Ann Thorac Surg 1996;61:1535-1536
© 1996 The Society of Thoracic Surgeons
Case Report
Retained Sponge After Thoracotomy That Mimicked Aspergilloma
Hiroaki Nomori, MD,
Hirotoshi Horio, MD,
Tokio Hasegawa, MD,
Tsuguo Naruke, MD
Departments of Surgery and Plastic Surgery, Saiseikai Central Hospital, Tokyo, Japan
Accepted for publication November 3, 1995.
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Abstract
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A 63-year-old man, who had had operation for the treatment of pulmonary tuberculosis 40 years before the present disorder, was admitted to our hospital with massive hemoptysis. Radiologic examinations showed a mass shadow with a crescent air sign resembling aspergilloma. Operative exploration showed a well-encapsulated retained surgical sponge between the middle and lower lobes. A bronchial fistula was present in the lower lobe. The appearance of the crescent air sign was caused by drainage of exudative effusion around the retained sponge. Intrathoracic retained surgical sponges associated with bronchial fistula should be included in the differential diagnosis of patients who have mass shadows with crescent air signs but no evidence of Aspergillus infection, and who have a history of thoracotomy.
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Introduction
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Although there have been several reports of intraperitoneal retained surgical sponges [1, 2], intrathoracic sponges rarely have been reported [3]. We present a case of an intrathoracic retained surgical sponge, which had been left at the site of operation for pulmonary tuberculosis 40 years before resembled aspergilloma in both clinical symptoms and radiologic findings. We also reviewed four reported cases of intrathoracic retained surgical sponges that also showed clinical and radiologic findings resembling aspergilloma [4–6].
The patient was a 63-year-old man. He had received a thoracoplasty and segmentectomy of the right upper lobe for the treatment of pulmonary tuberculosis at another hospital in 1955. A chest roentgenogram in 1961 showed a mass shadow 10 x 6 cm in size in the middle lung field, but no further examination or treatment was performed because he had no symptoms. Since 1977, he had complained of hemosputum every 1 or 2 years. On March 7, 1995, he suddenly complained of massive hemoptysis and was admitted to Saiseikai Central Hospital.
Chest roentgenography, computed tomographic scan, and magnetic resonance imaging scan showed a thin-walled cavitary lesion consisting of a homogeneous mass and an air crescent, which resembled aspergilloma (Figs 1, 2
). The size of the lesion was decreased to 7 x 5 cm compared with that in 1961. However, the computed tomography-guided biopsy did not show Aspergillus, and the serum anti-Aspergillus antibody levels were negative. Bronchoscopy showed a coagulum in the anterior basal bronchus of the right lower lobe, which was suspected to be the drainage bronchus. Laboratory examination showed low-grade inflammation, ie, 0.4 mg/dL of C-reactive protein, a blood sedimentation rate of 27 mm/h, and a white blood cell count of 5,900/µL. Bronchial angiography showed a remarkable increase in flow of the vessels to the capsule of the cavitary lesion.
Thoracotomy revealed a well-encapsulated retained surgical sponge, measuring 5 x 4 cm, between the middle and lower lobes. A bronchial fistula was present in the lower lobe. The lesion was opened, and a fenestra was made. After 2 months, the bronchial fistula was closed by suture, and the lesion was obliterated by intrathoracic transposition of the major pectoralis muscle flap. The postoperative course was satisfactory, and the patient was discharged from the hospital 1 month after the last operation.
On pathologic examination, the specimen consisted of a standard size surgical sponge containing fibrinoid necrotic material. Bacteriologic examination showed no infection, including tuberculosis and Aspergillus.
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Comment
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There have been several reported cases of intrathoracic retained surgical sponges in Japan. Of these, 4 cases radiologically showed a mass shadow partially surrounded by an air crescent [4–6], resembling aspergilloma. All of these cases were associated with bronchial fistula. The symptoms were hemosputum or hemoptysis in 4 cases and fever in 1 case, which also resembled those of aspergilloma.
It has been reported that intraperitoneal retained surgical sponges may cause fistula in the gastrointestinal tract [1, 2]. Similarly, the present case was associated with a bronchial fistula and showed radiologic findings resembling aspergilloma by the following mechanisms: (1) the retained surgical sponge between the middle and lower lobes caused an aseptic response that created encapsulation, resulting in a foreign body granuloma; (2) the granuloma compressed the lung, causing inflammation; and (3) the inflammation created the bronchial fistula, which drained the exudative effusion, resulting in a decrease of the lesion and appearance of a crescent air sign.
Intrathoracic retained surgical sponges should be included in the differential diagnosis of patients who have aspergilloma-like mass shadows but no evidence of Aspergillus infection, and who have a history of thoracotomy.
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Footnotes
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Address reprint requests to Dr Nomori, Department of Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108, Japan.
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References
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- Choi BI, Kim SH, Yu ES, Chung HS, Han MC, Kim CW. Retained surgical sponge: diagnosis with CT and sonography. AJR 1988;150:1047–50.[Abstract/Free Full Text]
- Mason LB. Migration of surgical sponge into small intestine. JAMA 1968;205:938–9.[Abstract/Free Full Text]
- Taylor FH, Zollinger RW, Edgerton TA, Harr CD, Shenoy VB. Intrapulmonary foreign body: sponge retained for 43 years. J Thorac Imaging 1994;9:56–9.[Medline]
- Sasai T, Sakakibara S, Kaji M, et al. A case report of thoracic foreign body resembling fungus ball on chest X-ray [Abstract]. Thorac Surg 1989;42:138–40.
- Mizutani S, Sugie T, Yoshida N, Koyama A, Mori J, Kawabata Y. Two cases of gauze foreign body appearing with a meniscus sign [Abstract]. J Jpn Soc Bronchol 1990;12:322–7.
- Kawashima M, Katoh O, Aoki Y, Nakahara Y, Yamada H. A case of gauzeoma with recurrent massive hemoptysis mimicking aspergilloma [Abstract]. Jpn J Thorac Dis 1994;32:152–5.
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Abstract
Introduction
