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A, B: PA and lateral chest X-Ray: Left upper lobe apicoposterior segment opacity obscuring aortic knob (shown by ). Left lower zone opacity obscuring left cardiac border (shown by ).
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Chest X-ray (CXR) was done, with posteroanterior (PA) and lateral views showing left upper zone opacification obscuring the left cardiac knob [Fig. 1A,B].
A: CT angiogram of the chest, MIP coronal. B: MIP parasagittal. C: Coronal reconstructed. There is outpouching contrast content reverse 'S' shape structure of the aorta lateral to the left subclavian artery with peripheral density as shown by ().
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The features were suggestive of aneurysm, which complicated with aortobronchial fistula surrounded by haematoma [Fig. 2A-C].
A CT angiogram of the chest, lung window showing left upper lobe pleural density adjacent to the aortic knob () with surrounding lung density (). B: Bilateral diffuse patchy scattering lung opacities mostly centrilobular () and left lingula inferior segment consolidation ().
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The lingula segment of the left upper lobe had consolidative changes and there were also bilateral diffuse patchy scattering centrilobar opacities, which suggested an active pulmonary infection [Fig. 3A,B].
A: Angiogram of thoracic aorta, showing bovine trunk and focal aneurysm distal to LSA. B: Stentgraft is deployed, resulting in complete occlusion of LSA. Vascular plug (Amplatzer) was deployed at the origin of LSA to prevent endoleak.
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Artery (LCCA) had a common origin with brachiocephalic trunk [Fig. 4A]. At approximately 10 mm distal to the LSA, a focal aneurysm was noted on the proximal descending aorta, with 13 mm base. The appearance suggested a vascular aneurysm (Fig. 4A). TEVAR was performed via the right groin access, using Medtronic navion thoracic stentgraft with coverage of the LSA [Fig. 4B].
A: Through posterolateral thoracotomy, left apico-posterior segment was mobilized from aorta, exposing aortic fistula site as pointed out by the end of the Yankauer suction tip. B: An apico-posterior segment was retracted anteroinferiorly to expose the pulmonary site of the fistula.
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The apical part of apico-posterior segment was attached to the aorta at the fistula site, which on mobilization the two were separated without bleeding [Fig. 5]. Although acid-fast bacilli were not identified [Fig. 5C,D], mycobacterial infection was still favoured.
A: Poorly formed granuloma with admixed chronic inflammation. B: Well formed granuloma with Langhan-type giant cell and central necrosis. C: Granuloma with admixed Langhan-type giant cell. D: Negative Ziehl Neelsen (ZN) stain for fast bacilli.
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Hematoxylin and Eosin (H&E) sections [Fig. 6A,B] showed fibrous connective tissue with poorly formed granulomas while lung sections showed necrotizing granulomatous inflammation.