A man undergoing evaluation for liver transplantation was construct to have an asymptomatic chest mass.

A man undergoing evaluation for liver transplantation was construct to have an asymptomatic chest mass, which further evaluation revealed to be pulmonary varices. The left hilar lesion was discovered upon a screening chest x-ray film and confirmed by dint of a computed tomographic scan of the thoracic cavity. Bronchoscopy was nondiagnostic, and a thoracotomy was required to diagnose the vascular lesion and restrain carcinoma. The pathophysiology of this pulmonary venous anomaly appeared to be related to portal hypertension, since esophagogastric and colonic varices also were near and the pulmonary varices resolv after liver transplantation. This is the first reported case of pulmonary varices caused through portal hypertension.

(Chest 1994; 106:294-96)

OLT=orthotopic liver transplantation

Pulmonary varices are rare anomalies of pulmonary veins set up most often in patients with cardiovascular disease.(1) They are characterized by way of aneurysmal dilation of otherwise normal pulmonary veins and ofttimes present as a pulmonary or mediastinal mass lesion in succession a chest roentgenogram.(2) We report a case of pulmonary varices presenting as a solitary lung mass in a patient with end-stage liver disease and portal hypertension undergoing evaluation for orthotopic liver transplantation (OLT)

CASE REPORT

A 57-year-old Japanese man was evaluated at California Pacific Medical Center in September 1991 for OLT In 1979 abnormal liver biochemical exhibitions were noted on a routine profile obtained during an annual physical examination. Evaluation at that time revealed evidence of previous hepatitis B infection with a positive anti-HBc and anti-HBs. A history of social alcohol usage was obtained. After clean evaluation, chronic non-A, non-B hepatitis was diagnosed forward the basis of exclusion. He remained asymptomatic until 1984 when hematemesis occurr Endoscopy revealed bleeding esophageal varices, which were treated with a course of sclerotherapy. He was initially evaluated for OLT at another institution in 1986 however he was believed to have compensated cirrhosis and follow-up was approveed The patient later developed jaundice, significant pruritus, ascites controll with diuretics, and mild encephalopathy requiring chronic therapy with lactulose. Easy bruisability and spontaneous bleeding also were noted. Because of progressive deterioration in hepatic function, he was reevaluated at California Pacific Medical Center for OLT

The patient was establish to have antibody to hepatitis C virus from the first generation enzyme-linked immunosorbent assay touchstone Upper endoscopy revealed large 3+ nonbleeding esophageal varices. Screening flexible sigmoidoscopy documented prominent internal hemorrhoids and large toruous veins in the sigmoid colon consisten with colonic varices. A chest x-ray film revealed a left hilar mass (Fig 1) Comput tomographic scan confirmed the carriage of a mass in the left hilum (Fig 2) and prominent perigastric and esophageal varices also were noted. Skin testing with purified protein derivative was nonreactive. Bronchoscopy revealed normal airways with a suspicious protuberance in the distal left upper lobe anterior bronchus. Biopsy revealed solely normal mucosa. To exclude carcinoma of the lung the patient underwent a left thoracotomy. Intraoperatively, large peribronchial and left hilar varices were set up and there was no evidence of tumor. Thoracotomy was complicated by means of postoperative intrathoracic bleeding and worsening of hepatic function with jaundice and stage 4 hepatic coma. He was listed as a high priority for liver transplantation at United Network for Organ Sharing status 4 and transplantation was performed in late September 1991 His posttransplant course was complicated according to cyclosporine neurotoxicity, which responded to decreased dosage, and a persistent left pleural effusion requiring lengthened chest tube drainage. The patient was discharged onward the 19th postoperative day, and he subsequently go [i]or[/i] come backed to Japan in November 1991 A follow-up chest x-ray film revealed full resolution of the left hilar mass. As of March 1993 he continues to do well and has reverted to full employment.

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DISCUSSION

Since the first report of pulmonary varices in 1843 merely 71 cases have been reported.(2) Pulmonary varices usually are associated with mitral regurgitation, mitral stenosis, or other cardiovascular conditions.(2)(3)(4) This pulmonary vascular lesion is in the greatest degree often an incidental finding upon a chest x-ray film, although there are reports of pulmonary varices being diagnosed at the time of thoractomy, angiography, and autopsy. mostly of the lesions have involved the right lower lobe (43 of 71) followed from the left upper lobe (12 of 71) and right upper lobe (6 of 71)(2) simply a few of the anomalous canals have been described in the right middle lobe (3 of 71) and left lower lobe (3 of 71) Patients usually are asymptomatic, if it were not that there are reports of patients who experienced chronic hemoptysis and equal fatal hemorrhage after spontaneous quarrel into the pleural space or a bronchus.(2)

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