2024年 · 第104卷第32期

A 56-year-old male went to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University in March 2017 with "cough and expectoration for more than 3 months and shortness of breath for more than 5 months after activity". Three months ago, I went to the local hospital for complaining of symptoms, and the CT report only showed a small nodule in the upper lobe of the right lung, but there was nothing special. After perfect bronchoscopy, the local hospital diagnosed multiple chondritis of the trachea. Later, he was transferred to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University for further treatment. No obvious abnormalities were found in physical examination, laboratory examination and pulmonary function examination. CT showed that multiple cartilage ring calcification could be seen in the anterior and middle part of the trachea, and local high-density shadows could be seen protruding into the tracheal lumen, and no abnormalities were found in the tracheal membrane (Figure 1); Bronchoscopy showed multiple diffuse nodular proliferative changes in the middle and upper trachea. The nodular lesions were located at the tracheal cartilage ring, showing a star-like appearance, and there were no abnormalities in the mucosa and membrane between the tracheal cartilage ring (Figure 2). Mucosal biopsy was taken under microscope and combined with pathological slides from local hospitals. After pathological consultation, it was shown that mucosal basal cell proliferation, basement membrane thickening, massive lymphocyte infiltration and multifocal cartilage ossification were seen, which was consistent with ossifying tracheobronchiopathy. Symptomatic treatment such as cough relief, phlegm reduction and immune regulation were intermittently given, and long-term outpatient follow-up was performed, and the condition was stable. In May 2021, the patient was admitted to hospital due to aggravation of shortness of breath. There was no significant increase in bronchoscopic lesions after reexamination, and the results of alveolar lavage suggested Staphylococcus aureus infection. After anti-infection, cough and phlegm treatment, he was improved and discharged from hospital. The bronchoscopic features of ossifying tracheobronchopathy are evident. CT has important diagnostic value for this disease. The characteristic CT manifestations are multiple calcified nodules in the anterior wall of trachea, but no abnormalities are found in the membrane of trachea; Its CT findings should be differentiated from tracheal amyloidosis and recurrent polychondritis of trachea. The treatment is mainly symptomatic. If the enlargement of the lesion leads to airway stenosis, respiratory intervention is needed. Therefore, the combination of CT and bronchoscopy is an important means to identify the disease.

The patient, a 62-year-old female, visited the outpatient department of respiratory and critical care medicine of the First Affiliated Hospital of Naval Medical University on December 25, 2021 due to "cough and shortness of breath for more than 1 month". More than 1 month ago, the patient had cough and white phlegm without obvious trigger, accompanied by chest tightness and shortness of breath, obvious when moving and lying down, wheezing sounds could be heard, no chest pain, hemoptysis, and no fever. He is a farmer, has no history of smoking or drinking, and has denied a history of chronic diseases. On physical examination, bipolar wheezing sounds could be heard in the left lung. Laboratory test results: blood routine white blood cells 4.57×10⁹/L, blood neutrophils 47.0%, blood eosinophils 5.7%; Carbohydrate antigen 125 and squamous cell carcinoma-related antigen are within the normal range; Blood gas normal; The pulmonary ventilation function test was normal. Enhanced chest CT showed a soft tissue density shadow at the level of tracheal protuberance, about 1.3 cm in diameter. The CT value of plain scan was 23.5 HU, and the CT value after enhancement was 25.7 HU (Figure 1). Bronchoscopy showed a spherical neoplasm near the left main bronchial opening in the lower trachea (Figure 2). The surface mucosa of the neoplasm was smooth and the blood supply was abundant. The neoplasm was removed by trap. Pathology and immunohistochemistry confirmed that it was tracheal leiomyoma. The patient's cough and asthma improved significantly after operation, and occasionally coughed a small amount of dark red bloody sputum. He was discharged 3 days later. One outpatient CT follow-up one year later showed no tumor recurrence.

The patient, a 63-year-old male, underwent "combined thoracolaparoscopic resection of cardia cancer and gastroesophagothoracic anastomosis" for "poorly differentiated adenocarcinoma of the cardia". Neoadjuvant chemoradiotherapy was performed before surgery. Fever occurred on the 12th postoperative day, and chest CT was performed after oral administration of meglumine diatrizoate, which showed an air-containing cavity in the posterior mediastinum. The proximal end of this cavity communicated with the left main bronchus (Fig. 1, arrow) and the distal end communicated with the esophagogastric anastomosis (Fig. 2, arrow). Intraesophageal contrast medium was filled into the mediastinal cavity (Fig. 2, triangle). Bedside bronchoscopy showed mucosal erosion of the left main bronchial wall, covered with purulent coating, and a fistula in between (Figure 3, arrow). Diagnosis of esophageal-mediastinal-bronchial fistula, secondary mediastinitis possible. The patient's family requested conservative treatment. Two days later, the patient's condition worsened, severe pneumonia and septic shock occurred, and his family gave up treatment and voluntarily discharged the hospital. Tracheoesophageal fistula is a serious complication that may occur after surgery of esophageal and cardia tumors. It usually occurs in the left main bronchus and the middle and lower segments of trachea, and its clinical feature is choking and cough after swallowing. Upper gastrointestinal angiography, CT, MRI, bronchoscopy and gastroscopy are useful for diagnosing and distinguishing local anatomical relationships. For suitable patients, endoscopic placement of tracheal and/or esophageal stents may be a therapeutic option for fistula closure. In this patient, tracheoesophageal fistula was complicated after cardia cancer surgery. Combined with the location of the fistula, endotracheal Y-type silicone or metal-covered stent may be considered. However, the family required conservative treatment, and subsequent severe infection occurred with poor outcome.

A 31-year-old male went to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of University of Science and Technology of China (Anhui Provincial Hospital) for "chest pain for 1 month". The patient developed persistent dull pain in the right chest 1 month ago, which gradually worsened, without cough, hemoptysis, asthma, fever, etc. He had a history of smoking for more than 10 years, with an average of 20 cigarettes a day, and had not quit smoking. Career as a truck driver. A family genetic history is denied. CT of the patient's chest showed multiple irregular cystic lesions in both upper lungs with different sizes, accompanied by multiple nodules (Figures A ~ C), bone destruction of the sternal stem and thoracic 4 vertebrae with soft tissue density shadows, and Langerhans cell histiocytosis (LCH) is considered to be more likely. Sternal soft tissue biopsy was performed. The pathological results showed that Langerhans histiocyte proliferation with a large amount of eosinophil infiltration. Immunohistochemical results showed that CD1a (+), Langerin (+), S100 (+), CD68 (+), CD4 (+), BRAF V600E (+), CD21 (-), CD35 (-), CD (-), Ki-67 (+, about 20%). LCH is a rare disease of unknown cause characterized by infiltration and destruction of adjacent structures by Langerhans cells, the organs most commonly invaded include bones, lungs, skin, lymph nodes, and the pituitary gland. Pulmonary LCH is more common in young smokers and more common in men. It is manifested as nodular lesions in both lungs, which may be accompanied by diffuse cystic lesions, mainly in the middle and upper lung fields, and the cystic lesions may increase with the progression of the disease. This patient was a young man with a long history of heavy smoking. Multiple irregular cystic lesions with nodular shadows in both upper lungs were seen on chest CT. Finally, LCH was confirmed by tissue biopsy pathology.