Incidental finding of pulmonary lymphangitis carcinomatosa i
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The present case has been reported in the recent issue of the Indian Journal of Anaesthesia.

A 45-year-old male patient, a chronic smoker was referred for management of chest pain and progressively increasing respiratory distress following blunt chest trauma 3 months back. A high-resolution computed tomography (HRCT) showed bilateral hydropneumothorax with multiple rib fractures. The patient was shifted ICU with signs of respiratory failure. He was managed as a sequela of blunt chest trauma with bilateral chest tubes in situ, intermittent non-invasive ventilation (NIV), antibiotics, adequate analgesia and supportive management.

Subsequently, chest tubes were removed after confirming minimal fluid on ultrasound chest, but dyspnoea still persisted. Repeat HRCT chest reported infective pathology (atypical pneumonia) and lesions in the apical segment of right upper lobe consistent with lymphangitis carcinomatosa, which needed further evaluation. During the stay of patient in ICU, arterial blood gases reported persistently high pCO2 with mild hypoxia. Patient was also then managed as a case of acute exacerbation of COPD with type 2 respiratory failure.

Echocardiography done later was found to be within normal values. Subsequently, a repeat contrast-enhanced computed tomography (CECT) lung done 2 weeks later showed a spiculated nodule in upper part of right lower lobe, multiple sclerotic lesions in vertebral body of D1 and sternum, and a lytic lesion in D11 (with pedicles) in bone window.

Ultrasound abdomen showed hepatomegaly with multiple space-occupying lesions in both lobes of the liver, likely to be metastasis. Fine-needle aspiration cytology of space occupying lesion in liver reported adenocarcinoma metastasis.

Chemotherapy could not be started due to poor general condition of patient. Subsequently, patient expired after 10 days of diagnosis of occult primary malignancy with pulmonary lymphangitis carcinomatosa (PLC) and liver metastasis.

Major takeaway:-
- In this patient, the clinical presentation of PLC became evident only after chest trauma and was an incidental finding.

- Although PLC is rare, it should be included as a differential diagnosis in a young male patient with progressively increasing respiratory failure.

Dr. A●●●●●v C●●●●●●●y
Dr. A●●●●●v C●●●●●●●y Critical Care Medicine
WITH hydropneumo how was the patient asymptomatic for such long duration? May be there was a bulla rupture which led to the pneumo.
Jan 17, 2019Like