Teaching Case

A 45-year-old lady presented with left-sided chest pain. Clinical examination and blood tests were normal. Chest X-ray was performed to exclude a pneumothorax. There is past medical history of childhood chest infections. There is no other significant past medical history and no previous imaging available from her childhood.

Plain film of chest was performed in A&E, which demonstrated a large lucency of the left upper lobe with tracheal displacement and was reported as bulla (Fig. 1). A CT was performed to further assess the compression due to the bulla. Axial views of the lung window demonstrated an expanded left upper lobe (Fig. 2. CT). Sagittal views of the lung window demonstrated no bullae or pneumothorax, and mediastinum was displaced to the opposite side (Fig. 2,3). There was compression of the lingular segment (Fig. 4) but bronchi remained patent. The lower lobes were not compressed and had equal volume (Fig.5).

Lobar emphysema or - more correctly - lobar overinflation as it is recently described, is a rare condition more common in male neonates. The left upper lobe is most commonly affected. It is one entity out of a spectrum of congenital lung malformations, and it may be associated with other malformations [1, 6]. When there is any double about imaging findings it is prudent to confirm them with CT, as in this case, instead of proceeding to chest drain insertion [2]. It is uncommon to find a long term follow-up of such cases into adulthood [2]. The management of symptomatic cases is usually surgical and not controversial. The management of asymptomatic cases or incidental findings of an unrelated cause is conservative (observation) or surgical. We live in a world of patient choice so it is fair to state that modern management is guided by patient choice; in our case the patient had opted for conservative management of infections as and when they occurred, and the condition has not affected her life adversely to warrant surgical intervention. The role of imaging is to support patients opting for conservative management when there are no underlying structural abnormalities like cysts or bullae, or to support the surgical team when they are present [2,3]. Imaging also plays a valuable role in the preoperative assessment of this condition [4]. It is also important to make patients aware of the diagnosis, and to document it in medical notes if and when they need anaesthetic intervention [5]. Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.