Bilateral thoracotomy for horseshoe lung complicated with severe aspergilloma: a case report

Horseshoe lung is a rare congenital malformation in which the lung protrudes from the mediastinum to the other side. Owing to the high frequency of other fatal cardiovascular complications, it is often diagnosed in childhood and rarely unnoted until adulthood. We report a case of horseshoe lung in an older patient who underwent thoracotomy. The patient was a 69-year-old man with chronic obstructive pulmonary disease (COPD) and a history of heavy smoking. The patient was admitted to the hospital because of acute exacerbation of COPD. Computed tomography revealed horseshoe lung and pulmonary sequestration with pneumonia. This was the first time that he was diagnosed with horseshoe lung; however, he had been treated for pneumonia multiple times before. Surgery for the horseshoe lung was recommended; however, the patient declined it because his symptoms of acute COPD exacerbation were relieved by medication. Aspergillus infection of the horseshoe lung led to frequent bloody sputum, and the patient’s respiratory condition gradually worsened. Two years after the initial diagnosis, the patient decided to undergo the surgery. Surgery was performed in the order of left and right thoracotomies, with posterolateral thoracotomies performed bilaterally. Surgery was difficult because of strong adhesions around the inflamed lung; however, the lung was removed in one lump. The patient was extubated on postoperative day (POD) 1, and rehabilitation was initiated. His high sputum volume caused postoperative pneumonia, and the patient was again placed on a ventilator on POD 9. He underwent open-window surgery for concomitant pyothorax. The patient was weaned off the ventilator when the inflammation improved and was discharged on POD 133. The patient lived at home, developed severe pneumonia 4 months later, and died of respiratory failure. Pulmonary sequestration and horseshoe lungs are congenital malformations that require surgery. The selection of the optimal time for surgery is important.