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Pulmonary arterio-venous malformation on endobronchial ultrasound bronchoscopy
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  1. Nishant Kumar Chauhan1,
  2. Rengarajan Rajagopal2,
  3. Benhur Joel Shadrach3,
  4. Naveen Dutt1
  1. 1Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
  2. 2Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
  3. 3Pulmonary Medicine, Dr Rela Institute and Medical Centre, Chennai, India
  1. Correspondence to Dr Nishant Kumar Chauhan, Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India; nishant97{at}gmail.com

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A-21-year old woman presented with exertional breathlessness, fatigue and episodic mild haemoptysis for the past 7 months. Peripheral arterial oxygen saturation (SpO2) was 87% on room air. Clubbing and central cyanosis were present. There was no improvement in SpO2 and cyanosis with supplemental oxygen therapy. Chest radiograph revealed a heterogeneous opacity in right upper zone (figure 1A). CT pulmonary angiogram revealed diffuse pulmonary A-V malformation (PAVM) involving apical and anterior segments of right upper lobe with multiple pulmonary arterial branches directly communicating with the pulmonary veins (figure 1B). A subcentrimetric area of diffusely enhancing soft tissue attenuation was seen alongside right lower end of trachea adjacent to PAVM, for which endobronchial ultrasound (EBUS) was advised by the radiologist for possible diagnostic sampling to rule out any associated chronic inflammatory lesion. Convex probe (CP)-EBUS scanning extending from station 2R to 10R was performed that revealed a large lesion with multiple hypoechoic areas interspersed with hyperechoic areas (figure 1C). Doppler mode of EBUS revealed a ‘mosaic-pattern’ indicative of mixing of arterial and venous blood consistent with PAVMs (figure 1D). No other abnormality was detected so no sampling was done. A bubble echocardiogram also confirmed the intrapulmonary shunt. The patient was taken for angioembolisation of PAVM. Multiple feeding arteries were embolised using multiple microcoils and vascular plug. There was a significant improvement in baseline SpO2 from 85% to 94% post angioembolisation.

Figure 1

(A) Patient’s chest radiograph shows a heterogenous opacity in right upper zone and metallic artefacts of clothing. (B) CT pulmonary angiography shows diffusely enhancing soft tissue surrounding the right main bronchus with large vascular channels in the right mediastinal region (marked within red circle). (C) Lymph node station 10R with multiple hypoechoic areas interspersed with hyperechoic areas on EBUS B-mode. (D) The same lesion shows a red-blue ‘mosaic-pattern’ on colour Doppler mode. EBUS, endobronchial ultrasound.

Thin section CT scanning is the imaging of choice to diagnose a PAVM. This also helps in planning the treatment.1 A good acoustic window to image PAVMs is possible during non-invasive transthoracic ultrasonography when the location of PAVM is close to pleura or only partially embedding the parenchyma.2 3 In our patient, since the lesion was located centrally, close to mediastinum, colour Doppler mode during CP-EBUS bronchoscopy was able to provide a vivid image of a ‘mosaic-pattern’ indicative of PAVM. This is the first report to mention the use of CP-EBUS bronchoscopy in being able to detect a PAVM.

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This study involves human participants but since the procedure was performed as a part of patient management and is now being submitted as case report, ethics approval was not required. Participants gave informed consent to participate in the study before taking part.

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Footnotes

  • Contributors NKC was involved in concept/design of study, acquisition and interpretation of data, manuscript preparation and final approval, integrity of work. RR was involved in acquisition and interpretation of data, manuscript preparation and final approval,Integrity of work. BJS was involved in acquisition and interpretation of data, manuscript preparation and final approval. ND was involved in manuscript preparation and final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.