Uncommon Etiology of Chest Pain: Pulmonary Sequestration
A previously healthy 26 year old male presented to the emergency department (ED) with chest pain for 1 hour. The patient stated the substernal pain was 10/10 in severity, non-radiating and worse with deep inspiration. He experienced intermittent left arm numbness that started after the onset of the chest pain but denied heart palpitations, diaphoresis, shortness of breath, hemoptysis, cough or recent fevers. On physical exam, vital signs were unremarkable, and he was cooperative and able to speak in full sentences. Chest auscultation did not detect any abnormalities. An electrocardiogram was read as normal. A chest radiograph revealed a lung lesion in the left lower lobe. A computed tomography (CT) of the chest showed a 11 cm × 9 cm × 10.5 cm round, well-defined, heterogeneous mass consistent in location with the lesion noted on the chest radiograph. The patient’s chest pain was well controlled on oral analgesics, and after consultation with the surgical service he was scheduled for an outpatient appointment for follow up and treatment. The patient was discharged and prescribed acetaminophen-hydrocodone 500 mg-5 mg oral tablets to be taken as needed for pain 1–2 tablets every 4–6 hours with a maximum of 8 tablets per day. He was advised to return to the ED if symptoms persisted or worsened.\nThe patient returned to the ED 1 day later with recurrent chest pain that was now more localized around his left lower ribs and rated as 8 out of 10 in severity. His vital signs remained within normal limits and his physical exam was unchanged from discharge. A repeat chest CT showed no changes. His pain management therapy was changed to acetaminophen-oxycodone 325 mg–7.5 mg oral tablets to be taken as needed for pain 1 tablet every 4 hours with a maximum of 6 tablets per day. This adjustment resulted in symptomatic relief of his chest pain. With improved symptoms and unchanged imaging, he was discharged with strict follow-up instructions.\nThe patient returned 3 days later for his scheduled outpatient appointment. The surgical service obtained a chest magnetic resonance angiogram with contrast that revealed a cystic lesion measuring 108.7 mm by 104.0 mm (). A thoracotomy with resection of an extralobar pulmonary sequestration (PS) was completed without intraoperative or post-operative complications. The non-communicating lung parenchyma was being supplied by an artery arising from the abdominal aorta. The patient was discharged home on post-operative day 4.\nAt a follow-up outpatient appointment 1 week after discharge, the patient remained asymptomatic, and a repeat chest radiograph showed resolution of the PS. The patient did not require further outpatient follow-up.