Purpose or Case Report: Demonstrate a rare cause of respiratory distress in a full-term newborn to illustrate the importance of chest radiography (CXR) in guiding the work up.
Methods & Materials: The patient’s electronic medical record was reviewed including clinical notes, diagnostic imaging, treatment, and surgical pathology. Diagnostic imaging studies reviewed include CXR, CT and MRI.
Results: Full term newborn presents with delayed crying and subsequent respiratory distress. (CXR): hyperinflated left lung with normal vascularity, rightward shift of the mediastinum and atelectasis of the right lung. Chest CT: right lung atelectasis, hyperexpanded left lung, severe narrowing left bronchus, and mediastinal shift. Patient continued with respiratory failure and was transferred to our institution with the diagnosis of distal tracheal and bronchial stenosis with a hypoplastic right lung.
Bronchoscopy: 90% occlusion of the left main bronchus by a blueish, pulsatile structure. Subsequent review of outside CT showed no vascular abnormality or external compression in this area, but a low attenuation area was noted near the carina. Chest MRI: well-circumscribed, T2 bright lesion abutting the carina, main stem bronchi, narrowing the left. The lesion was dark on T1, showed no arterial, venous or delayed enhancement. Bronchogenic cyst was the main diagnostic consideration. After excision, flexible bronchoscopy, showed mild narrowing but no obstruction of the left bronchus. The patient was extubated but required airway support for several days before discharge on room air.
Conclusions: Respiratory distress in a newborn is a common perinatal symptom resulting in a CXR to aid in the differential diagnosis. In this case the CXR showed a hyperexpanded left lung with normal vascularity. Causes for this appearance are limited: Small contralateral lung from hypoplasia or atelectasis, or hyper-inflated lung from air trapping. Bronchoscopy demonstrated compression of the left bronchus by a lesion which was further delineated by MRI as a bronchogenic cyst resulting in a ball valve effect. This was likely present in utero, leading to hyperexpansion of the left lung and extrinsic compression of the right lung which may be hypoplastic.
A bronchogenic cyst is a bud of normal embryonal tissue, which is separated from the ventral foregut. Bronchogenic cysts are a relatively common incidental finding and is usually seen in the mediastinum or hilum, near the airways. There are few reports in the literature of airway obstruction due to a bronchogenic cyst.