British Journal of Radiology (2005) 78, 851-853
© 2005 British Institute of Radiology
doi: 10.1259/bjr/61657645
Intrathoracic gossypiboma: radiographic and CT findings
T Suwatanapongched, MD1,
S Boonkasem, MD2,
E Sathianpitayakul, MD3 and
P Leelachaikul, MD4
Departments of 1 Radiology, 2 Surgery, 3 Internal Medicine and 4 Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Correspondence: Thitiporn Suwatanapongched, MD, Diagnostic Radiology Division, Department of Radiology, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, 270 Rama VI Road, Rajthevi, Bangkok 10400, Thailand
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Abstract
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Intrathoracic gossypiboma, a retained surgical sponge in the thoracic cavity, is a rare but serious consequence following surgery. Because of its rare occurrence and non-specific clinical and radiographic presentations, the diagnosis is often missed. Herein we report a patient presenting with a chronic recurrent cough due to a retained surgical sponge in the pleural cavity. The patient has been misdiagnosed with bronchiectasis for 22 years. The characteristic spongiform appearance on CT and a history of previous thoracic surgery led to the diagnosis of a gossypiboma that was confirmed at surgery.
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Introduction
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Intrathoracic gossypiboma, a retained surgical sponge in the thoracic cavity, is a rare but serious consequence of negligence during surgery [1, 2]. The retained sponge may induce an aseptic foreign body reaction with subsequent fibrosis and granuloma formation [1–3]. Clinical and radiological appearances are variable, depending on the location and chronicity of the retained sponge. Two frequent sites of intrathoracic gossypiboma are the pleural and pericardial cavities [1–14]. Because of its rare occurrence and a low index of suspicion, the diagnosis can be easily missed. A case report herein illustrates intrathoracic gossypiboma that has been mistaken for bronchiectasis for 22 years.
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Case report
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A 22-year-old woman presented to our hospital with a history of chronic recurrent cough. At 3 years of age, she sustained a penetrating wound to the left lower chest in an accident. A left thoracotomy with resection of rib fragments and a portion of the left lower lobe was performed at another hospital. Her post-operative course was complicated by what was thought to be an infected surgical wound. She was discharged from the hospital 3 months after the surgery. Since then, she has had a chronic recurrent cough with productive sputum and/or haemoptysis.
Physical examination revealed two surgical scars at the left lateral chest wall with diminished breath sounds and fine crepitations at the left lower lung zone. Other physical findings were unremarkable. Serial examinations of sputum for acid-fast bacilli were negative.
Initial routine chest radiographs were taken. The posteroanterior projection (Figure 1a
) revealed an ill-defined opacity at the inferolateral aspect of the left hemithorax. On the lateral projection (Figure 1b), the lesion appeared as a well-marginated cavitary mass containing an unusual striped appearance in the centre. The lesion remained stable on follow-up radiographs. Despite the unusual radiographic appearance, the possibility of a gossypiboma was not entertained. Then, the patient was treated conservatively for bronchiectasis.
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Figure 1. (a) Posteroanterior chest radiograph showing an ill-defined opacity at the inferolateral aspect of the left hemithorax. Note old healed fractures of the left lower ribs. (b) Left lateral chest radiograph revealing a well-marginated cavitary mass containing an unusual striped appearance in the centre.
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3 years later, CT scan of the chest was requested for further evaluation of bronchiectasis. CT scan was performed on a four-multidetector CT scanner (LightSpeed Plus Qx/I; GE Medical System, Milwaukee, WI). Non-enhanced CT (Figure 2a) revealed a thick-walled, well-encapsulated pleural-based mass in the left lower hemithorax. The mass contained mixed high- and low-attenuation contents with gas bubbles in the centre, having the so-called spongiform appearance. Tubular bronchiectasis was seen in the adjacent lung parenchyma (Figure 2b). Following an intravenous contrast injection, there was marked enhancement of the wall of the mass (Figure 2c). Multiple enlarged lymph nodes were seen at the left hilum. The CT appearance and a history of previous thoracic surgery led to a presumptive diagnosis of an intrathoracic gossypiboma.
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Figure 2. (a) Non-enhanced CT scan at the level of the heart showing a thick-walled, well-encapsulated pleural-based mass containing mixed high- and low-attenuation contents with gas bubbles in the centre, having the so-called spongiform appearance. (b) Non-enhanced CT scan with lung-window setting at the lower level revealing tubular bronchiectatic change with bronchovascular crowding in the adjacent left lower lobe. Note old depressed rib fractures and scar at the left chest wall. (c) Coronal reformation of enhanced CT showing marked enhancement of the wall of the mass. Gas collections in the central part of the mass account for an unusual striped appearance seen on the lateral chest radiograph.
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An exploratory surgery of the left hemithorax was performed. A thick-walled, well-encapsulated mass was found at the lower left pleural cavity. The mass contained strong-smelling purulent materials and several fragments of a disintegrated surgical sponge. The mass was dissected and removed. Histopathological examination revealed a thick, fibrous wall of the mass and presence of foreign body fragments, which were consistent with sponge fibres, mixed with fibrinopurulent exudates. Foci of chronic and active inflammatory changes with fibrosis were seen in the wall and in the adjacent lung parenchyma. No organism was found.
The patient recovered uneventfully with complete resolution of all clinical symptoms on follow-up.
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Discussion
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In retrospect, the patient had a typical presentation of intrathoracic gossypiboma as described in the literature, namely cough, expectoration or recurrent haemoptysis [1–5]. Other reported clinical symptoms included chest pain, low-grade fever, weight loss and bilious expectoration [1, 6–8].
The plain chest radiograph is often an initial examination. It usually reveals an unusual opacity or an atypical mass in the chest that generally does not change over time [1–6]. In the present case, the appearance on the lateral chest radiograph was similar to a whirl-like gas collection seen with a retained surgical sponge in the abdomen [1, 3, 10]. A radiopaque marker within a surgical sponge is not always a reliable sign and may be misinterpreted as pleural calcification, a surgical suture or an epicardial pacing wire [1–3, 10–12].
CT is the most effective method for detection of a retained surgical sponge in the pleural cavity. The typical feature is a thin- or thick-walled mass having a spongiform pattern with gas bubbles. This pattern is a well-recognized CT finding of a retained surgical sponge in the abdomen [1–5]. However, in the early post-operative period, this pattern may mimic the appearance of gel-foam particles placed to control intraoperative haemorrhage or may be confused with a complicated haematoma or an abscess [1, 4, 15]. In a chronic, long-standing case, the pattern may mimic the appearance of an echinococcal cyst or an intracavitary fungus ball with formation of loose mycelial fronds [4, 5]. The retained sponge may invaginate into the adjacent lung, giving a false radiological impression of an intrapulmonary lesion and subsequent formation of bronchiectasis, as appeared in this case [2].
Other CT features of pleural gossypiboma are less specific. They may appear as a complex pleural-based mass having concentric layers of different densities, a mass having high-density component, or a calcified pleural mass [2, 3, 6, 7]. A surgical sponge retained in the pericardial cavity usually appears as a well-encapsulated cystic mass at the pericardiac or retrocardiac region [10, 13, 14].
Magnetic resonance features of intrathoracic gossypiboma have been described. They may appear as a pseudocystic mass containing a movable body or a mass having low signal intensity on T2 weighted images [9, 14, 16].
In conclusion, the diagnosis of intrathoracic gossypiboma may be easily overlooked. An awareness of this condition in any individual having prior surgery and characteristic CT appearance will alert one to entertain the diagnosis. Early recognition and prompt treatment will reduce the sequelae of this undesirable condition.
Received for publication January 26, 2005.
Revision received March 25, 2005.
Accepted for publication April 7, 2005.
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Abstract
Introduction
