“Bulging fissure sign” on chest radiograph: Strong predictor of central airway malignancy

Shital Patil; Neel Tandel; Omprakash Bhangdiya

doi:10.4103/japt.japt_9_23

CASE REPORT

Year : 2023 | Volume : 6 | Issue : 1 | Page : 22-25

“Bulging fissure sign” on chest radiograph: Strong predictor of central airway malignancy

Shital Patil¹, Neel Tandel², Omprakash Bhangdiya²
¹ Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra, India
² Radiodiagnosis, MIMSR Medical College, Latur, Maharashtra, India

Date of Submission	02-Mar-2023
Date of Decision	19-Mar-2023
Date of Acceptance	05-Apr-2023
Date of Web Publication	29-Apr-2023

Correspondence Address:
Prof. Shital Patil
MIMSR Medical College, Latur, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_9_23

Abstract

A bulging fissure sign in a chest radiograph is usually associated with right upper lobe lung collapse with horizontal fissural effusion or collection. Etiology and pathophysiology traced to infective and noninfective causes. Commonly bulging fissure sign is described with lung malignancy in old age. Infective etiologies are infective types in children and adults with comorbid conditions. In this case report, we have reported a 54-year-old male presented with cough and hemoptysis with progressive worsening of shortness of breath. Clinically tubular breath sounds in the right infraclavicular region with egophony were heard. Chest X-ray documented right lung consolidation or mass lesion with bulging fissures. Bronchoscopy was done after clinical stabilization and showed endobronchial polypoidal growth in the right mainstem bronchus causing near-complete occlusion of the bronchial lumen. Endobronchial needle aspiration cytology and forceps-guided (forcep biopsy) histopathology suggestive of “squamous cell” type of lung malignancy for bulging fissure sign in our case. A high index of suspicion is must to rule out underlying malignancy and bronchoscopy is “gold-standard” test in cases with bulging fissure sign to confirm a diagnosis.

Keywords: Bronchoscopy, bulging fissure sign, chest radiograph, endobronchial needle aspiration, squamous cell carcinoma

How to cite this article:
Patil S, Tandel N, Bhangdiya O. “Bulging fissure sign” on chest radiograph: Strong predictor of central airway malignancy. J Assoc Pulmonologist Tamilnadu 2023;6:22-5

How to cite this URL:
Patil S, Tandel N, Bhangdiya O. “Bulging fissure sign” on chest radiograph: Strong predictor of central airway malignancy. J Assoc Pulmonologist Tamilnadu [serial online] 2023 [cited 2023 May 29];6:22-5. Available from: https://www.japt.in//text.asp?2023/6/1/22/375463

Introduction

The bulging fissure sign represents expansive lobar consolidation causing fissural bulging or displacement by copious amounts of inflammatory exudate within the affected parenchyma. Classically associated with right upper lobe (RUL) consolidation due to Klebsiella pneumoniae, any form of pneumonia can manifest the bulging fissure sign. The sign is frequently seen in patients with pneumococcal pneumonia.^[1],[2] The prevalence of this sign is decreasing, likely because of the prompt administration of antibiotic therapy to patients with suspected pneumonia.^[3] The bulging fissure sign is also less commonly detected in patients with hospital-acquired K. pneumonia than in those with community-acquired Klebsiella infection.^[4] Other diseases that manifest a bulging fissure include any space-occupying process in the lung, such as pulmonary hemorrhage, lung abscess, and tumor. Due to the endobronchial nature of pathophysiology, bronchoscopy is very important tool to confirm the diagnosis.^[5] Whenever tropical workup is negative and malignancy is the suspected pathology for bulging fissure, bronchoscopy is considered as gold-standard technique.^[6]

Case Report

A 54-year-old male, farmer, smoker, normotensive, nondiabetic, referred to our center by family physician for complaints of:

Dry cough with intermittent yellowish-white sputum for 1 month
Hemoptysis – minimal streaky type associated with yellow-white sputum for 2 weeks, exaggerated with cough, no history of massive hemoptysis
Shortness of breath for 2 weeks, Grade II
Dull aching chest pain right side localized to the scapular region right side
No fever in the past 1 month
Chronic smoker with smoking index of 30 pack years.

Family members said that he was treated with intravenous antibiotics for 7 days by a family physician and showed poor response to antibiotics and other supportive care during hospitalization. Chest X-ray done by family physician documented right upper zone consolidation [Figure 1]. He was referred by family physician for poor response to antibiotics and radiological worsening observed in a follow-up chest X-ray done after 7 days of antibiotics. We have clearly noted “bulging fissure sign,” i.e., homogeneous opacification right upper zone with bowing of horizontal fissure in chest radiograph [Figure 2].

Figure 1: Chest X-ray PA view showing homogenous opacity right upper lobe. PA: Posterio-anterior

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Figure 2: Chest X-ray PA view showing homogeneous opacification right upper zone with bowing of horizontal fissure i.e. Bulging fissure sign. PA: Posterio-anterior

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Clinical examination documented:

Well-nourished, moderately built, anxious male, no cyanosis, or clubbing
Heart rate – 98/min, respiratory rate – 24/bpm, blood pressure – 110/60 mmHg
PsO_2: 90% at room air resting and 96% at with oxygen 1 L/min by nasal cannula
Respiratory system examination revealed bronchial breath sounds, i.e., tubular breath sounds in the right infraclavicular region with egophony heard. Other lung fields normal vesicular breathing
Other systemic examinations were normal.

Laboratory examination documented as:

Hemoglobin – 11.0 g%, total white blood cells – 21,000/mm³, polymorphs – 85%, platelet count – 490,000/μL
Kidney function test – serum creatinine – 1.1 mg/dl (0.6–1.2 mg/dl), blood urea – 28 mg/dl (10–40 mg/dl)
Liver function tests – normal
C-reactive protein – 86 mg/L (0–6 mg/L), random blood sugar level – 110 mg%
Lactate dehydrogenase – 1080 IU/L (70–470 IU/L), uric acid – 3.4 mg (3.5–7.5 mg/dL)
Procalcitonin: 0.05 ng/ml (normal)
Viral markers: HIV I and II negative Australia antigen-negative
Sputum gram stain: Gram-positive cocci in chains
Sputum culture: No growth.

We have decided to further investigate with bronchoscopy due to the absence of fever, minimal hemoptysis, poor response to antibiotics, negative procalcitonin, and importantly bulging fissure sign in the chest radiograph.

Fiberoptic video – bronchoscopy done in bronchoscopy suit with all necessary precautions with topical anesthesia (xylocaine jelly plus spray and xylocaine solution) and documented polypoid growth in right mainstem bronchus.

Bronchoscopy documented polypoidal, multinodular growth in right mainstem bronchus causing near total occlusion of lumen. Bronchoscopy was unable to negotiate distal growth. Growth was fleshy and bleed on touch and showed a yellowish-white slough overlying it [Figure 3].

Figure 3: Bronchoscopy documented polypoidal, multinodular growth in right mainstem bronchus causing near total occlusion of lumen

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We have performed endobronchial needle aspiration (EBNA) cytology as the first procedure during bronchoscopy due to the presence of slough overgrowth and chances of negative growth and forceps biopsy (FB) as the second technique during bronchoscopy.

EBNA cytology documented squamous cell type of lung malignancy [Figure 4].

Figure 4: EBNA cytology showing malignant cell positive for squamous cell type of lung cancer in 40x

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Histopathology confirmed as nonsmall cell lung cancer most likely as squamous cell lung cancer [Figure 5].

Figure 5: Histopathology analysis shows Squamous cell lung cancer of poorly differentiated type

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Further, immunohistochemistry analysis (done due to nonsmall type in histopathology) documented as:

Epidermal growth factor receptor – Negative
ALK – Negative
ROS – Negative.

Oncologist opinion was taken for the treatment of squamous cell cancer and further assessment in view for chemotherapy and radiotherapy was done. A positron emission tomography scan was done and showed liver and bone metastasis. Due to the central airway tumor and disseminated nature, oncologist decided on palliative chemoradiotherapy in the oncology department.

Discussion

Bulging fissure sign

The bulging fissure sign refers to lobar consolidation where the affected portion of the lung is expanded, causing displacement of the adjacent fissure. Any type of pneumonia or space-occupying process can lead to a bulging (sagging) fissure sign. Classically, it has been described in RUL consolidation secondary to K. pneumonia. It is now rarely seen due to prompt antibiotic therapy for suspected pneumonia.

The most common infective causative agents are:^[7]

Streptococcus pneumoniae: Pneumococcal pneumonia
K. pneumoniae: K. pneumonia
Pseudomonas aeruginosa: Pseudomonas pulmonary infection
Staphylococcus aureus.

Other uncommon agents are:^[1],[8]

Legionella pneumophila causing legionella pneumonia
Haemophilus influenzae pneumonia
Plague pneumonia
Mycobacterium tuberculosis.

It may also be seen with:^[9],[10]

Lung adenocarcinoma
Lung abscess
Pulmonary hemorrhage.

We have decided to further investigate with bronchoscopy due to the absence of fever, minimal hemoptysis, poor response to antibiotics, negative procalcitonin, and importantly bulging fissure sign in the chest radiograph.^[11] We have performed EBNA cytology as the first procedure during bronchoscopy due to the presence of slough overgrowth and chances of negative growth and FB as the second technique during bronchoscopy. EBNA has documented very “crucial role” and should be considered as “complimentary” to conventional diagnostic techniques in diagnosing lung cancer during bronchoscopy in the presence of endobronchial growth.^[12] Importantly, EBNA samples can give rapid results and decrease chance for repeat procedure by guiding the adequacy of samples before the end of bronchoscopy procedure. EBNA is considered safe, especially when fleshy vascular endobronchial growth is present and the risk of bleeding is high with FB. EBNA cytology samples can give comparable results to histopathology. EBNA samples are equally processed for immunohistochemistry analysis as histopathology samples. Thus, EBNA is a beneficial, safe, and minimally invasive bronchoscopic technique with an insignificant side effect in the diagnosis of bronchogenic carcinoma.^[13]

Similarly, authors have mentioned that the bulging fissure sign has been regarded as a classical but nonspecific^[14] feature of pneumonia caused by K. pneumoniae. It occurs due to exudates produced by the causative organisms that expand the lobe and cause a “bowing” or a “bulge” in the fissure.

In the present case report, we have documented constitutional symptoms such as cough, hemopoiesis, and shortness of breath with the absence of fever with negative sepsis screening panel given clue to work for noninfective cause for bulging fissure sign. With interventional pulmonology, fiberoptic video bronchoscopy technique has given diagnostic clues as lung malignancy. EBNA has been important bronchoscopy-guided method apart from FB for confirming the diagnosis.

Key learning points from this case report are:

“Bulging fissure” in chest radiograph is usually associated with infective etiology. Still, malignancy is one of the common causes in noncomorbid class and cases with tobacco smoke exposure
Infective cause for bulging fissures is usually seen in pediatric cases and cases with comorbidities such as alcoholism, diabetes mellitus, chronic obstructive pulmonary disease, stroke, geriatric cases with air conditioner, or humidified air exposure
Malignancy as cause for bulging fissures suspected in cases with atypical constitutional symptoms, i.e., absence of fever with sputum and shortness of breath and negative procalcitonin
Bronchoscopy is gold-standard test to diagnose endobronchial pathology than high-resolution computed tomography thorax. It should be done to rule out exact cause for the bulging fissure sign
Various bronchoscopy-guided techniques are available and sequence of techniques usually depends on choice and expertise by operator during procedure. EBNA is underutilized over FB in endobronchial lesions due to the lack of trainings, and fear of bronchoscope damage by EBNA during procedure
Although FB is a more sensitive test than EBNA, there will be chances of inadequate sampling during FB due to superficial necrosis, blood clot, or crush artifacts resulting into negative yield. Hence, EBNA is an important tool
Bulging fissure sign is documented in nonsquamous cell lung cancer or adenocarcinoma. In search of published literature, our case of squamous cell carcinoma as the cause for bulging fissure sign is the first case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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