AB 27. Unusual presentation of a pulmonary hamartoma

Background: Presentation of an unusual case of pulmonary hamartoma.
Materials and methods: Clinical presentation, imaging and outcome.
Results: A male patient, 73 years old, ex-smoker, 80 pack-years, was admitted at the outpatient department, complaining of acute, intense dyspnea, right-sided and retrosternal chest pain for the past few hours and hemoptysis for the past 12 days. Medical history: chronic obstructive airway disease (FEV₁: 1.72 L - 63% predicted), carotid and abdominal aortic aneyrysm and two temporary ischemic vascular episodes. Chest radiograph showed elevation of the right hemidiaphragm, infiltrates at the right upper and middle lung field and traction of the trachea to the right. Due to resistant hypoxemia (pO₂: 49 mmHg, pCO₂: 39 mmHg, ph: 7.4 on 30 lt O₂/min) he was intubated and put on mechanical ventilation. After intubation his radiograph showed complete atelectasis of the right lung. Computed tomography with i.v. contrast infusion revealed no vascular thrombi, but a thelomatous projection in the lumen of the right main bronchus, causing atelectasis to segments of all the lobes of the right lung. Bronchoscopy was performed, showing a mass occluding the right main bronchus. Two successful attempts were made for partial debulking of the mass bronchoscopically, as the initial oxygenation of the patient was difficult, with an FiO₂ of 100%. With a tentative diagnosis of hamartoma, a right upper lobectomy (sleeve resection) was performed (the mass originated from the posterior segment of the upper lobe) and hamartoma was confirmed. Afterwards the patient had pump failure and required tracheostomy and prolonged mechanical ventilation with gradual amelioration. The tracheostomy was finally closed and the patient was released in excellent condition after a two-month hospital stay. Pulmonary hamartomas usually present as an asymptomatic peripheral nodule and are the commonest benign pulmonary nodules (75%). In big series endobronchial localization is less than 6%, while in another study obstructive signs were present in 14%. The present case was unusual in that it presented with respiratory failure requiring intubation, due to the position of the lesion very close to the origin of the right mainstem bronchus.
Conclusions: Even benign pulmonary tumors may mimick an advanced lung carcinoma, so special attention is needed in the diagnostic procedures.