Attending Pulmonary and Critical Care Physician The Jewish Hospital of Cincinnati - Mercy Health, United States
Introduction: Right Middle lobe Syndrome (RMLS) is an under-recognized cause of recurrent atelectasis. It may present as recurrent pneumonia and chronic productive cough. Its treatment is by managing the underlying etiology. It is unusual for activated charcoal aspiration to cause RMLS. We present a case of RMLS persisting for twenty-four-years after charcoal aspiration after detoxification to broaden the literature of long-term sequelae of charcoal aspiration and non-obstructive RMLS.
Description: DM is a 64-year-old female who, in 1999 had an intentional-medication-overdose and received activated charcoal detoxification with a significant aspiration event. She presented to pulmonology with recurrent pneumonia and bronchitis. Imaging revealed right middle lobe bronchiectasis and scarring. Bronchoscopy was negative. PFT was consistent with COPD. She received treatments with inhalers, steroids, and antibiotics. Her symptoms persisted and bronchoscopy was repeated with biopsies discolored black and cultures negative. She received lobectomy by video-assisted thoracoscopic surgery (VATS) with diffuse pigment deposition and inflammatory changes of the resected specimen. She has since had resolution of her symptoms.
Discussion: Aspiration of charcoal can lead to acute and chronic lung disease. RMLS should be considered in patients with recurrent pulmonary symptoms of productive cough and pneumonia that may be misdiagnosed as pneumonia or acute on chronic COPD and asthma exacerbations. Our case of RMLS was ongoing for over twenty-four years refractory to medical management requiring lobectomy by VATS. Ultimately, the management of this non-obstructive RMLS requiring lobectomy consisted of ICU level care with interdisciplinary teamwork of critical care, pulmonology, and cardiothoracic surgery.
