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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 462-464

A rare case of an azygos lobe in the right lung of a 45-year-old female


Department of Pulmonary, Ketki Research Institute of Medical Sciences, Nagpur, Maharashtra, India

Date of Submission07-Jan-2020
Date of Decision10-May-2020
Date of Acceptance15-Jul-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Sameer Ashok Arbat
Department of Pulmonary, Ketki Research Institute of Medical Sciences, 275, Central Bazar Road, Ramdaspeth, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_4_20

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  Abstract 


A 45-year-old female, who was a known case of bronchial asthma with a past history of pulmonary tuberculosis (TB) came to us with chief complaints of cough with expectoration and multiple episodes of blood in sputum. The patient was diagnosed with pulmonary TB and had received empirical AKT without microbiological evidence at other health-care centers. At our hospital, she was found to have right paratracheal opacity on chest X-ray. A computed tomography scan of the chest showed an azygos lobe in the right lung. There was consolidation in the azygos lobe that lead to the symptoms of cough and hemoptysis.

Keywords: Azygos lobe, hemoptysis, lung


How to cite this article:
Arbat SA, Arbat AP, Singh T, Deshpande PS. A rare case of an azygos lobe in the right lung of a 45-year-old female. J Datta Meghe Inst Med Sci Univ 2020;15:462-4

How to cite this URL:
Arbat SA, Arbat AP, Singh T, Deshpande PS. A rare case of an azygos lobe in the right lung of a 45-year-old female. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 25];15:462-4. Available from: http://www.journaldmims.com/text.asp?2020/15/3/462/308569




  Introduction Top


Azygos lobe is a rare lung malformation and lacks typical clinical symptoms. It is usually present in the apicomedial portion of the right lung and is separated from the rest of the lung by a convex azygos fissure. It is a developmental anomaly, which is developed during the embryogenic stage due to the defect of the migration of the azygos vein.[1] Mostly, it is diagnosed incidentally while imaging. As reported by various groups, a high-resolution computerized tomography (HRCT) scan and chest radiograph show 1.2% and 0.4% prevalence of the azygos lobe, respectively. Clinicians and surgeons should know about the azygos lobe in avoiding misdiagnosis. Other complications of the azygos lobe include pneumothorax, atelectasis, bronchiectasis, and hemoptysis. Thus, the awareness to clinical implication and anatomical knowledge about the azygos lobe is required, which, in turn, will ensure the best plan to diagnose and handle it in different clinical manifestations.


  Case Report Top


The present case report describes a rare anatomical variation of the right lung, found incidentally on a computerized tomography scan in a 45-year-old female patient, who was a known case of bronchial asthma and had a past history of pulmonary tuberculosis (TB) for which she received? AKT empirically in 2012 with no microbiological evidence. This anomalous structure was not identified earlier during her course of the treatment in multiple other hospitals. The patient was treated with antibiotics and antitussive without significant relief of symptoms. Now, she presented at our hospital, with complaints of cough with expectoration for the past 8 days, and she also had multiple episodes of blood in sputum for the past 2 days. On imaging studies, a peculiar finding was noted in the right lung and was recognized as an azygos lobe [Figure 1],[Figure 2],[Figure 3]. On further investigation, it was found that the azygos lobe was infected due to the accumulation of secretions. We performed bronchial washing, which was sent for further investigations. The patient was discharged on antibiotics.
Figure 1: Chest X-ray (postero-anterior view). Chest X-ray showing Type C azygos lobe (represented by →) with medially located trigonum simulating a mediastinal mass

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Figure 2: (a and b) High-resolution computerized tomography chest showing azygos lobe.High-resolution computerized tomography image (mediastinal and parenchymal window) of the patient with azygos lobe in the right lung (represented by yellow colored →)

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  Discussion Top


Azygos lobe was first described by Heinrich Wrisberg in 1778.[2] An azygos lobe is a rare, but normal anatomic variant of the right upper lobe found in 1% of anatomical specimens[3],[4] and is twice as common in males than that of females.[5] In our case, the patient was female who is less prevalent. Azygos lobe is often misdiagnosed as it may mimic an enlarged thymus, a substernal goiter, a localized pneumothorax, bulla, lung abscess, or neoplasm.[3],[4] As described by Ndiaye et al., there are three types of azygos fissure, namely Type A, Type B, and Type C.[2] According to the author, Type A is a more or less horizontal fissure that cuts the lateral portion of the lung between the apex and a point located 2 cm above. On the contrary, Type B and Type C are the vertical fissures. Type B divides the apex into two lateral halves, whereas Type C starts from the mediastinal aspect of the lung and cuts off a small portion of the upper lobe, which is fixed above the root of the lung. Our case was consistent with Type C. Ndiaye et al., also reported that, a very deep fissure may compress the underlying bronchus draining the azygos lobe and thus lead to atelectasis or bronchiectasis.[2] Such findings were not observed in the present case.

Azygos lobe is usually an incidental finding. As reported, its frequency varies from 0.4% to 1.2% on chest radiograph and HRCT scans. Similarly, in our case, azygos lobe was identified through a chest radiograph; further confirmed by HRCT of the chest. Here, the azygos lobe was located in the apicomedial portion of the right lung and was separated from the rest of the right upper lobe by a visible fissure. The fissure was identified as a fine, convex line on her chest radiograph in the paramediastinal portion of her right lung. Understanding the structure of the azygos lobe is important, thus, bronchoscopy was performed which showed secretions in the right upper lobe, and no obvious site of bleeding was seen. The patient had relief after receiving 3 days of intravenous antibiotics and treatment for bronchial asthma. The patient was discharged with follow-up after 7 days.

In general, azygos lobe is documented to be present at the right lung; however, the rarest case of the left lung azygos lobe is also reported.[6]

Recognition of azygos lobe is important for thoracoscopic procedure as partial obstruction of surgical site view has been reported by Smith et al.[7] during thoracoscopic sympathectomy. In general, azygos fissure helps in preventing the spread of infection to the azygos lobe from the different parts of the lung. However, many cases of recurrent hemoptysis as a complication of azygos lobe have been reported,[8] which was also present in our case. Spontaneous pneumothorax, as a complication of azygos lobe, has been reported.[9] Such patients can be misdiagnosed as TB, as seen in our case.[10],[11],[12],[13],[14],[15],[16]


  Conclusion Top


Azygos lobe is a rare challenging variant of lung malformation that is often mislead as other pathological interpretations. Similarly, in our case, where a female patient with azygos lobe in the right lung was given antitubercular medication during her treatment at multiple other hospitals. At our center, azygos lobe was detected through the chest X-ray and HRCT scan. Azygos lobe was infected, which lead to multiple episodes of blood in sputum in the patient. Thus, we conclude that, the knowledge of this rare variant is needed to avoid misdiagnosis and entail the proper line of treatment.

Acknowledgment

We would like to thank Dr. Swapnil Bakamwar of KRIMS Hospital, Nagpur, India, who provided expertise and insight in this case study.

We thank our colleague, Dr. Sweta R. Chourasia, for assisting in compilation and writing this case report.

We thank Hemant Balapure, Technician, KRIMS Hospital, Nagpur, India, for assisting in the bronchoscopy procedure.

Declaration of patient consent

The authors certify that they had obtained an appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name will not be published, and due efforts will be made to conceal her identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mata J, Cáceres J, Alegret X, Coscojuela P, De Marcos JA. Imaging of the azygos lobe: Normal anatomy and variations. AJR Am J Roentgenol 1991;156:931-7.  Back to cited text no. 1
    
2.
Ndiaye A, Ndiaye NB, Ndiaye A, Diop M, Ndoye JM, Dia A. The azygos lobe: An unusual anatomical observation with pathological and surgical implications. Anat Sci Int 2012;87:174-8.  Back to cited text no. 2
    
3.
Felson B. The azygos lobe: Its variation in health and disease. Semin Roentgenol 1989;24:56-66.  Back to cited text no. 3
    
4.
Salve VT, Atram JS, Mhaske YV. Azygos lobe presenting as right para-tracheal shadow. Lung India 2015;32:85-6.  Back to cited text no. 4
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5.
Caceres J, Mata JM, Andreu J. The azygos lobe: Normal variants that may simulate disease. Eur J Radiol 1998;27:15-20.  Back to cited text no. 5
    
6.
Lesser MB. Left azygos lobe. Report of a case. Dis Chest 1964;46:95-6.  Back to cited text no. 6
    
7.
Smith J, Karthik S, Thorpe JA. Pulmonary azygous lobe: A potential obstacle during thoracoscopic sympathectomy. Eur J Cardiothorac Surg 2004;25:137.  Back to cited text no. 7
    
8.
Denega T, Alkul S, Islam E, Alalawi R. Recurrent hemoptysis – A complication associated with an azygos lobe. Southwest Respir Crit Care Chron 2015;3:?44-7.  Back to cited text no. 8
    
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Asai K, Urabe N, Takeichi H. Spontaneous pneumothorax and a coexistent azygos lobe. Jpn J Thorac Cardiovasc Surg 2005;53:604-6.  Back to cited text no. 9
    
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Ganasathi K, Jadhav U, Belsare A. To Study the Utility of Fibreoptic Bronchoscopy in Diagnosis of Various Lung Conditions: A Study Protocol. Int J Pharm Res 2019;11:2022–25. Available from: https://doi.org/10.31838/ijpr/2019.11.04.504. [Last accessed on 2019 Nov 18].  Back to cited text no. 10
    
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Lalwani L, Kazi A, Quazi N, Quazi Z, Gaidhane A, Taksande A, et al. Study Protocol for a Randomised Controlled Trial Comparing the Effect of Lung Recruitment Manoeuvres as an Adjunct to Conventional Chest Physiotherapy in Postoperative Paediatric Congenital Heart Disease Patients on Mechanical Ventilation. Eur J Mol Clin Med 2020;7:2588-97.  Back to cited text no. 11
    
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Sharma SK, Chaubey J, Singh BK, Sharma R, Mittal A, Sharma A. Drug Resistance Patterns among Extra-Pulmonary Tuberculosis Cases in a Tertiary Care Centre in North India. Int J Tuberc Lung Dis 2017;21: 1112-17. Available from: https://doi.org/10.5588/ijtld.16.0939. [Last accessed on 2019 Nov 18].  Back to cited text no. 12
    
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Sharma T, Ghewade B, Jadhav U, Chaudhari S. Clinical Profile of Lung Cancer at Acharya Vinoba Bhave Rural Hospital. J Datta Meghe Inst Med Sci Univ 2017:12:41-4. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_21_17. [Last accessed on 2019 Nov 18].  Back to cited text no. 13
    
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Dhamgaye TM. In Reply: Latent TB Treatment in Pregnant Women: A Patient Perspective. Int J Tuberc Lung Dis 2020;24:1226-7. Available from: https://doi.org/10.5588/ijtld.20.0390. [Last accessed on 2019 Nov 18].  Back to cited text no. 14
    
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Dhamgaye TM, Bhaskaran DS. An Unusual Pulmonary Metastatic Manifestation of Gestational Choriocarcinoma: A Diagnostic Dilemma. Lung India 2017;34:490-1. Available from: https://doi.org/10.4103/lungindia.lungindia_77_14. [Last accessed on 2019 Nov 18].  Back to cited text no. 15
    
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Abbafati C, Machado DB, Cislaghi B, Salman OM, Karanikolos M, McKee M, et al. Five insights from the Global Burden of Disease Study 2019. Lancet 2020;396:1135-59.  Back to cited text no. 16
    


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