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Man with shortness of breath and pulmonary consolidation
  1. Mesut Mutluoglu,
  2. Ruben Vandenbulcke,
  3. Kristof De Smet
  1. Department of Radiologie, AZ Delta Campus Brugsesteenweg, Roeselare, Belgium
  1. Correspondence to Dr Mesut Mutluoglu, AZ Delta Campus Brugsesteenweg, Roeselare, 8800, Belgium; mesut.mutluoglu{at}azdelta.be

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Clinical introduction

A 53-year-old man presented with shortness of breath complicated by intermittent and repetitive attacks of productive cough, fever and haemoptysis. He denies any occupational or environmental exposure and reports the use of two cures of antibiotic treatment 1 month apart without satisfying relief. He also reports a night sleep with the air conditioning open and a medical history of atrial fibrillation treated with radiofrequency ablation 3 months previously. Physical examination was unremarkable. A chest CT in lung window coronal reconstruction (figure 1A) demonstrates an area of consolidation with ground glass in the left upper lobe, and an axial section in mediastinal window provides an additional clue to diagnosis (figure 1B).

Figure 1

(A) Coronal reformatted CT image in lung window showing an area of consolidation with ground glass in the left upper lobe. (B) Axial section CT image in mediastinal window providing an additional clue to diagnosis.

Question

Which is the most likely diagnosis?

  1. Legionella pneumonia

  2. Pulmonary embolism

  3. Pulmonary vein stenosis

  4. Organising pneumonia

For answer see page 02.

For question see page 01.

Answer

The answer is C.

This is a case of pulmonary consolidation secondary to stenosis of the left upper pulmonary vein (PV) (figure 2, arrow) following radiofrequency ablation treatment (RAT). The prevalence of PV stenosis following RAT is around 1.3% in experienced centres and as high as 42.4% in non-experienced centres.1 RAT constitutes the delivery of targeted energy to the left atrial wall immediately outside of the PV and just proximal to the pulmonary venoatrial junction which is a risk factor for developing periadventitial inflammation and/or collagen deposition with resulting fibrosis around the PV.

Figure 2

Axial section CT image in mediastinal window showing stenosis of the left upper pulmonary vein (arrow).

Misdiagnosis is frequent and patients usually receive a diagnosis of pneumonia, or less frequently interstitial lung disease or pulmonary emboli with resulting unnecessary antibiotic treatment or invasive interventions such as bronchoscopy or inferior vena cava filters.2 Delayed diagnosis is, therefore, frequent and the majority of patients develop progression of the stenosis with severe intraparenchymal lung damage. Treatment of choice is PV stenting, which restores optimal venous return and reduces the risk of PV restenosis (online supplemental file 1). The pulmonary consolidation completely resolved, and the symptoms of the patients were successfully relieved following stenting of the stenosed left superior PV.

Supplemental material

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Not applicable.

References

Footnotes

  • Contributors MM and RV contributed to the conception and design of the study. KDS reviewed the manuscript for intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.