary
  mass, its management and differential diagnoses

3
History

• Boy M, 5 hours old
• Born term (40 weeks), LGA (3732 g)
• 21 y/o G1P1
• Prenatal History unremarkable
• Natal History Born at CDN
• SROM - clear amniotic fluid, unknown amount
• NSVD, vertex presentation, APGAR 9,9

4
History

• 2nd hour feeding was started, vomiting,
  tachypnea
• 5th hour of life persistence of tachypnea
• Transferred to Thomason via EMS

5
Physical Examination

• VS T- 99.4 HR- 140 RR-89
  
• BP - 57/33 (MAP 43-47) O2 Sat 82-92
• Alert, and active
• No icterus, no rashes
• Open flat fontanelle
• Eyes, normal shape and size with equal red reflex

6
Physical Examination

• Ears normally set, no gross anomalies
• Nose nares are patent, intact palate
• Lungs and Chest anteriorly - clear and equal
  breath sounds posteriorly - slightly decreased
  breath sounds on the left hemithorax, ICS
  retractions, mild tachypnea

7
Physical Examination

• Chest normal rate and rhythm, pulses equal on
  all extremities, no murmur
• Abdomen umbilical stump clean, with 3 vessels,
  soft, non tender, no organomegaly, no masses,
  normal bowel sounds
• Genitalia normal male genitalia

8
Physical Examination

• Back and spine no gross defects
• Limbs and hips no hip clicks, 10 fingers and
  toes, symmetric movements, capillary refill lt 3
  seconds
• Neurologic normal suck, tone, grasp, cry, Moro,
  root

9
Assessment and Plan

• Term male infant
• Suspected sepsis secondary to respiratory
  distress and desaturations
• TTN vs Pneumonia
• Plan Sepsis work up, CXR
• NPO, Isolette, Oxygen
• Ampicillin and Gentamicin

10
Course in the NICU

• Initial CXR density in the left retrocardiac
  area
• Unlikely pneumonia or atelectasis
• Differential diagnoses
• Intra or Extra lobar sequestration
• Mediastinal neuroblastoma
• Broncho foregut malformation
• Neuroenteric malformation
• Intrathoracic kidneys

11
(No Transcript)
12
Course in the NICU

• Case discussed with Radiologist
• CT scan of the thorax
• Ultrasound of abdomen and thorax
• Echocardiogram normal

13
Course in the NICU

• CT scan of the thorax
• Soft tissue mass with no calcifications
• No diaphragmatic eventration, no evidence of
  hernia
• Differentials Teratoma, Neuroblastoma

14
(No Transcript)
15
(No Transcript)
16
Course in the NICU

• Sonogram of the abdomen normal gas pattern,
  liver pancreas and kidneys-within the cavity
• Sonogram of the thorax
• Left hemithorax mass
• Arterial supply from the aorta
• Vein drainage-origin not established
• Consider Extralobar Sequestration

17
(No Transcript)
18
(No Transcript)
19
Course in the NICU

• 4th hospital day referral to pediatric surgery
• Images were reviewed
• Plan removal of the pulmonary mass

20
Course in the NICU

• 5th hospital day Surgery (Thoracotomy)
• Intra-op findings
• Pulmonary sequestrum
• Arterial aspect supplying the mass emerges from
  the thoracic aorta
• Venous drainage into the intercostal vein
• Resection of pulmonary sequestration

21
(No Transcript)
22
Chext X-ray Post-op
23
(No Transcript)
24
Post- operative Course

• Uncomplicated recovery
• Patient was discharged on 6th post-op day

25
(No Transcript)
26
(No Transcript)
27
Pathological Findings

• It consists of a 6.5 x 4.5 x 3.0 cm lower lobe of
  lung tissue. It has an attached purple tan cystic
  structure filled with hemorrhagic serous fluid
  and air. This cystic structure measures 1.5 cm in
  greatest diameter.
• Diagnosis pulmonary sequestration with minimal
  interstitial lymphocytic inflammation dilated
  congested blood vessels and focal parenchymal
  hemorrhage.

28
Differential diagnoses

• Pneumonia
• Diaphragmatic hernia
• Teratoma
• Neuroblastoma
• CCAM

29
Extralobar Pulmonary Sequestration

• Non-functioning lung tissue
• Aberrant blood supply- systemic circulation
• Has its own pleura
• Associated with other anomalies
• Congenital

30
Extra vs Intralobar

• INTRALOBAR
• Acquired/ congenital
• Systemic blood supply
• Pulmonary venous drainage
• Pleura shared with adjacent normal lung

• EXTRALOBAR
• Congenital
• Systemic blood supply
• Systemic venous drainage
• Own pleura

31
Extra vs Intralobar
32
Epidemiology

• Incidence 0.15-1.7
• 15-25- extralobar
• 75-85- intralobar
• 41 male to female
• 60- first 6 months of life

33
Embryology
34
Prenatal Diagnosis and Treatment

• No hydrops- follow closely with ultrasound
• With hydrops- thoracoamniotic shunt
• Postnatally- resection

35
Diagnosis

• Plain x-ray- triangular or oval shape opacity
• CT- cystic component
• Color Doppler ultrasound- anomalous vessels
• MRI- venous drainage

36
Treatment

• Surgical resection
• Thoracoscopy
• Arterial embolization

37
Complications

• Hemorrhage
• Empyema
• Hemothorax
• Hemoperitoneum
• Air leak
• Bronchopleural fistula

• Wound infection
• Atelectasis
• Infections
• Secretions management
• Respiratory failure

38
Prognosis

• With hydrops fetalis- dismal
• Without hydrops - excellent

39

• Baby boy M is presently being followed in our
  high risk clinic, growing and developing without
  significant pulmonary residuals.