Correspondence Address:
Dr. Vinod Govindasaami
A2, Udayar Block, Sri Ramachandra Medical Centre, Porur, Chennai - 600 116, Tamil Nadu
India

Full Text



Sir,

We had a patient, a 38-year-old male, who came to the outpatient department with complaints of cough with expectoration and breathing difficulty on and off for the past 3 years and had been treated with inhaled corticosteroids and inhaled long-acting beta2 agonist with which he had partial relief of symptoms. He had no complaints of any other respiratory symptoms or any constitutional symptoms. His old records showed spirometry done showing a reduction in maximal mid-expiratory flow 3 years before the current presentation and a chest x-ray done at that time showing left upper and mid-zone reticular opacities.

In the outpatient department (OPD), his heart rate was 82/min, blood pressure 120/78 mmHg, and oxygen saturation was 98% on room air. High resolution computed tomography thorax, done for delineating the X-ray opacities further, demonstrated left upper lobe apicoposterior segment and left lower lobe superior segment showing fibrosis with traction bronchiectasis. And also there was an aberrant origin of the left pulmonary artery from the right main pulmonary artery, which was coursing between the trachea and esophagus, causing minimal indentation of the posterior aspect of the distal trachea and anterior indentation of the esophagus [Figure 1]. The patient was advised bronchoscopy for the assessment of airway compression due to vascular anomaly but was unwilling.{Figure 1}

Aberrant left pulmonary artery, also known as left pulmonary artery sling (LPAS), is a rare congenital disease that mostly presents during infancy with obstructive symptoms but unusually can be diagnosed in adulthood either with symptoms or incidentally. It can mimic asthma.[1] The most plausible pathogenesis that has been put forward is due to developmental failure of the 6th aortic arch in fetal life. This anomaly is usually associated with other congenital malformations of the tracheobronchial tree and cardiovascular anatomy.[2] Based on associated tracheobronchial tree anomalies, LPAS is classified as Type 1A, 1B, and Type 2.[3] Computed tomography is the investigation of choice that would diagnose the vascular anomaly precisely and also would help identify the associated tracheobronchial anomalies. Echocardiography can assess the presence of coexisting congenital cardiovascular anomalies. Bronchoscopy will complement computed tomography in the evaluation of the tracheobronchial tree for (a) degree of airway compression due to the anomaly and (b) associated anomalies. Surgical repair is pursued only in patients with severe or recurrent symptoms.[4]

Learning points/take-home messages:

LPAS presents with airway symptoms which can be misdiagnosed as the more common chronic airway diseases seen in the adult population - bronchial asthma or chronic obstructive pulmonary diseasePatients with severe or recurrent symptoms benefit from surgical repair and carries a good prognosis postoperatively.

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Conflicts of interest

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References