Scientific Letter
Spontaneous Regression of Pulmonary Emphysematous Bulla
Regresión espontánea de una bulla enfisematosa pulmonar
Cristina Benito Bernáldez
, Virginia Almadana Pacheco
Corresponding author
Servicio de Neumología, Hospital Universitario Virgen Macarena, Sevilla, Spain
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They can appear in normal pulmonary parenchyma, or more commonly, in the context of generalized emphysema. The natural course of pulmonary bullae is characterized by progressive growth, but it is not uncommon for them to present long periods of stability. In contrast, spontaneous regression is unusual.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 55-year-old man, former smoker of 50 pack-years who gave up 16 years previously, who attended our hospital in June 2012 with cough, daily expectoration, and dyspnea MRC grade 1, with no significant exacerbations. Lung function tests showed a moderate obstructive pattern, with a forced vital capacity (FVC) of 4890<span class="elsevierStyleHsp" style=""></span>cc (106%), forced expiratory volume in 1 second (FEV1) of 2740<span class="elsevierStyleHsp" style=""></span>cc (74%), FEV1/FVC ratio of 56% and normal carbon monoxide diffusion (DLCO). Computed tomography (CT) revealed severe bilateral mixed centrilobular and paraseptal pulmonary emphysema, primarily involving the upper lobes, containing frank areas of pulmonary parenchymal destruction and a large paraseptal emphysematous bulla in the anterior segment of the right upper lobe (RUL), longest diameter 9<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Given these findings and persisting symptoms, surgical bullectomy was proposed, which the patient refused.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In November 2015, a follow-up chest CT was performed, which revealed a nodular image with slightly spiculated margins in the paramediastinal region of the RUL, in close contact with the fat of the anterior line of pleural reflection, measuring 18<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>mm in the anteroposterior and transversal diameter on the axial plane, and 4<span class="elsevierStyleHsp" style=""></span>cm in length on the sagittal plane. Extensive areas of parenchymal pulmonary destruction could still be observed, associated with the prevailing emphysema pattern in the upper lobes. Of particular interest was the disappearance of the large bulla in the anterior segment of the RUL (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Given the suspicion of a malignant solitary pulmonary nodule, a positron emission tomography (PET) was requested that showed a moderately hypermetabolic pulmonary lesions in the RUL, consistent with malignancy, so the lesion was surgically removed. Video-assisted thoracoscopic wedge resection was performed, and pathology study found the lesion to be a residual sclerotic pulmonary nodule, consistent with thrombosed cavernous hemangioma, forming organized dystrophic calcification. In the subsequent lung function tests after resolution of the bulla, no improvement was found on spirometry, with FVC 4600<span class="elsevierStyleHsp" style=""></span>cc (100%), FEV1 2690<span class="elsevierStyleHsp" style=""></span>cc (74%) and a FEV1/FVC ratio of 58%.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As mentioned above, the natural course of bullae is progressive growth, to the extent that giant bullae can become so large that they even cause adjacent parenchyma to collapse.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Treatment of choice is surgery, which has been shown to improve dyspnea, gas exchange, lung function, and exercise capacity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> A few cases of spontaneous regression of an emphysematous bulla have been reported, the first of which was probably that published by Douglas and Grant in 1957.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The process is usually preceded by clinical symptoms consistent with a respiratory infection, manifesting as cough and expectoration, generally with parenchymal consolidation surrounding the bulla and an air-fluid level within. Radiological resolution of air-fluid levels is usually very slow, generally taking more than 70 days, and the use of antibiotics does not speed up the process, so their systematic use is not recommended in asymptomatic patients.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–7</span></a> The causative mechanism is unknown, although most authors suggest that it is due to bronchial obstruction by exudate and inflammation, with subsequent reabsorption of the air-fluid content,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> or else it might be an inflammatory process within the bulla which causes it to seal.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although in most cases an improvement in lung function has been reported,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> this might not occur, as in the case described by Wahbi and Arnold in 1996,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and in our patient, possibly due to the size of the bulla.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our case, the mechanism underlying resolution of the bulla is unclear. At no time was there evidence of inflammatory signs on the CT or previous chest radiographs, making this case unusual, since regression was totally asymptomatic, with no associated infection or tumor. The finding of cavernous hemangioma was incidental, and we do not believe that it is associated with resolution of the bulla.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Benito Bernáldez C, Almadana Pacheco V. Regresión espontánea de una bulla enfisematosa pulmonar. Arch Bronconeumol. 2017;53:347–348.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 470 "Ancho" => 2000 "Tamanyo" => 138771 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT images showing a large bulla in the RUL (A), spiculated pulmonary nodule in the RUL, along with resolution of the large bulla in this region (B), and the image after surgical resection of the pulmonary nodule with continued absence of the large emphysematous pulmonary bulla (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous regression of a giant pulmonary bulla" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 3 | 6 |
| 2024 October | 52 | 20 | 72 |
| 2024 September | 71 | 17 | 88 |
| 2024 August | 75 | 36 | 111 |
| 2024 July | 64 | 18 | 82 |
| 2024 June | 103 | 31 | 134 |
| 2024 May | 109 | 26 | 135 |
| 2024 April | 61 | 30 | 91 |
| 2024 March | 70 | 14 | 84 |
| 2024 February | 48 | 26 | 74 |
| 2023 March | 10 | 3 | 13 |
| 2023 February | 39 | 17 | 56 |
| 2023 January | 58 | 37 | 95 |
| 2022 December | 59 | 37 | 96 |
| 2022 November | 56 | 25 | 81 |
| 2022 October | 54 | 36 | 90 |
| 2022 September | 43 | 21 | 64 |
| 2022 August | 44 | 49 | 93 |
| 2022 July | 51 | 54 | 105 |
| 2022 June | 45 | 39 | 84 |
| 2022 May | 33 | 37 | 70 |
| 2022 April | 60 | 32 | 92 |
| 2022 March | 73 | 37 | 110 |
| 2022 February | 37 | 31 | 68 |
| 2022 January | 76 | 47 | 123 |
| 2021 December | 60 | 44 | 104 |
| 2021 November | 54 | 46 | 100 |
| 2021 October | 50 | 43 | 93 |
| 2021 September | 37 | 42 | 79 |
| 2021 August | 39 | 49 | 88 |
| 2021 July | 35 | 35 | 70 |
| 2021 June | 45 | 39 | 84 |
| 2021 May | 44 | 51 | 95 |
| 2021 April | 125 | 113 | 238 |
| 2021 March | 69 | 33 | 102 |
| 2021 February | 41 | 35 | 76 |
| 2021 January | 38 | 22 | 60 |
| 2020 December | 51 | 22 | 73 |
| 2020 November | 42 | 19 | 61 |
| 2020 October | 44 | 13 | 57 |
| 2020 September | 56 | 20 | 76 |
| 2020 August | 35 | 20 | 55 |
| 2020 July | 46 | 32 | 78 |
| 2020 June | 37 | 13 | 50 |
| 2020 May | 36 | 14 | 50 |
| 2020 April | 55 | 16 | 71 |
| 2020 March | 61 | 15 | 76 |
| 2020 February | 68 | 19 | 87 |
| 2020 January | 60 | 17 | 77 |
| 2019 December | 62 | 24 | 86 |
| 2019 November | 44 | 29 | 73 |
| 2019 October | 47 | 14 | 61 |
| 2019 September | 40 | 11 | 51 |
| 2019 August | 40 | 19 | 59 |
| 2019 July | 35 | 18 | 53 |
| 2019 June | 31 | 16 | 47 |
| 2019 May | 50 | 10 | 60 |
| 2019 April | 73 | 33 | 106 |
| 2019 March | 42 | 24 | 66 |
| 2019 February | 59 | 20 | 79 |
| 2019 January | 38 | 13 | 51 |
| 2018 December | 38 | 13 | 51 |
| 2018 November | 41 | 14 | 55 |
| 2018 October | 80 | 32 | 112 |
| 2018 September | 25 | 17 | 42 |
| 2018 May | 21 | 2 | 23 |
| 2018 April | 17 | 7 | 24 |
| 2018 March | 17 | 1 | 18 |
| 2018 February | 21 | 9 | 30 |
| 2018 January | 20 | 5 | 25 |
| 2017 December | 33 | 5 | 38 |
| 2017 November | 18 | 9 | 27 |
| 2017 October | 23 | 13 | 36 |
| 2017 September | 28 | 10 | 38 |
| 2017 August | 1 | 0 | 1 |
| 2017 June | 3 | 0 | 3 |
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