Finger-in-glove sign in congenital bronchial atresia

A 60-year-old woman was referred to the authors’ hospital in 2012, with a three-month history of nonproductive cough. She had no chest pain, night sweats or fever. She had no known toxic habits, nor surgical or medical background of interest. The chest x-ray showed loss of normal lung markings in the left upper lobe and a rounded, branching opacity mass lesion in the area of the left hilum (finger-in-glove sign) (Figure 1A). A computed tomography scan of the chest showed mucoid impactation, segmental hyperlucency and decreased vascularity of the left upper lobe (Figure 1B). Three-dimensional reconstruction of the bronchial tree revealed an atretic apicoposterior segmental bronchus of the left upper lobe confirming the diagnosis of congenital bronchial atresia (Figure 1C).

Figure 1).

A Posteroanterior radiograph showing loss of normal lung markings in the left upper lobe and a rounded, branching opacity mass lesion (glove-in-finger sign) in the area of the left hilum (white arrow). B Axial computed tomography image revealing mucoid impaction, segmental hyperlucency and decreased vascularity in the left upper lobe. C Three-dimensional reconstruction of the bronchial tree. No division of the corresponding bronchi, confirming the diagnosis of left upper lobe congenital bronchial atresia (arrows)

KEY LEARNING POINTS

• Congenital bronchial atresia is a rare anomaly characterized by normal bronchial ramification from a central blind bronchial sac filled with mucus (mucocoele). The regional hyperinflation is due to a check valve mechanism in the collateral ventilation through the alveolar pores of Kohn, the bronchoalveolar channels of Lambert, or the interbronchiolar channels.

• Distal to the bronchial atresia secretions accumulate, leading to mucoid impaction surrounded by segmental hyperlucency caused by a combination of trapped air and oligaemia.

• The apicoposterior segmental bronchus of the left upper lobe is most commonly affected.

• Sixty percent of patients are asymptomatic, their anomaly being discovered on a routine chest radiograph.

• Computed tomography (with contrast if necessary) is the diagnostic test of choice.

• The differential diagnosis of finger-in-glove sign includes mucus impaction due to cystic fibrosis, allergic bronchopulmonary asperigillosis, broncholithiasis, foreign body aspiration and malignancies.

The ‘Images in Respiratory Medicine’ section of the Canadian Respiratory Journal aims to highlight the importance of visual interpretation, whether physiological, radiological, bronchoscopic, surgical/thorascopic or histological, in the diagnosis of chest diseases. Submissions should exemplify a classic, particularly dramatic or intriguing presentation of a disease while offering an important educational message to the reader (insightful diagnostic pearls or differential diagnosis, etc). This section is not intended to be a vehicle for publication of case reports (see the Clinical-Pathologic-Conferences for case-based leaning series).