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Finger-in-Glove Sign in Congenital Bronchial Atresia

Can Respir J Vol 22 No X Month 2015 1
©2015 Pulsus Group Inc. All rights reserved
Finger-in-glove sign in congenital bronchial atresia
Miguel Ariza-Prota MD1, José Luis Diez Jarilla MD, Amador Prieto MD2,
Ana Pando-Sandoval MD1, Pere Casan MD1
1Hospital Universitario Central de Asturias (HUCA). Instituto Nacional de Silicosis (INS). Área del Pulmón. Facultad de Medicina.
Universidad de Oviedo. Oviedo. España; 2Hospital Universitario Central de Asturias (HUCA). Departamento de Radiología. Oviedo, España.
Correspondence: Dr Miguel Angel Ariza Prota, Instituto Nacional de Silicosis (INS), Área del Pulmón, Hospital Universitario Central de Asturias
(HUCA), Facultad de Medicina, Universidad de Oviedo, Avenida Roma s/n, Oviedo, Asturias 33011, Spain.
Telephone 34-69006806, e-mail
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, branch-
ing 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 vascular-
ity of the left upper lobe (Figure 1B). Three-dimensional reconstruc-
tion of the bronchial tree revealed an atretic apicoposterior segmental
bronchus of the left upper lobe confirming the diagnosis of congenital
bronchial atresia (Figure 1C).
• 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
1. Nussbaumer-Ochsner Y, Kohler M. Finger-in-glove sign in bronchial
atresia. Thorax 2011;66:182.
2. Jederlinic PJ, Sicilian LS, Baigelman W, Gaensler EA. Congenital
bronchial atresia. A report of 4 cases and a review of the literature.
Medicine 1986;65:73-83.
Finger-in-glove sign and other CT and radiographic features.
Radiographics 2008;28:1369-82.
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 (arrow). No division of the corresponding bronchi, confirming the
diagnosis of left upper lobe congenital bronchial atresia (arrows)
The ‘Images in Respiratory Medicine’ section of the Canadian
Respiratory Journal aims to highlight the importance of visual inter-
pretation, whether physiological, radiological, bronchoscopic, sur-
gical/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).
... En la radiografía se puede identificar hiperlucidez en el 67% de los casos debido al atrapamiento aéreo, nódulo o masa hiliar radiopaca correspondiente al mucocele (incluyendo el signo del «dedo en guante») 8 en el 89% de los pacientes o ambos hallazgos en el 67%. 9 La TAC es más sensible que la RT en la detección de hiperinsuflación, en la descripción de la morfología del broncocele y de la vasculatura anómala. 2 El reconocimiento de esta condición infrecuente implica plantear diagnóstico diferencial con las alteraciones incidentales y focales de la vía aérea en adultos que generen compactación de moco como aspergilosis broncopulmonar alérgica, fibrosis quística, obstrucciones adquiridas (cuerpos extraños, neoplasias) y broncolitiasis. 2,6,8 Uno de los métodos para descartar diagnósticos diferenciales es la broncoscopia, que podría permitir la identificación extremo ciego del bronquio atrésico; sin embargo, dependerá que tan distal se localice la atresia. 1 Las broncoscopias realizadas a los casos presentados no identificaron anomalías endobronquiales, siendo reportadas como normales. ...
... El paciente asintomático por lo común no requiere tratamiento, reservándose la resección quirúrgica del área afectada para los pacientes que presenten complicaciones importantes como infecciones a repetición o que comprometan una porción significativa del parénquima pulmonar. 6,8 El tratamiento definido en nuestros casos, de acuerdo a la presentación clínica correspondió a manejo expectante o conservador. conclusión La serie de casos presentada permitió realizar una comparación con los aspectos de la AB descritos en la literatura, ...
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Mucoid impaction is a relatively common finding at chest radiography and computed tomography (CT). Both congenital and acquired abnormalities may cause mucoid impaction of the large airways that often manifests as tubular opacities known as the finger-in-glove sign. The congenital conditions in which this sign most often appears are segmental bronchial atresia and cystic fibrosis. The sign also may be observed in many acquired conditions, include inflammatory and infectious diseases (allergic bronchopulmonary aspergillosis, broncholithiasis, and foreign body aspiration), benign neoplastic processes (bronchial hamartoma, lipoma, and papillomatosis), and malignancies (bronchogenic carcinoma, carcinoid tumor, and metastases). To point to the correct diagnosis, the radiologist must be familiar with the key radiographic and CT features that enable differentiation among the various likely causes. CT is more useful than chest radiography for differentiating between mucoid impaction and other disease processes, such as arteriovenous malformation, and for directing further diagnostic evaluation. In addition, knowledge of the patient's medical history, clinical symptoms and signs, and predisposing factors is important.
A 31-year-old, HIV-positive man presented with a history of chronic dry cough. Chest x-ray showed a rounded, branching opacity in the left upper lung (finger-in-glove sign,figure 1A). CT showed mucoid impaction, segmental hyperlucency and decreased vascularity of the left upper lobe (figure 1B). 3D reconstruction of the bronchial tree revealed an atretic apicoposterior segmental bronchus of the …
The clinical, radiographic, and pathologic findings in 82 patients with congenital bronchial atresia (CBA) have been reviewed, and we have discussed 4 additional cases. Most patients are asymptomatic and come to attention because of abnormal radiographic findings of a round or lobulated perihilar, solid, or cystic mass--the mucoid impaction sign. Typically, the region distal to the mass is hyperinflated. Recently, computed tomography has been shown to be diagnostic and its use obviates the need for other more complex imaging modalities or surgical exploration. Excisional surgery has been performed to preserve lung function in younger patients, because of lack of familiarity with the entity or, as in 2 of our cases, to prevent recurrent infections. Pathologic findings include a cystic, blindly terminating, mucus-filled bronchocele without connection to the main bronchial tree, but with normal subsequent generations of bronchi. Distally there is noncollapsible hyperinflation of the corresponding lung segment or lobe as the result of collateral ventilation from the surrounding lung. The anomaly is the result of an insult to the growing bronchial tree in early development. The differential diagnosis most often includes allergic bronchopulmonary aspergillosis, but cystic bronchiectasis, bronchogenic cysts, and intrapulmonary sequestration should also be considered. Unusual features in our 4 cases included recurrent pulmonary infections in 2 patients and thoracic cage asymmetry in 1.