Pulmonary Mass in a Neonate

1. Pulmonary Mass in a Neonate Filomena Hazel R. Villa, MD PL 1- Pediatrics

2. Objective • To present a case of a neonate with pulmonary mass, its management and differential diagnoses

3. History • Boy M, 5 hours old • Born term (40 weeks), LGA (3732 g) • 21 y/o G1P1 • Prenatal History: unremarkable • Natal History: Born at CDN SROM - clear amniotic fluid, unknown amount NSVD, vertex presentation, APGAR 9,9

4. History • 2nd hour: feeding was started, + vomiting, tachypnea • 5th hour of life: persistence of tachypnea • Transferred to Thomason via EMS

5. Physical Examination • VS: T- 99.4; HR- 140; RR-89 BP - 57/33 (MAP 43-47) O2 Sat: 82-92% • Alert, and active • No icterus, no rashes • Open flat fontanelle • Eyes, normal shape and size with equal red reflex

6. Physical Examination • Ears: normally set, no gross anomalies • Nose: nares are patent, intact palate • Lungs and Chest: anteriorly - clear and equal breath sounds; posteriorly - slightly decreased breath sounds on the left hemithorax, ICS retractions, mild tachypnea

7. Physical Examination • Chest: normal rate and rhythm, pulses equal on all extremities, no murmur • Abdomen: umbilical stump: clean, with 3 vessels, soft, non tender, no organomegaly, no masses, normal bowel sounds • Genitalia: normal male genitalia

8. Physical Examination • Back and spine: no gross defects • Limbs and hips: no hip clicks, 10 fingers and toes, symmetric movements, capillary refill < 3 seconds • Neurologic: normal suck, tone, grasp, cry, Moro, root

9. Assessment and Plan • Term male infant • Suspected sepsis secondary to respiratory distress and desaturations • TTN vs Pneumonia • Plan: Sepsis work up, CXR • NPO, Isolette, Oxygen • Ampicillin and Gentamicin

10. Course in the NICU • Initial CXR: density in the left retrocardiac area • Unlikely pneumonia or atelectasis • Differential diagnoses: • Intra or Extra lobar sequestration • Mediastinal neuroblastoma • Broncho foregut malformation • Neuroenteric malformation • Intrathoracic kidneys

12. Course in the NICU • Case discussed with Radiologist • CT scan of the thorax • Ultrasound of abdomen and thorax • Echocardiogram: normal

13. Course in the NICU • CT scan of the thorax: • Soft tissue mass with no calcifications • No diaphragmatic eventration, no evidence of hernia • Differentials: Teratoma, Neuroblastoma

16. Course in the NICU • Sonogram of the abdomen: normal gas pattern, liver pancreas and kidneys-within the cavity • Sonogram of the thorax: • Left hemithorax mass • Arterial supply from the aorta • Vein drainage-origin not established • Consider: Extralobar Sequestration

19. Course in the NICU • 4th hospital day: referral to pediatric surgery • Images were reviewed • Plan: removal of the pulmonary mass

20. Course in the NICU • 5th hospital day: Surgery (Thoracotomy) • Intra-op findings: • Pulmonary sequestrum • Arterial aspect supplying the mass emerges from the thoracic aorta • Venous drainage into the intercostal vein • Resection of pulmonary sequestration

22. Chext X-ray Post-op

24. Post- operative Course • Uncomplicated recovery • Patient was discharged on 6th post-op day

27. Pathological Findings • It consists of a 6.5 x 4.5 x 3.0 cm lower lobe of lung tissue. It has an attached purple tan cystic structure filled with hemorrhagic serous fluid and air. This cystic structure measures 1.5 cm in greatest diameter. • Diagnosis: pulmonary sequestration with minimal interstitial lymphocytic inflammation dilated congested blood vessels and focal parenchymal hemorrhage.

28. Differential diagnoses • Pneumonia • Diaphragmatic hernia • Teratoma • Neuroblastoma • CCAM

29. Extralobar Pulmonary Sequestration • Non-functioning lung tissue • Aberrant blood supply- systemic circulation • Has its own pleura • Associated with other anomalies • Congenital

30. Extra vs Intralobar INTRALOBAR • Acquired/ congenital • Systemic blood supply • Pulmonary venous drainage • Pleura shared with adjacent normal lung EXTRALOBAR • Congenital • Systemic blood supply • Systemic venous drainage • Own pleura

31. Extra vs Intralobar

32. Epidemiology • Incidence: 0.15-1.7% • 15-25%- extralobar • 75-85%- intralobar • 4:1 male to female • 60%- first 6 months of life

33. Embryology

34. Prenatal Diagnosis and Treatment • No hydrops- follow closely with ultrasound • With hydrops- thoracoamniotic shunt • Postnatally- resection

35. Diagnosis • Plain x-ray- triangular or oval shape opacity • CT- cystic component • Color Doppler ultrasound- anomalous vessels • MRI- venous drainage

36. Treatment • Surgical resection • Thoracoscopy • Arterial embolization

37. Hemorrhage Empyema Hemothorax Hemoperitoneum Air leak Bronchopleural fistula Wound infection Atelectasis Infections Secretions management Respiratory failure Complications

38. Prognosis • With hydrops fetalis- dismal • Without hydrops - excellent

39. Baby boy M is presently being followed in our high risk clinic, growing and developing without significant pulmonary residuals.