Case Study: Solitary Pulmonary Hamartoma with Complications in a 14-year-old Girl

Summary

Pulmonary hamartomas are rare, benign lesions of the lung and may be multiple in number. Recently, a 14-year-old girl presented with clinical symptoms of tuberculosis, and after transthoracic biopsy, the diagnosis was confirmed as a solitary hamartoma of the right lung, complicated by recurrent interstitial infections. However, a surgical resection was done, and the patient is now free of symptoms.

Background

Pulmonary hamartomas are uncommon benign lesions of the lung and comprise nearly 8% of all lung tumors. They are usually incidental, small-sized, solitary, peripherally located, asymptomatic lesions that are incidentally detected on a chest X-ray or CT scan, or at autopsy. Occasionally, they may be very big in size and may clinically mimic thymoma, tuberculosis, congenital malformations or malignancy. Recently, a 14-year-old girl presented with clinical symptoms of tuberculosis, and the final diagnosis was found to be a large chondroid hamartoma. We learnt a lot from the case.

Case Presentation

A 14-year-old girl presented with recurrent productive and irritative coughs for the last year. Occasional hemoptysis and intermittent low-grade fever was present. She had features of malnutrition. On clinical examination, basal crypts were present in the lower right lung, anterior aspect. S1/S2 normal. BP: 110/66 mm Hg. Pulse rate: 86/min. Respiratory rate: 26/min. Dullness was present over the right lung, mid to lower zone. Bilateral cervical lymph nodes were enlarged, discrete, hard and multiple, up to 1.5 cm in diameter.

Investigations

Routine hemogram revealed neutrophilic leukocytosis, high ESR, moderate hypochromic microcytic anemia and thrombocytosis. Sputum for AFB was negative. IgE level was [s2If !is_user_logged_in()]…

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BAL fluid studies showed features of acute-on-chronic inflammation. FNAC from neck lymph nodes reported reactive follicular hyperplasia.

X-ray and CT-scan of the chest revealed opacity in the right mid-zone, measuring 8 cm in diameter, neoplastic. Monteux tuberculin test was negative. Transthoracic core needle biopsy was performed.

Histopathology revealed chondroid hamartoma complicated by interstitial pneumonia, consolidation / organising inflammation. No evidence of malignancy or tuberculosis. No specific infective organisms detected. (See Figure 1.)
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Differential Diagnosis

  1. Congenital broncho-pulmonary malformation complicated by inflammation
  2. Tuberculosis
  3. Thymoma
  4. Germ cell tumor
  5. Consolidation / collapse
  6. Benign tumors including hamartomas
  7. Lymphoma
  8. Carcinomas
  9. Abscess
  10. Aspergilloma

Treatment

After a course of broad-spectrum antibiotics and pre-anaesthetic check-up, excision of the tumor was done by cardio-thoracic surgeons.

Outcome and Follow Up

The patient is now doing well, 6 months after surgery.

Discussion

Chondroid hamartomas (CH) of the lung are usually detected in adults, with a peak incidence in the sixth decade.

CHs are usually solitary and well-circumscribed, with an average of 2 cm. A very large size is rare. Sometimes they may be multiple, also. They are of two types, viz., peripheral parenchymal and central endobronchial. The former type, comprising more than 90%, arises from small bronchi and is generally asymptomatic. The remaining smaller number (of endobronchial type) arises from large bronchi and is often associated with obstructive symptoms. Radiologically, CHs account for 7-14% of pulmonary coin lesions. Some cases may show a popcorn pattern of calcification.

Transthoracic FNAC or biopsy can be used to establish the diagnosis as in the present case. It could be detected incidentally during routine imaging studies, but if the duration is long, the scenario could be complicated and might mimic diseases with grave consequences, like tuberculosis and even malignancy. In that case, proper therapy is delayed due to unnecessary investigations and intercurrent infections. Empirically, anti-tubercular drugs were started in this case without any improvement, and of course, the final diagnosis proved that it was unnecessary.

Learning Points/Take Home Messages

Early diagnosis of pulmonary hamartoma is necessary to prevent complications, and trans-thoracic biopsy should be considered in doubtful cases!

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at EKO Diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

 

References (click to show/hide)

  1. Jones RC, Cleve EA. Solitary circumscribed lesions of lung. Arch Intern Med 1954; 93:842-51.
  2. King TE, Christopher KL, Schwarz MI. Multiple pulmonary chondromatous hamartomas. Hum Pathol 1982; 13:496-7.
  3. Hansen CP, Holtveg H, Francis D. Pulmonary hamartoma. J Thorac Cardiovasc Surg 1992; 104:676-8.
  4. Wiatrowska BA, Yazdi HM, Matzinger FR, MacDonald LL. Fine needle aspiration biopsy of pulmonary hamartomas. Radiologic, cytologic and immunocytochemical study of 15 cases. Acta Cytol 1995; 39:1167-74.


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