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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 41-44

Swyer-James-Macleod Syndrome: A Rare Finding in a Case of Haemoptysis


1 Department of Respiratory Medicine, Command Hospital, Kolkata, West Bengal, India
2 Department of Radiology, Command Hospital, Kolkata, West Bengal, India
3 Department of Respiratory Medicine, MH, Namkum, Ranchi, Jharkhand, India

Date of Submission17-Apr-2020
Date of Decision30-Jun-2020
Date of Acceptance31-Jul-2020
Date of Web Publication15-Feb-2021

Correspondence Address:
Dr. Neeraj Sharma
Pulmonologist, Department of Respiratory Medicine, Command Hospital Eastern Command, Near Visa house, Alipore, Kolkata, West Bengal 700027
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_18_20

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  Abstract 


Swyer-James-MacLeod Syndrome (SJMS) is a rare cause of a hyperlucent unilateral hemithorax. It is usually found in childhood and is a long-term sequalae of postinfectious bronchiolitis obliterans. It can be an incidental finding in adults. Most patients are asymptomatic. However, some patients can present with recurrent pulmonary infections, haemoptysis or dyspnoea. The diagnosis of SJMS is made radiographically by chest x-ray and CT scan. Majority of symptomatic patients will require conservative management. It is also important to rule out other diseases which have similar radiological picture as inaccurate diagnoses can lead to inappropriate therapy. Here we report a case of 63-year-old woman who presented with haemoptysis and progressive dyspnoea and was subsequently diagnosed as a case of SJMS.

Keywords: Haemoptysis, hyperlucent hemithorax, Swyer-James-Macleod Syndrome


How to cite this article:
Sharma N, Gupta P, Yadav A. Swyer-James-Macleod Syndrome: A Rare Finding in a Case of Haemoptysis. J Assoc Chest Physicians 2021;9:41-4

How to cite this URL:
Sharma N, Gupta P, Yadav A. Swyer-James-Macleod Syndrome: A Rare Finding in a Case of Haemoptysis. J Assoc Chest Physicians [serial online] 2021 [cited 2021 Apr 10];9:41-4. Available from: https://www.jacpjournal.org/text.asp?2021/9/1/41/309469




  Introduction Top


Swyer-James-MacLeod Syndrome (SJMS) is rare cause of a hyperlucent unilateral hemithorax.[1] It is a long-term sequalae of postinfectious bronchiolitis obliterans that occurs during childhood. It can be an incidental finding in adults. It is characterized by pulmonary artery hypoplasia and/or agenesis which results in hypoperfusion of the pulmonary parenchyma. Radiographic or computed tomography (CT) imaging is required for the diagnosis. The characteristic radiological feature is a hyperlucent unilateral hemithorax with decreased bronchovascular markings.[2] Most patients are asymptomatic. However, some patients can present with recurrent pulmonary infections, haemoptysis or dyspnoea.[3] Here we report a case of 63-year-old woman who presented with haemoptysis and progressive dyspnoea and was subsequently diagnosed as a case of SJMS.


  Case presentation Top


A 63-year-old woman presented to the emergency department with a one-month history of productive cough with intermittent haemoptysis and progressive dyspnoea on exertion. There was no h/o fever, anorexia and weight loss. She denied h/o smoking and biomass fuel exposure. Her past medical history revealed recurrent pulmonary infections in childhood. She was not on any medical follow up and treatment for same. On general examination she had pallor and was normotensive with pulse rate of 90 beats per minute. She had respiratory rate of 24 breaths per minute with an oxygen saturation of 90% while breathing room air. Respiratory examination revealed use of accessory muscles of respiration and reduced movement of left hemithorax. On chest auscultation there was diminished vesicular breath sounds over left hemithorax. On evaluation she had a haemoglobin of 8 g/dl with normal total leucocyte count. Serum electrolytes and other biochemical parameters were with in normal limits. Her sputum for AFB was negative. Her chest X-ray [Figure 1] showed hyperlucent left hemithorax. She was subjected to CT chest [Figure 2] which showed mosaic perfusion of right lung, hyperlucent left lung with bronchiectatic changes and hypoplastic left pulmonary artery. She also underwent CT pulmonary angiography [Figure 3] which showed hypoplastic left pulmonary artery and its branches with differential attenuation of both lungs, findings consistent with Swyer-James-McLeod syndrome. There was a mixed defect (mild obstruction and restriction) noted on spirometry. She was managed with oral antibiotics, nebulisation with bronchodilators and steroids and other supportive therapy. She responded well to the therapy and was later discharged on inhaled bronchodilators and steroids. She was advised and influenza and pneumococcal vaccinations.
Figure 1 Chest radiograph (PA view) of the patient

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Figure 2 CT scan of chest

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Figure 3 CT pulmonary angiography of chest

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  Discussion Top


SJMS is considered a fairly rare condition characterized by unilateral hyperlucency of some or all of the lung. It was first described in the year 1953 by Swyer and James.[4] It is considered to be a disease which is acquired secondary to viral bronchiolitis and pneumonitis in childhood. The causative organisms associated with it are Paramyxovirus morbillivirus, Bordetella pertussis, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Influenza A and Adenovirus types 3, 7 and 21. Regardless of this association, it is fairly uncommon occurring in around 3.8%–4.3% of patients with bronchiolitis obliterans.[3]The infectious agent causes an inflammatory response, which leads to obliteration of peripheral airways in the infected lung. In most cases, both the bronchioles and small bronchi are affected. There is submucosal fibrosis of the airways leading to luminal occlusion and irregularity. This inflammation also results in obliteration of the vascularity of the lung and impeded lung development. In some cases, the lung distal to diseased bronchioles becomes hyperinflated with pan-acinar emphysematous changes.[5]

Most patients are clinically asymptomatic. Symptomatic patients typically have persistent cough, exertional dyspnoea and occasionally haemoptysis. Some patients will give history of repeated pulmonary infections in childhood. The patients who have little or no associated sequelae bronchiectasis will be asymptomatic or have minimal symptoms.

The diagnosis of SJMS is made radiographically by chest x-ray and CT scan. The characteristic radiographic findings include a unilateral hyperlucent lung along with decreased broncho-vascular markings, slight displacement of the mediastinum to the affected side and a small hilar shadow.[6] The hyperlucency can sometimes be limited to one lobe rather than entire lung. In detecting hyperlucent lung regions, CT chest is more sensitive than chest radiograph, and is also superior in determining the severity and distribution of the disease.[7] CT scan findings may also include bronchiolectasis, bronchiectasis, scarring and atelectasis.[8] Around 30% of patients will have bronchiectatic changes on CT chest and these patients usually have more severe exacerbations as compared to those who do not have bronchiectasis.[8] The presence of bronchiectasis also explains the obstructive-restrictive pattern (mixed pattern) typically seen on spirometry. Pulmonary angiography is not an important investigation for the diagnosis of SJMS although it can show hypoplasia and diminished size of the affected pulmonary artery.

Treatment of SMJS is usually individualized depending on the symptoms of the patient. It ranges from conservative management to surgical intervention. Majority of symptomatic patients will require conservative management which includes chest physiotherapy, inhaled bronchodilators and low-dose inhaled corticosteroids.[9] Patients should also be given pneumococcal and Influenza vaccinations. Long-term oxygen therapy may be appropriate in cases with severe disease and respiratory failure. Surgical intervention is usually considered for patients who have severe disease, repeated pulmonary infections and are not responding to optimal medical management. The surgical procedures carried out are pneumectomy, lobectomy or segmentectomy depending on extent of disease and the other co-morbidities of the patient.[9] Prognosis is generally dependent on the presence or absence of bronchiectasis.

There are several important differential diagnoses that should be kept in mind when assessing any individual with unilateral pulmonary hyperlucency. It includes pneumothorax, congenital lobar emphysema, pulmonary artery hypoplasia and asymmetric emphysema.[2] Another rare cause of a unilateral hyperlucent hemithorax is Poland syndrome. It is a congenital anomaly characterised by unilateral absence of the pectoralis major and minor muscles, hypoplasia of the breast and nipple and scarcity of subcutaneous tissue.[10]


  Conclusion Top


Swyer-James-Macleod syndrome is a rare disease that should be considered in individuals with recurrent pulmonary infections, dyspnoea and haemoptysis. The diagnosis is made radiographically by chest x-ray and CT scan which shows unilateral hyperlucent hemithorax with decreased bronchovascular markings. Majority of symptomatic patients will require conservative management. It is also important to rule out other diseases which have similar radiological picture as inaccurate diagnoses can lead to inappropriate therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tortajada M, Gracia M, García E, Hernández R. Diagnostic considerations in unilateral hyperlucency of the lung (Swyer-James-MacLeod Syndrome). Allergol Immunopathol (Madr) 2004;32:265-70.  Back to cited text no. 1
    
2.
Fregonese L, Girosi D, Battistini E, Fregonese B, Risso FM, Bava GL, Rossi GA. Clinical, physiologic, and roentgenographic changes after pneumonectomy in a boy with Macleod/Swyer-James syndrome and bronchiectasis. Pediatr Pulmonol 2002;34:412-6.  Back to cited text no. 2
    
3.
Abba AA, Al-Mobeireek AF, Clinical spectrum of Swyer-James Macleod syndrome in adults. Saudi Med J 2003;24:195e198.  Back to cited text no. 3
    
4.
Sulaiman A, Cavaille A, Vaunois B, Swyer-James-MacLeod syndrome; repeated chest drainages in a patient misdiagnosed with pneumothorax. Interact CardioVasc Thorac Surg 2009;8:482-4.  Back to cited text no. 4
    
5.
Khalil KF, Saeed W. Swyer-James-MacLeod syndrome. J Coll Phys Surg Pak 2008;18:190e 192.  Back to cited text no. 5
    
6.
Gómez Belda AB, Martínez-Moragón E, Fernández Fabrellas E. Swyer-James syndrome: diagnostic contributions of helical computerized tomography. Arch Bronconeumol 2000;36:421-2.  Back to cited text no. 6
    
7.
Moore AD, Godwin JD, Dietrich PA, Verschakelen JA, Henderson WR Jr. Swyer-James syndrome: CT findings in eight patients. Am J Roentgenol 158:1211e1215  Back to cited text no. 7
    
8.
Singal KK, Bhatti KP, Gupta A, Gupta N, Samra R, Gautam S. Swyer-James-MacLeod syndrome: a rare case. Bangladesh J Med Sci 2015;14:402.  Back to cited text no. 8
    
9.
Tasaki A, Nakanishi A. Lung volume reduction surgery for a professional athlete with Swyer-James syndrome. Ann Thorac Surg 2005;80:342e344.  Back to cited text no. 9
    
10.
Altinsoy B, Altintas N. Diagnostic approach to unilateral hyperlucent lung. JRSM Short Rep 2011;2:95, http://dx.doi.org/10.1258/shorts.2011.011080.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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