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RAPIDLY PROGRESSIVE LUNG BULLA IN A PATIENT WITH ASTHMA

Maimonides Medical Center, Brooklyn, NY

INTRODUCTION: Bullous lung disease is commonly seen in patients with COPD. We report a case of a giant lower lobe bulla in a young patient with bronchial asthma.

CASE PRESENTATION: A 19-year-old female presented with a two-week history of sharp pleuritic right-sided chest pain associated with worsening dyspnea. She had a history of asthma diagnosed at age 8, but was well controlled with inhaled fluticasone and albuterol as needed. She denied recent wheezing and did not feel better after albuterol use. No history of tobacco, drug or alcohol use. Family history was negative. No recent travel vigorous exercise was reported. A chest x-ray obtained by her primary care practitioner one week prior to admission was reportedly "normal". Physical examination revealed minimal air entry to the right base, but minimal wheezing. ABG on room air revealed pH 7.41, pCO2 37, pO2 99. Chest x-ray revealed a radiolucent zone in the right base. CT of the chest revealed a 13 cm bulla at the right base associated with right middle lobe atelectasis and shift of the mediastinum to the left. Alpha 1 antitrypsin levels were normal, genetic testing for cystic fibrosis was negative. Due to the worsening of the symptoms despite maximal therapy for her asthma, an open bullectomy was performed with improvement of her symptoms. The space occupied by the bulla was occupied by normal lung tissue. At six months follow up she is asymptomatic with well-controlled asthma.

DISCUSSIONS: A lung bulla is defined as an emphysematous space of more than 1 cm in diameter in the inflated lung. Its wall is formed by pleura, connective tissue and compressed lung parenchyma. They can be morphologically categorized into three types. Type 1 has a narrow neck and is well demarcated by pleura. There is a small amount of lung that is over distended. They commonly originate from subpleural locations in the apex of the upper lobe or along the costophrenic angle of the middle lobe or lingual. Type 2 bullae have a broad neck and are frequently located on the anterior and diaphragmatic surface. They have a high predilection for developing a pneumothorax. Type 3 represent an exaggerated form of emphysema and lie deep within the lung parenchyma. Bullae can also be subdivided as either primary associated with normal pulmonary parenchyma, or secondary associated with obstructive lung disease and emphysema. Most bullae do not require surgical resection. Patients with symptoms such as chest pain, dyspnea, and hemoptysis associated with the bullae that have not corrected with medical management may be treated surgically. Recurrent infections of the bullae require surgical bullectomy. Bullectomy is also indicated if the bulla is large enough to cause mediastinal shift and atelectasis of the contralateral lung.

CONCLUSION: Rapidly enlarging bulla may rarely complicate asthma. Bullectomy relieves symptoms and restores normal lung function.

DISCLOSURE: Yatin Mehta, No Financial Disclosure Information; No Product/Research Disclosure Information

REFERENCES:

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