pulmonary mass in a neonate
DESCRIPTION
Pulmonary Mass in a Neonate. Filomena Hazel R. Villa, MD PL 1- Pediatrics. Objective. To present a case of a neonate with pulmonary mass, its management and differential diagnoses. History. Boy M, 5 hours old Born term (40 weeks), LGA (3732 g) 21 y/o G1P1 Prenatal History: unremarkable - PowerPoint PPT PresentationTRANSCRIPT
Pulmonary Mass Pulmonary Mass in a Neonatein a Neonate
Filomena Hazel R. Villa, MDFilomena Hazel R. Villa, MD
PL 1- PediatricsPL 1- Pediatrics
ObjectiveObjective
To present a case of a neonate with To present a case of a neonate with pulmonary mass, its management and pulmonary mass, its management and differential diagnosesdifferential diagnoses
HistoryHistory
Boy M, 5 hours oldBoy M, 5 hours old Born term (40 weeks), LGA (3732 g)Born term (40 weeks), LGA (3732 g) 21 y/o G1P1 21 y/o G1P1 Prenatal History: unremarkablePrenatal History: unremarkable Natal History: Born at CDNNatal History: Born at CDN
SROM - clear amniotic fluid, unknown amountSROM - clear amniotic fluid, unknown amountNSVD, vertex presentation, APGAR 9,9NSVD, vertex presentation, APGAR 9,9
HistoryHistory
22ndnd hour: feeding was started, + vomiting, hour: feeding was started, + vomiting, tachypneatachypnea
55thth hour of life: persistence of tachypnea hour of life: persistence of tachypnea
Transferred to Thomason via EMSTransferred to Thomason via EMS
Physical ExaminationPhysical Examination VS: T- 99.4; HR- 140; RR-89 VS: T- 99.4; HR- 140; RR-89
BP - 57/33 (MAP 43-47) O2 Sat: 82-92%BP - 57/33 (MAP 43-47) O2 Sat: 82-92%
Alert, and activeAlert, and active
No icterus, no rashesNo icterus, no rashes
Open flat fontanelleOpen flat fontanelle
Eyes, normal shape and size with equal red Eyes, normal shape and size with equal red reflexreflex
Physical ExaminationPhysical Examination
Ears: normally set, no gross anomaliesEars: normally set, no gross anomalies
Nose: nares are patent, intact palateNose: nares are patent, intact palate
Lungs and Chest: anteriorly - clear and equal Lungs and Chest: anteriorly - clear and equal breath sounds; breath sounds; posteriorly - slightly posteriorly - slightly decreased breath sounds on the left decreased breath sounds on the left hemithorax, ICS retractions, mild tachypneahemithorax, ICS retractions, mild tachypnea
Chest: normal rate and rhythm, pulses equal Chest: normal rate and rhythm, pulses equal on all extremities, no murmuron all extremities, no murmur
Abdomen: umbilical stump: clean, with 3 Abdomen: umbilical stump: clean, with 3 vessels, soft, non tender, no organomegaly, vessels, soft, non tender, no organomegaly, no masses, normal bowel soundsno masses, normal bowel sounds
Genitalia: normal male genitaliaGenitalia: normal male genitalia
Physical ExaminationPhysical Examination
Back and spine: no gross defectsBack and spine: no gross defects
Limbs and hips: no hip clicks, 10 fingers and Limbs and hips: no hip clicks, 10 fingers and toes, symmetric movements, capillary refill < toes, symmetric movements, capillary refill < 3 seconds3 seconds
Neurologic: normal suck, tone, grasp, cry, Neurologic: normal suck, tone, grasp, cry, Moro, rootMoro, root
Physical ExaminationPhysical Examination
Assessment and PlanAssessment and Plan
Term male infantTerm male infant Suspected sepsis secondary to respiratory Suspected sepsis secondary to respiratory
distress and desaturations distress and desaturations TTN vs PneumoniaTTN vs Pneumonia
Plan: Sepsis work up, CXRPlan: Sepsis work up, CXR NPO, Isolette, OxygenNPO, Isolette, Oxygen Ampicillin and GentamicinAmpicillin and Gentamicin
Course in the NICUCourse in the NICU
Initial CXR: density in the left retrocardiac areaInitial CXR: density in the left retrocardiac area
Unlikely pneumonia or atelectasisUnlikely pneumonia or atelectasis
Differential diagnoses: Differential diagnoses: 1.1. Intra or Extra lobar sequestrationIntra or Extra lobar sequestration2.2. Mediastinal neuroblastomaMediastinal neuroblastoma3.3. Broncho foregut malformationBroncho foregut malformation4.4. Neuroenteric malformationNeuroenteric malformation5.5. Intrathoracic kidneys Intrathoracic kidneys
Case discussed with RadiologistCase discussed with Radiologist
CT scan of the thoraxCT scan of the thorax
Ultrasound of abdomen and thoraxUltrasound of abdomen and thorax
Echocardiogram: normalEchocardiogram: normal
Course in the NICUCourse in the NICU
CT scan of the thorax:CT scan of the thorax:
Soft tissue mass with no calcificationsSoft tissue mass with no calcifications No diaphragmatic eventration, no evidence of No diaphragmatic eventration, no evidence of
herniahernia Differentials: Teratoma, NeuroblastomaDifferentials: Teratoma, Neuroblastoma
Course in the NICUCourse in the NICU
Sonogram of the abdomen: normal gas pattern, Sonogram of the abdomen: normal gas pattern, liver pancreas and kidneys-within the cavityliver pancreas and kidneys-within the cavity
Sonogram of the thorax: Sonogram of the thorax: Left hemithorax mass Left hemithorax mass Arterial supply from the aortaArterial supply from the aorta Vein drainage-origin not establishedVein drainage-origin not established
Consider: Consider: Extralobar SequestrationExtralobar Sequestration
Course in the NICUCourse in the NICU
44thth hospital day: referral to pediatric hospital day: referral to pediatric surgerysurgery
Images were reviewedImages were reviewed
Plan: removal of the pulmonary massPlan: removal of the pulmonary mass
Course in the NICUCourse in the NICU
55thth hospital day: Surgery (Thoracotomy) hospital day: Surgery (Thoracotomy)
Intra-op findings: Intra-op findings: Pulmonary sequestrumPulmonary sequestrum Arterial aspect supplying the mass emerges from the Arterial aspect supplying the mass emerges from the
thoracic aortathoracic aorta Venous drainage into the intercostal veinVenous drainage into the intercostal vein Resection of pulmonary sequestrationResection of pulmonary sequestration
Course in the NICUCourse in the NICU
Chext X-ray Post-op
Uncomplicated recoveryUncomplicated recovery
Patient was discharged on 6Patient was discharged on 6thth post-op day post-op day
Post- operative CoursePost- operative Course
Pathological FindingsPathological Findings
It consists of a 6.5 x 4.5 x 3.0 cm lower lobe of lung It consists of a 6.5 x 4.5 x 3.0 cm lower lobe of lung tissue. It has an attached purple tan cystic structure tissue. It has an attached purple tan cystic structure filled with hemorrhagic serous fluid and air. This filled with hemorrhagic serous fluid and air. This cystic structure measures 1.5 cm in greatest cystic structure measures 1.5 cm in greatest diameter.diameter.
Diagnosis: pulmonary sequestration with minimal Diagnosis: pulmonary sequestration with minimal interstitial lymphocytic inflammation dilated interstitial lymphocytic inflammation dilated congested blood vessels and focal parenchymal congested blood vessels and focal parenchymal hemorrhage.hemorrhage.
Differential diagnosesDifferential diagnoses
PneumoniaPneumonia Diaphragmatic herniaDiaphragmatic hernia TeratomaTeratoma NeuroblastomaNeuroblastoma CCAMCCAM
Extralobar Pulmonary SequestrationExtralobar Pulmonary Sequestration
Non-functioning lung tissueNon-functioning lung tissue Aberrant blood supply- systemic circulationAberrant blood supply- systemic circulation Has its own pleuraHas its own pleura Associated with other anomaliesAssociated with other anomalies CongenitalCongenital
EXTRALOBAREXTRALOBAR CongenitalCongenital Systemic blood supplySystemic blood supply Systemic venous drainageSystemic venous drainage Own pleuraOwn pleura
INTRALOBARINTRALOBAR Acquired/ congenitalAcquired/ congenital Systemic blood supplySystemic blood supply Pulmonary venous drainagePulmonary venous drainage Pleura shared with adjacent Pleura shared with adjacent
normal lungnormal lung
Extra vs IntralobarExtra vs Intralobar
Extra vs IntralobarExtra vs Intralobar
EpidemiologyEpidemiology
Incidence: 0.15-1.7%Incidence: 0.15-1.7% 15-25%- extralobar15-25%- extralobar 75-85%- intralobar75-85%- intralobar 4:1 male to female 4:1 male to female 60%- first 6 months of life60%- first 6 months of life
EmbryologyEmbryology
Prenatal Diagnosis and TreatmentPrenatal Diagnosis and Treatment
No hydrops- follow closely with ultrasoundNo hydrops- follow closely with ultrasound
With hydrops- thoracoamniotic shuntWith hydrops- thoracoamniotic shunt
Postnatally- resectionPostnatally- resection
DiagnosisDiagnosis
Plain x-ray- triangular or oval shape opacityPlain x-ray- triangular or oval shape opacity CT- cystic componentCT- cystic component Color Doppler ultrasound- anomalous Color Doppler ultrasound- anomalous
vesselsvessels MRI- venous drainageMRI- venous drainage
TreatmentTreatment
Surgical resectionSurgical resection
ThoracoscopyThoracoscopy
Arterial embolizationArterial embolization
ComplicationsComplications
HemorrhageHemorrhage
EmpyemaEmpyema
HemothoraxHemothorax
HemoperitoneumHemoperitoneum
Air leakAir leak
Bronchopleural fistulaBronchopleural fistula
Wound infectionWound infection
AtelectasisAtelectasis
InfectionsInfections
Secretions Secretions managementmanagement
Respiratory failureRespiratory failure
PrognosisPrognosis
With hydrops fetalis- dismalWith hydrops fetalis- dismal
Without hydrops - excellentWithout hydrops - excellent
Baby boy M is presently being followed in Baby boy M is presently being followed in our high risk clinic, growing and our high risk clinic, growing and developing without significant pulmonary developing without significant pulmonary residuals.residuals.