Intrapulmonary teratoma misdiagnosed as lung abscess

doi:10.21203/rs.3.rs-1651651/v1

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Intrapulmonary teratoma misdiagnosed as lung abscess

https://doi.org/10.21203/rs.3.rs-1651651/v1

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Background: Intrapulmonary teratoma (IPT) is a rare type of extra gonadal teratoma. Due to the non-specific symptoms, it can be easily misdiagnosed as other diseases. The patient with IPT in our case was initially misdiagnosed with lung abscess, although he underwent bronchoscopy and percutaneous lung puncture biopsy.

Case presentation: We reported an intrapulmonary teratoma in a 42-year-old male, who has persistent cough, expectoration and hemoptysis symptoms. Chest computed tomography showed a cavitary mass in the left upper lobe with heterogeneous components. The patient was misdiagnosed with lung abscess at first, who underwent some invasive examinations and was administered different antibiotics in peripheral hospitals. The mass containing silky and nonpigmented hairs were found in the left upper lobe by bronchoscopy in our hospital. Considering the rare bronchoscopic appearance, surgical resection was recommended and postoperative histopathologic examination finally confirmed the diagnosis of IPT.

Conclusion: IPTs usually present non-specific symptoms and indistinguishable chest images, which can be easily misdiagnosed. The presences of fat and sebaceous material or masses of hair are highly specific and pathognomic signs for IPT. Accurate diagnosis and prompt treatmemt are of great significance for the prognosis of patients with IPT.

Teratoma

Lung

Case report

Pathology

Teratomas are uncommon neoplasms derived from germ cells and are characterized by the presence of virtually any tissue type[1]. Intrapulmonary teratomas (IPT) as a type of extragonadal teratoma is considered extremely rare, which can occur at any age[2]. Primary lung teratomas have rarely been first reported by Mohr in 1839. IPTs usually present non-specific symptoms such as cough, sputum, hemoptysis and fever, which can be easily misdiagnosed as other diseases, particularly in cases with cavitary mass[3–4]. This report describes the management of a rare case of benign intrapulmonary teratoma in a 42-year-old male involving the left upper lobe of the lung. Although the patient underwent some invasive examinations, he was initially misdiagnosed before operation .

A 42-year-old male was transferred to our hospital as a case of intermittent cough, expectoration and hemoptysis for over 1 year. He denied any fever, rashes, fatigue, chest pain, dyspnea, weight loss, or a history of smoking. Chest computed tomography showed a heterogeneous components-containing lesion measuring 5.6× 3.1 cm in the left upper lobe 1 year ago(Fig. 1).

Subsequently, he reported a previous admission due to cough and hemoptysis in which the left upper bronchial infection was diagnosed by bronchoscopy. Then his symptoms alleviated after antibacterial treatment. One month ago, the patient's cough and expectoration symptoms were more severe than before. Chest CT scan showed that the lesion in the left upper lobe of the lung was larger. Computed Tomography guided percutaneous lung biopsy failed to identify tumor cells or pathogens in the peripheral hospital. A serum tuberculosis antibody test was negative. Considering the symptoms of persistent cough, expectoration and cavitary lesion of chest images, the patient was diagnosed with lung abscess and was treated with different antibiotics. However, his symptoms were not relieved and accompanied by intermittent hemoptysis. He was transferred to our hospital and chest computed tomography showed a cavitary mass(5.9 × 5.9 cm) in the left upper lobe with heterogeneous components(Fig. 2).

Silky and nonpigmented hairs were found in the left upper lobe by bronchoscopy(Fig. 3).

Considering the rare bronchoscopic appearance, the diagnosis of IPT was suspected and surgical resection was recommended.

Subsequently, the patient underwent left upper lobectomy via a posterolateral thoracotomy through the fourth intercostal space in the thoracic surgery department of our hospital. The specimen revealed a solid-cystic mass containing calcifications, sebaceous materials and hairs. Histopathological examination revealed a mature cystic intrapulmonary teratoma without any malignant cells(Fig. 4).

Teratomas are rare neoplasms composed of tissue elements derived from the germinal layers of the embryo with a low malignant transformation potency. IPT refers to the primary tumor in the lung without teratoma in the mediastinum, due to their slow growth and voluminosity of the lung, presents mostly at the 3rd decade[2].

Most of the previous studies of IPTs are case reports[5–6]. The definitive diagnosis is only achieved following histopathological analysis of postoperative specimen, CT guided lung biopsy and bronchoscopic biopsy. Teratomas can be divided into benign and malignant according to the degree of tumor differentiation. Due to the rarity, non-specific symptoms, normal laboratory test results, and indistinguishable chest images, intrapulmonary teratoma is easy to be misdiagnosed as other diseases, particularly in cases with cavitary lesions, including pulmonary tuberculosis, lung abscess, bronchiectasis, invasive pulmonary aspergillosis, and so on. Similar characteristics have been presented in our case, such as the common clinical symptoms of expectoration and hemoptysis, and cavitary lesions in chest radiography. Due to the failure of bronchoscopy and percutaneous lung biopsy to identify tumor cells or pathogens at first, the patient in our case was initially misdiagnosed with lung abscess and treated with different antibiotics. Re- bronchoscopy plays an important role in the correct diagnosis of the case. The presences of fat and sebaceous material or masses of hair are highly specific and pathognomic signs for IPT. In our case, silky and nonpigmented hairs were found in the left upper lobe by bronchoscopy. Considering the rare bronchoscopic appearance, surgical resection was recommended and postoperative histopathologic examination finally confirmed the diagnosis of IPT.

The tumor was composed of stratified squamous and respiratory epithelium, fat and sebaceous material, and masses of hair.

In conclusion, IPTs usually present non-specific symptoms and indistinguishable chest images, which can be easily misdiagnosed before operation. The presences of fat and sebaceous material or masses of hair are highly specific and pathognomic signs for IPT. Complete surgical resection is the gold standard in the treatment of IPT to avoid malignant transformation[3]. Accurate diagnosis and prompt treatmemt are of great significance for the prognosis of patients with IPT.

IPT: Intrapulmonary teratoma; CT: Computed tomography

Ethics approval and consent to participate

The present study was approved by the Medical Ethics Committee of Shanxi Provincial People's Hospital. The purpose of this report was completely explained to the patient and written inform consent was obtained from the patient.

Consent for publication

Written informed consent for publication of the patient’s clinical details and pathologic images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Availability of data and materials

Data of the patient can be requested from authors. Please write to the corresponding author if you are interested in such data.

Competing interests

The authors declare that they have no competing interests.

Funding

No source of funding.

Authors’ contributions

FL designed the study, collected the data and drafted the manuscript. LZ reviewed the pathological slide and provided the microscopic sections. YW and CY finished bronchoscopy. JH performed the left upper lobectomy. All authors read and approved the final version of the manuscript.

Acknowledgments

Not applicable

Author details

¹Department of Pulmonary and Critical Care Medicine, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012 China. ²Department of Thoracic Surgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi Shanxi 030012 China. ³Department of Pathology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012, China.

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No competing interests reported.

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Intrapulmonary teratoma misdiagnosed as lung abscess

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