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Table of Contents
CASE REPORT  
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 419-421
Unusual “cardiac” cause of hemoptysis: Accessory cardiac bronchus


1 Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
2 Department of Cardiothoracic and Vascular Surgery, PGIMER, Chandigarh, India

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Date of Submission20-Aug-2019
Date of Acceptance28-Oct-2019
Date of Web Publication09-Jul-2021
 

   Abstract 


Hemoptysis is a common presenting feature of tuberculosis, pulmonary parenchymal malignancy, bronchiectasis, or a cardiac pathology as mitral stenosis. Relevant clinical history, physical examination, laboratory investigations, and radiology usually identify the cause of hemoptysis in the majority of the cases. We report a case of a 50-year-old male with intermittent hemoptysis which was the presenting feature of accessory cardiac bronchus.

Keywords: Cardiac bronchus, hemoptysis, thoracotomy

How to cite this article:
Dogra N, Singla K, Kajal K, Mahajan S, Biswas I. Unusual “cardiac” cause of hemoptysis: Accessory cardiac bronchus. Ann Card Anaesth 2021;24:419-21

How to cite this URL:
Dogra N, Singla K, Kajal K, Mahajan S, Biswas I. Unusual “cardiac” cause of hemoptysis: Accessory cardiac bronchus. Ann Card Anaesth [serial online] 2021 [cited 2021 Aug 4];24:419-21. Available from: https://www.annals.in/text.asp?2021/24/3/419/320930





   Introduction Top


Hemoptysis is a common presenting feature of pulmonary parenchymal and tracheobronchial tree pathologies, a cardiac disorder like mitral stenosis and right-sided infective endocarditis with septic pulmonary emboli, vascular causes as pulmonary embolism, vascular malformations, eroded aortic aneurysms, coagulopathy, and bleeding disorders. Of these, tuberculosis, bronchiectasis, and lung abscess are the most common causes of hemoptysis.[1] Accessory cardiac bronchus (ACB), a rare congenital anomaly of the tracheobronchial tree, is usually an incidental finding which may rarely present with recurrent hemoptysis, infection, or malignant changes. The present case guides the caregivers to be aware of accessory cardiac bronchus as an unusual cause of hemoptysis.


   Case Report Top


A 50-year-old male known smoker, smoking 7-8 cigarettes/day for the last 10 years presented with complaints of intermittent hemoptysis for last 2 years. He denied any history of low-grade fever, loss of appetite, night sweats, weight loss, chest pain, trauma, or breathlessness. There was no history of exposure to any drugs (antiplatelets, anticoagulants) or bleeding disorder. His sputum for acid-fast bacilli (AFB) was negative. Diagnostic evaluation for his symptom on the previous occasions at other hospitals was inconclusive with a normal reported chest X-ray and computed tomography (CT) scan exam. Fiberoptic bronchoscopy findings reported blood in right and left main bronchial system. Presently, his physical examination revealed a temperature of 37°C, pulse rate of 82/min, blood pressure of 142/84 mmHg, respiratory rate of 12/min, oxygen saturation of 98%, normal respiratory sounds, and a normal chest X-ray. Laboratory investigations revealed a normal blood value including normal platelet count and coagulation parameters. His transthoracic echocardiography revealed normal right and left ventricular functions without any evidence of mitral stenosis/right-sided infective endocarditis or pulmonary hypertension. High-resolution CT scan showed localized pocket of air density medial to bronchus intermedius on axial [Figure 1] and coronal sections [Figure 2] suggesting accessory cardiac bronchus. No lung tissue was associated with accessory cardiac bronchus. Subsequent fiberoptic bronchoscopy confirmed accessory cardiac bronchus originating medially from bronchus intermedius opposite to the right upper lobe bronchus, whose lumen was partially obscured by small a clot. Bronchial and pulmonary angiography revealed no abnormality in tracheobronchial tree or pulmonary drainage.
Figure 1: CT scan axial view at the level of right pulmonary artery: arrow showing localized area of air density suggesting ACB arising from the medial wall of bronchus intermedius

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Figure 2: CT scan coronal view. Arrow showing accessory cardiac bronchus as a short blind diverticulum arising from medial wall of bronchus intermedius. There is no associated lung tissue

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A right thoracotomy was performed and accessory cardiac bronchus was identified. ACB extended 3 cm toward pericardium without any associated lobule. It was resected with preservation of vagus nerve. Bronchus intermedius was closed in two layers. Subsequent pathological examination revealed a tubular structure ending blindly with cartilage rings, inflamed and ulcerated mucosa with the collection of neutrophils and fibrous tissue. Hemoptysis was attributed to this inflamed vascularized accessory cardiac bronchus. The patient is asymptomatic currently with no recurrent hemoptysis at 6-month follow-up.


   Discussion Top


Brock defined accessory cardiac bronchus as a “supernumerary bronchus arising from the inner wall of the right main bronchus or intermediate bronchus opposite to the origin of the right upper lobe bronchus.”[2] ACB is a rare anomaly of the tracheobronchial tree with an incidence of 0.07–0.5%.[3],[4] Three types of ACB are described on the basis of bronchographic appearance: 1) Diverticular type with short ACB with a blind end and no associated lung tissue, 2) Tubular type with distal terminal branches ventilating a small lobule, and 3) Intermediate type with long diverticulum ending blindly without terminal branching or a ventilated lobule.[5] ACB in our case was diverticular type. ACB runs in a caudal direction paralleling the intermediate bronchus toward the heart, hence, the name “cardiac bronchus.” ACB is lined by normal bronchial mucosa and has cartilage within its wall, which distinguishes it from an acquired fistula or diverticulum.[2]

ACB is usually an incidental finding reported on CT scan, presenting as an air pocket medial to bronchus intermedius with or without an abnormal area of circumbronchial enhancing tissue representing vestigial lung tissue.[6] Usually present in isolation, ACB has been described with other tracheobronchial anomalies as tracheal bronchus and with anomalous drainage of the right pulmonary artery into left atrium.[2],[7],[8] ACB may present with hemoptysis, malignant changes,[9] or middle lobe syndrome. ACB may be symptomatic due to infection in pooled up secretions in a blind diverticulum. Middle lobe syndrome has been described in conjunction with ACB as any infection in ACB rapidly spreads to the middle lobe bronchus, leading to consolidation due to its close anatomical origin with ACB (on lateral and medial walls of bronchus intermedius, respectively).[10] Although easily recognizable on CT scan and fiberoptic bronchoscopy by its characteristic origin medially from bronchus intermedius, the ACB was missed in our patient on bronchoscopy and CT scan by two different physicians on different occasion, probably suggesting ignorance about its occurrence and low incidence of symptomatic presentation. The present case report highlights the possibility of accessory cardiac bronchus as an unusual cause of hemoptysis and its management by surgical resection if symptomatic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bidwell JL, Pachner RW. Hemoptysis: Diagnosis and management. Am Fam Physician 2005;72:1253-60.  Back to cited text no. 1
    
2.
Ghaye B, Szapiro D, Fanchamps JM, Dondelinger RF, Congenital bronchial abnormalities revisited. Radiographics 2001;21:105-19.  Back to cited text no. 2
    
3.
Ghaye B, Kos X, Dondelinger RF. Accessory cardiac bronchus: 3D CT demonstration in nine cases. Eur Radiol 1999;9:45-8.  Back to cited text no. 3
    
4.
Jackson GD, Littleton JT. Simultaneous occurrence of anomalous cardiac and tracheal bronchi: A case study. J Thorac Imaging 1988;3:59-60.  Back to cited text no. 4
    
5.
Mangiulea VG, Stinghe RV. The accessory cardiac bronchus. Bronchologic aspect and review of the literature. Dis Chest 1968;54:433-6.  Back to cited text no. 5
    
6.
McGuinness G, Naidich DP, Garay SM, Davis AL, Boyd AD, Mizrachi HH. Accessory cardiac bronchus CT features and clinical significance. Radiology 1993;189:563-6.  Back to cited text no. 6
    
7.
Beigelman C, Howarth NR, Chartrand-Lefebvre C, Grenier P. Congenital anomalies of tracheobronchial branching patterns: Spiral CT aspects in adults. Eur Radiol 1998;8:79-85.  Back to cited text no. 7
    
8.
Kwada S, Koide S, Yamazki S, Shohtsu A, Kato S, Watabe T, et al. Direct communication of right pulmonary artery and the left atrium associated with accessory cardiac bronchus. J Japan Assoc 1977;25:1497-503.  Back to cited text no. 8
    
9.
Miyahara R, Hasegawa S, Yoshimura T, Wada H. A case of squamous cell carcinoma arising from accessory cardiac bronchus. Eur J Cardiothorac Surg 2002;22:309.  Back to cited text no. 9
    
10.
Daskalakis MK. Middle lobe syndrome due to Accessory cardiac bronchus. South Med J 1983;76: 941-2.  Back to cited text no. 10
    

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Correspondence Address:
Karan Singla
Department of Anaesthesia and Intensive Care, 4th Floor, Nehru Hospital, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_118_19

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    Figures

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