Extralobar pulmonary sequestration presenting with torsion in an elderly patient: A case report

Abstract

Introduction and importance: Extralobar pulmonary sequestration with torsion is an exceptionally rare condition, especially in adults, and can present with nonspecific symptoms such as abdominal pain, making diagnosis challenging. Timely recognition is critical, as delayed treatment may lead to infarction and serious complications. This report describes the case of a patient with extralobar pulmonary sequestration who presented with abdominal pain.

Case presentation: An 83-year-old healthy female presented with increasing severe abdominal pain and mild fever that had developed for the past three weeks. Chest and abdominal computed tomography revealed a non-enhancing mass in the right posterior paravertebral area, with mild pleural effusion. Video-assisted thoracoscopic surgery to establish a definitive diagnosis revealed a yellow-whitish ovoid mass with congestion and necrosis, accompanied by bloody pleural effusion. The mass was connected to the mediastinum via a twisted feeding vessel. The final diagnosis was consistent with extralobar pulmonary sequestration with torsion and infarction. The patient's symptoms were relieved immediately after surgery.

Clinical discussion: Extralobar pulmonary sequestration with torsion is rare in adults. Abdominal pain is the hallmark symptom of this condition. The lack of contrast enhancement in the lesion with no visible feeding vascular pedicle or pleural effusion is imaging signs of pulmonary sequestration torsion, and surgical resection is the standard treatment.

Conclusion: This case highlights the importance of considering pulmonary sequestration in the differential diagnosis of unexplained abdominal pain with posterior mediastinal masses, underscoring the value of surgical exploration for diagnosis and treatment.

Keywords: Case report; Extralobar pulmonary sequestration; Surgery; Torsion; Video-assisted thoracic surgery.

Fig. 1

Chest roentgenogram showing a high-density mass (red arrows) in the right thoracic cavity with mild pleural effusion. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

Chest computed tomography (CT) findings. (A) A paraspinal mass is visible in the right posterior mediastinum (red arrow), along with pleural effusion (white arrow). (B) Contrast-enhanced scan showing a well-defined, non-enhancing soft tissue mass in the inferior medial right pleural space, as well as mild left pleural effusion. (C) Chest coronal CT image showing a well-defined soft tissue mass (red arrow) between the diaphragm and the spine in the inferior medial right pleural space without a clear feeding vessel. (D) Chest sagittal CT image showing a mass with slight marginal enhancement (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Magnetic resonance imaging findings. T1-weighted sagittal imaging shows a mass with predominantly low signal intensity (red arrows). (C) T2-weighted imaging shows a well-marginated oval mass (red arrows) with mild pleural effusion. (B) Contrast-enhanced T2 weighted coronal image shows a hypointense mass (red arrows) in the inferior medial right pleural space. (D) Contrast-enhanced T2 weighted axial image showing a homogeneous low signal in the mass (red arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4

Intraoperative findings. (A) A yellow-whitish mass (black arrows) attached to the chest wall, diaphragm, and right lower lobe is visible. (B) The mass shows congestion and necrosis (black arrows) above the diaphragm, and also displays visceral pleura. (C-D) A twisted feeding vessel connects the mass to the mediastinum (white arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 5

(A) The resected specimen. The mass measured 4.2 × 3.6 × 1.5 cm. (B) A cut section of the excised lesion showing a dark brown hemorrhagic mass. (C) Histological analysis revealed hemorrhagic and necrotic pulmonary tissue (hematoxylin and eosin staining). (D) The inner region of the necrotic tissue. Cartilage tissues (black arrows) and muscular vessels (red arrows) are evident (hematoxylin and eosin staining). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 6

Chest roentgenogram 1 year after the operation showing no apparent tumor shadow, and pleural effusion.