Scintigraphy showed no perfusion lung in. ..

A rare case of unilateral rib notching in patients with pulmonary emphysema reported. Vascular changes in major vessels were removed and the upper lobe of right lung (RUL) showed lack of perfusion, which coincides with the site notching edges. System of angiography showed enlarged and tortuous intercostal arteries, causing notching. Literature review revealed no documented case of emphysema associated with rib notching. Rib notching is from erosion of the upper or lower edge of the ribs, showing characteristic appearance on chest radiograph. Erosion in the lower regions of constant ripple through advanced intercostal arteries. Coarctation of the aorta remains by far the most common cause of deforestation in the lower aspects of the ribs, which usually cause a cut in the bottom third to ninth aspects ribs1. Quadriplegia as spinal cord injury is the most common cause of upper limit notching2 ribs. Although emphysema has been described as the probable reason behind notching3 edge, we found no well-documented case in the literature review. 42-year old patient who smoked 26 packs a year and suffered from progressive dyspnea for several years. At physical examination, asthenia, sotto voce, respiratory and clubs in hand have been found. Radiograph showed the chest of air capture in the upper parts of notching the bottom of the posterior regions of the fourth and fifth right hypochondrium. (Fig. 1). CT revealed clear signs of bullous emphysema mainly in the upper lobes. Alpha-1-antitripsin levels were normal. Functional tests showed a slight change in respiratory obstructive (FEV1 75%), increased RV (155%) and reduced CO diffusion (DLCO 54%, 51% CFA). ECG and arterial blood gas determination were normal. Magnetic resonance of the heart and great vessels, no changes of the cardiovascular system .. Angiography of the aorta and its branches showed a great expansion of human intercostal arteries. Bronchial arteries were dilated, tortuous. Fistulous communication between intercostal, subclavian and internal chest with pulmonary circulation was observed (Fig. 2). Scintigraphy of the lungs showed no perfusion in the right upper lobe and heterogeneous distribution in both lungs (Fig. 2b). Location rib notching is important to determine the etiologic diagnosis. Felling at least in the upper part than at the bottom, although they can sometimes overlooked because they are often slightly visible in chest X-ray. Rib notching may be due to the absence of stimuli secondary to repeated contraction of intercostal muscles, as occurs in tetraplegia4. The most common reason is the lower notching coarctation aorta5, being unilateral or bilateral according to the level of coarctation. From the hemodynamic point of view, it is possible for rib notching develop in other cardiovascular diseases due to increased intercostal arteries supplying blood to reverse the aorta, unlike in coarctation of the aorta. Among these conditions thrombosis of abdominal aorta, subclavian artery occlusion (Blelok-Taussigs operations 6 and Takayasuds arteritis7), and those that lead to a decrease in pulmonary artery supply1 (Tetrada Fallo, pulmonary atresia, pulmonary valve stenosis, Ebsteins defect and pulmonary emphysema). Emphysema have been reported to cause abnormal rib notching3. There are other disorders of venous etiology (superior vena cava obstruction) due to vascular shunt (pulmonary arteriovenous fistula or intercostal), neurogenic (intercostal nevrynomy) and bone (hyperparathyroidism or idiopathic). Idiopathic form is more common than expected. Location rib notching may be useful to distinguish pathological from normal form. Pathological forms, usually in the middle third of the posterior arch ribs1. This patient had unilateral notching, bottom and were located in the back of the middle third. Emphysema can often be associated with vascular deficiency are located in one or more regions of the lung, vascularization be normal or increased in other areas8. In this patient lasix 50 mg the lack of perfusion area consistent with the less emphysematous ventilated area. This progressive decrease in perfusion in this area leads to intercostal application of collateral in the form of compensation. At this level, the expansion of intercostal arteries develop as shown in arteriography in contact with the bottom of the upper ribs, resulting in rib notching. In postmortem studies, including 18 cases of emphysema, bronchial circulation decrease is observed which offset increased pulmonary blood flow, the precapillary anastomoses leads to enlargement and tortuosity of intercostal arteries, resulting in rib notching9. In our patient, the deficit is on the pulmonary vascular bed to the presence of bullae led to hypertrophy of the intercostal vascularization at this level and erosion of ribs in this area. Create on: Thu, 23 Feb 2012 22:49:22 -0600 (00,001,563)