Noninvasive Resolution of Vanishing Lung Syndrome

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Vanishing lung syndrome, also known as idiopathic giant bullous emphysema, is defined by large bullae that occupy at least one third of the hemi thorax with resultant compression of surrounding lung parenchyma. Rarely do the bullae resolve spontaneously. We report a case of spontaneous resolution of giant bullae in a female patient with a remote smoking history and undiagnosed chronic obstructive lung disease (COPD). CASE PRESENTATION: A 75-year-old woman presented to the emergency department (ED) with a four-week history of non-productive cough and one-week of progressive dyspnea. Medical history included NASH-cirrhosis, hepatocellular carcinoma, and tobacco use. The patient had a 46 pack-year smoking history however quit 19 years prior to presentation. The patient recently underwent trans arterial chemoembolization (TACE) and ablation of a residual hepatocellular tumor on the liver. In the ED, pulse oximetry was 93 % breathing ambient air. Computed tomography (CT) of the chest confirmed interval development of large bullae and severe volume loss of the left lung without pneumothorax as well as emphysematous changes throughout the right lung (Figure 1) when compared with CT from two months prior. Patient was admitted to the hospital for further monitoring. Pulse oximetry was measured during ambulation, oxygen level dropped to 83% while breathing ambient air. Supplemental oxygen was supplied along with antitussives, oral steroids, azithromycin, nebulized albuterol and ipratropium. Home oxygen, albuterol, fluticasone-salmeterol inhalers and antitussives were prescribed upon discharge. Two months later, follow-up CT of the chest revealed almost complete resolution of the bullae (Figure 2). The patient’s symptoms were much improved and she no longer required supplemental oxygen. DISCUSSION: Vanishing lung syndrome primarily affects the upper lung lobes, and is more prevalent in young males who are heavy smokers and in those with alpha-1 antitrypsin (A1AT) deficiency. These giant bullae are usually persistent and often require lung-volume reduction surgery or bullectomy. In this case, bullae were attributed to persistent coughing (possibly related to recent TACE/ablation procedure) - this is rare. There was no pneumothorax or infection. The patient tested negative for connective tissue disorders and A1AT level was normal. She had no environmental exposures such as coal mining, gold mining or to cotton textile dust. Resolution occurred with symptom control and administration of bronchodilators. CONCLUSIONS: Spontaneous resolution of giant bullae is rare, even more so in females. Intensifying bronchodilator therapy and symptom control should be attempted before invasive procedures are considered. Reference #1: Ladizinski, B. and Sankey, C. N Engl J Med. 2014; 370:e14 February 27, 2014 Reference #2: Byrd, R.P. and Roy, T.M. Austin J Pulm Respir Mws. 2014;1(4):1017 Reference #3: Sharma N., Justaniah A.M., Kanne J.P., Gurney J.W., and Mohammad T.L. J Thoracic Imaging. 2009 Aug;24(3):227-30 DISCLOSURE: The following authors have nothing to disclose: Stephanie Cull, Garrett Rampon, Abhishek Krishna, Setu Patolia No Product/Research Disclosure Information