Scientific Letter
Pneumatocele following lung cryobiopsy
Neumatocele posterior a criobiopsia pulmonar
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A) Antes de realizar CBTB: consolidaciones bilaterales con broncograma aéreo de distribución periférica y peribroncovascular. B) Un mes posterior a CBTB: lesión con nivel hidroaéreo en el lóbulo superior derecho. C y D) Tres meses posterior a CBTB<span class="elsevierStyleItalic">:</span> disminución de tamaño de la lesión con desaparición o reabsorción del contenido aéreo y persistencia del contenido hemático (hematocele).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Horacio Matías Castro, Esteban Javier Wainstein, Rodrigo Castro Azcurra, Alberto Seehaus" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Horacio Matías" "apellidos" => "Castro" ] 1 => array:2 [ "nombre" => "Esteban Javier" "apellidos" => "Wainstein" ] 2 => array:2 [ "nombre" => "Rodrigo" "apellidos" => "Castro Azcurra" ] 3 => array:2 [ "nombre" => "Alberto" "apellidos" => "Seehaus" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212921002317" "doi" => "10.1016/j.arbr.2021.06.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921002317?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289621000326?idApp=UINPBA00003Z" "url" => "/03002896/0000005700000009/v1_202109020750/S0300289621000326/v1_202109020750/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S1579212921002688" "issn" => "15792129" "doi" => "10.1016/j.arbr.2021.01.008" "estado" => "S300" "fechaPublicacion" => "2021-09-01" "aid" => "2735" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2021;57:601-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Is High-Flow Nasal Cannula Oxygen Therapy an Aerosol-Generating Medical Procedure?" 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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Esteban Javier" "apellidos" => "Wainstein" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "Castro Azcurra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Alberto" "apellidos" => "Seehaus" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección de Neumonologia, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de diagnóstico por imágenes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumatocele posterior a criobiopsia pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2081 "Ancho" => 2500 "Tamanyo" => 461464 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-resolution chest tomography. (A) before TBCB: bilateral consolidations with peripheral and peribronchovascular air bronchogram. (B) 1 month after TBCB: lesion with air-fluid level in right upper lobe. (C) and (D) 3 months after TBCB: decrease in the size of the lesion with disappearance or reabsorption of the air content and persistence of the bloody content (hematocele).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The gold standard for the diagnosis of diffuse interstitial lung diseases (ILD) is multidisciplinary evaluation<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Lung biopsy is sometimes necessary to increase diagnostic confidence<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Transbronchial cryobiopsy (TBCB) has emerged as an alternative to surgical biopsy with lower morbidity and mortality<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>. The most common complications of cryobiopsy are pneumothorax and bleeding<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a>. Although 3 cases of pulmonary cavitation following this procedure have been described, no associated cases of pneumatocele have been reported. We present a case of pneumatocele as a complication of TBCB.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 55-year-old man, non-smoker, who was referred to our institution for slowly resolving pneumonia. A month earlier, he presented with cough, dyspnea, and bilateral pulmonary opacities. He received empirical antibiotic treatment with amoxicillin-sulbactam and clarithromycin, then piperacillin-tazobactam and finally vancomycin, with no clinical improvement and worsening oxygenation. On admission, he was hypoxemic with an oxygen saturation of 90% breathing room air. The analysis showed no significant results: eosinophil count within normal limits, erythrocyte sedimentation rate 34 mm/h, serology negative for HIV, ANCA and ANA normal, and CPK within normal limits. Chest computed tomography (CT) showed bilateral consolidations, predominantly peripheral, with peribronchovascular distribution and some areas with reversed halo sign (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). We performed bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy using a 1.9 mm cryoprobe. Five biopsies were obtained from the right upper lobe, 3 in the posterior segment and 2 in the apical segment. The procedure was completed without complications. The pathology study showed characteristic findings of organizing pneumonia. We started treatment with prednisone at a dose of 0.5 mg/kg/day. The patient progressed without fever and his dyspnea improved progressively. One month after treatment, a follow-up chest X-ray showed a cavitary lesion in the upper field of the right hemithorax. A chest CT without contrast agent was performed to characterize the image, revealing a mass with smooth margins, 3 cm in diameter, in the posterior segment of the right upper lobe (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient was asymptomatic, with normal labs and erythrocyte sedimentation rate 5 mm/h; nevertheless, we obtained a BAL specimen from the affected lung segment. Microbiological results were negative and BAL cellularity was normal. The lesion was interpreted as a pneumatocele, caused by the TBCB. We decided to take a watchful waiting approach with clinical follow-up. Two months later, the patient was asymptomatic and CT showed persistence of the cavity with a homogeneous density of 30–40 Hounsfield units, in contact with the pleura and the oblique fissure (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C and D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The lesion was unlikely to have a neoplastic origin, given its morphology, rapid development, and reduced size on follow-up. Its appearance following TBCB and its location in one of the biopsied lung segments suggested that it was a complication of the TBCB. The absence of symptoms, laboratory test changes, and microbiological evidence in BAL, and a favorable clinical course without antibiotic treatment, further ruled out the possibility of a pulmonary abscess. Chest CT showed no pleural effusion and the pulmonary parenchyma surrounding the lesion was normal, so the hypotheses of a phantom tumor following the plane of the fissure or a pulmonary hematoma were therefore rejected. The radiological characteristics of the lesion – air-fluid cavity, thin, regular wall, with smooth margins – supported the diagnosis of pneumatocele. The density of 30–40 Hounsfield units suggested blood in the cavity<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as a secondary complication. In our opinion, the pneumatocele was the product of necrosis generated by the cryobiopsy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first reported case of post-TBCB pneumatocele. A pneumatocele is a thin-walled, gas-filled space contained within the lung parenchyma<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. It is usually solitary and transient, and sometimes contains fluid levels. Its pathogenesis has been associated with a combination of necrosis and a valvular mechanism in the airway that would allow air to enter but not exit<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. The described causes of pneumatocele are pneumonia, thoracic trauma, hydrocarbon ingestion, and positive pressure ventilation<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">TBCB is increasingly used for the evaluation of ILD, and this increase may lead to new complications. Complications reported include moderate-severe bleeding (14.2%), pneumothorax (9.4%), ILD exacerbation (0.3%), death (0.3%), pneumomediastinum, arrhythmias, and lung infections<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10</span></a>. There are 2 reports of cases of pulmonary abscesses<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> and 1 of a non-infectious cavitation<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>, but none of the series published to date has described the appearance of pneumothorax.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, pneumatocele is a possible complication of TBCB and should be taken into account in patients who undergo this procedure.</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: Castro HM, Wainstein EJ, Castro Azcurra R, Seehaus A. Neumatocele posterior a criobiopsia pulmonar. Arch Bronconeumol. 2021;57:599–600.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2081 "Ancho" => 2500 "Tamanyo" => 461464 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-resolution chest tomography. (A) before TBCB: bilateral consolidations with peripheral and peribronchovascular air bronchogram. (B) 1 month after TBCB: lesion with air-fluid level in right upper lobe. (C) and (D) 3 months after TBCB: decrease in the size of the lesion with disappearance or reabsorption of the air content and persistence of the bloody content (hematocele).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Raghu" 1 => "M. Remy-Jardin" 2 => "J.L. Myers" 3 => "L. Richeldi" 4 => "C.J. Ryerson" 5 => "D.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 51 | 15 | 66 |
| 2024 September | 54 | 15 | 69 |
| 2024 August | 66 | 46 | 112 |
| 2024 July | 59 | 21 | 80 |
| 2024 June | 49 | 19 | 68 |
| 2024 May | 72 | 24 | 96 |
| 2024 April | 36 | 20 | 56 |
| 2024 March | 48 | 22 | 70 |
| 2024 February | 36 | 32 | 68 |
| 2024 January | 36 | 29 | 65 |
| 2023 December | 26 | 25 | 51 |
| 2023 November | 46 | 18 | 64 |
| 2023 October | 40 | 30 | 70 |
| 2023 September | 39 | 30 | 69 |
| 2023 August | 27 | 35 | 62 |
| 2023 July | 43 | 30 | 73 |
| 2023 June | 29 | 8 | 37 |
| 2023 May | 41 | 18 | 59 |
| 2023 April | 43 | 21 | 64 |
| 2023 March | 54 | 26 | 80 |
| 2023 February | 34 | 16 | 50 |
| 2023 January | 36 | 31 | 67 |
| 2022 December | 65 | 29 | 94 |
| 2022 November | 72 | 32 | 104 |
| 2022 October | 79 | 38 | 117 |
| 2022 September | 75 | 26 | 101 |
| 2022 August | 93 | 44 | 137 |
| 2022 July | 75 | 43 | 118 |
| 2022 June | 46 | 37 | 83 |
| 2022 May | 40 | 25 | 65 |
| 2022 April | 61 | 31 | 92 |
| 2022 March | 72 | 37 | 109 |
| 2022 February | 25 | 27 | 52 |
| 2022 January | 1 | 0 | 1 |
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