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Spontaneous right whole-lung torsion secondary to bronchial carcinoma: a case report
© The Author(s). 2016
Received: 17 March 2016
Accepted: 6 July 2016
Published: 14 July 2016
Spontaneous whole lung torsion is an absolut rarity and most cases occur after previous surgery.
We present the case of a spontaneous whole-lung torsion in a 82-year old man. The patient was referred to our thoracic surgery department from the emergency department of a referring hospital with rapidly progressive dyspnea. CT-scan revealed a 180° degree counterclockwise torsion of the entire right lung with complete atelectasis and congestion of the upper lobe as well as pleural effusion. Thoracoscopy confirmed lung torsion and revealed hemorrhagic infarction of the upper lobe. Subsequently thoracotomy and upper lobectomy were performed. Most likely the lung torsion occurred due to a combination of pleural effusion and venous congestion with complete atelectasis of the upper lobe as a result of adenocarcinoma of the upper lobe.
To our knowledge this is the first reported case of a patient presenting with lung torsion as the first symptom of lung cancer. When lung torsion is suspected rapid diagnosis is crucial in order to prevent hemorrhagic lung infarction.
Pulmonary torsion is a rare event and occurs when a lobe or the entire lung rotates around the bronchovascular pedicle. Most cases occur secondary to thoracic surgical procedures and affect the middle lobe after upper lobe resection. Spontaneous torsions are very rare and may occur due to pneumothorax, pleural effusion, lobar atelectasis or well lobation . Spontaneous torsion of the entire lung is an extreme rarity with only four documented cases in the English literature since 1987 [2–5]. To our knowledge this is the first case of spontaneous lung torsion in combination with pleural effusion and upper lobe atelectasis caused by a primary bronchial carcinoma.
Unfortunately the patient died 2 months later due to rapid tumor progression.
Spontaneous torsion of an entire lung is an extremely rare condition with this case report being only the 5th reported case since 1987. Furthermore the reported case is the first occurring in a patient with bronchial carcinoma. In the presented case the 180° counterclockwise lung torsion was most likely due to occlusion of the upper lobe vein, resulting in hemorrhagic infarction of the affected lobe. In combination with a large malignant effusion, gravity might have caused the infarcted upper lobe to rotate downwards, whereas the still ventilated middle and lower lobe “floated” upwards on the pleural effusion.
Early recognition and prompt intervention are essential in preventing hemorrhagic infarction or gangrene of the lung, which may finally result in severe sepsis and multiorgan failure. Radiologic diagnosis of lung torsion can be tricky due to the rarity of this condition, especially in patients who have not undergone prior surgery.
Timely exploratory thoracoscopy and/or thoracotomy are mandatory for rapid recognition and treatment when torsion is radiologically suspected . Whether de-torsion is sufficient or not, which means that resection has to be performed, depends on intraoperative findings
KC was the doctor on duty in the Emergency Department/Thoracic Surgery Department and drafted the manuscript. KG helped to draft the manuscript and participated as an assistant during the surgical procedure. AF and RS were the doctors on duty in the district hospital where the patient was first admitted, and contributed to the diagnosis as well as drafted part of the manuscript. RAS Head of the Department/supervisor. GJK performed the surgical procedure, contributed the intraoperative pictures and helped with drafting and revision of the manuscript. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editors-in-Chief of this journal.
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