Lung lobe torsion in dogs: 22 cases (1981-1999)

OBJECTIVE: To identify breed disposition, postoperative complications, and outcome in dogs with lung lobe torsion. DESIGN: Retrospective study. ANIMALS: 22 client-owned dogs. PROCEDURE: Information on signalment; history; clinical findings; results of clinicopathologic testing, diagnostic imaging, and pleural fluid analysis; surgical treatment; intra- and postoperative complications; histologic findings; and outcome were obtained from medical records. RESULTS: All 22 dogs had pleural effusion; dyspnea was the most common reason for examination. Fifteen dogs were large deep-chested breeds; 5 were toy breeds. Afghan Hounds were overrepresented, compared with the hospital population. One dog was euthanatized without treatment; the remaining dogs underwent exploratory thoracotomy and lung lobectomy. Eleven dogs recovered from surgery without complications, but 3 of these later died of thoracic disease. Four dogs survived to discharge but had clinically important complications within 2 months, including chylothorax, mediastinal mesothelioma, gastric dilatation, and a second lung lobe torsion. Six dogs died or were euthanatized within 2 weeks after surgery because of acute respiratory distress syndrome, pneumonia, septic shock, pneumothorax, or chylothorax. Chylothorax was diagnosed in 8 of the 22 dogs, including 4 Afghan Hounds. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that lung lobe torsion is rare in dogs and develops most frequently in large deep-chested dogs, particularly Afghan Hounds. Other predisposing causes were not identified, but an association with chylothorax was evident, especially in Afghan Hounds. Prognosis for dogs with lung lobe torsion was fair to guarded.     

Use of computed tomography and minimum intensity projection in the detection of lobar pneumonia mimicking lung lobe torsion in a dog

A 10‐year‐old female spayed Dachshund was referred with progressive coughing for 1 month. The dog was tentatively diagnosed with right middle lung torsion based on pleural effusion, vesicular emphysema, abruptly ending bronchus in consolidated right middle lung, and no contrast enhancement of the affected lobe on radiography and computed tomography (CT). There was no evidence of torsion upon thoracotomy, and histological examination confirmed lobar pneumonia. The CT images were reevaluated using minimum intensity projection and revealed normal bronchial courses. The minimum intensity projection technique can be to assist in evaluation of the bronchial tree for dogs with suspected lung lobe torsion and other pulmonary diseases.     

Concurrent torsion of the right cranial and right middle lung lobes in a whippet

A four-year-old, entire male whippet was presented with a three-day history of lethargy, inappetence, occasional retching, a soft cough and intermittent episodes of haemoptysis. Clinical and laboratory findings, and thoracic radiographic and ultrasonographic studies suggested a diagnosis of lung lobe torsion. A concurrent lung lobe torsion of the right cranial and right middle lung lobes was confirmed at exploratory thoracotomy. Management included resection of both the affected lung lobes. No obvious underlying aetiology for the condition was apparent. The dog made a full recovery from the procedure and at the time of writing (11 months postoperatively) was reported to be well, exercising normally and showing no breathing abnormalities.     

Successive torsion of the right middle and left cranial lung lobes in a dog

This case report describes the torsion of two lung lobes in a dog. The animal was first presented for a torsion of the right middle lung lobe. Following the surgical resection of that lobe, the dog suffered another torsion of the left cranial lung lobe (cranial and caudal segments).     

Lung lobe torsion in association with a chronic diaphragmatic hernia and haemorrhagic pleural effusion in a cat

CLINICAL SUMMARY: This report describes torsion of the right cranial lung lobe in a cat with haemorrhagic pleural effusion and a chronic diaphragmatic hernia. Surgical treatment comprising lung lobectomy without de-rotation, and repair of the diaphragmatic defect, led to an uneventful recovery. PRACTICAL RELEVANCE: Lung lobe torsion is a rare condition in cats. While spontaneous lung lobe torsions may occur, a frequent association with underlying thoracic disease has been recognised in cats. However, neither haemorrhagic pleural effusion nor diaphragmatic hernia have been previously described in cats with lung lobe torsions, although they have been documented in dogs and humans. In a cat with suspected lung lobe torsion, a thorough search for an underlying disease should be undertaken.     

Right cranial lung lobe torsion after a diaphragmatic rupture repair in a Jack Russell terrier

A seven-year-old male Jack Russell terrier was presented with a history of coughing, generalised weakness and lethargy 10 days after an abdominal coeliotomy to repair a large diaphragmatic rupture. Thoracic radiographs demonstrated a soft tissue mass in the midcaudal right thoracic cavity. Ultrasonographic studies, bronchoscopy and subsequent exploratory thoracotomy confirmed a diagnosis of a right cranial lung lobe torsion (LLT), with an anomalous caudodorsal displacement of the affected lobe. LLT should be considered as a differential diagnosis for respiratory tract disease following diaphragmatic rupture repair.     

Usefulness of CT imaging for segmental lung lobe torsion without typical radiographic imaging in a Pomeranian

A 3-year-old, intact female Pomeranian presented with a 1-month history of coughing. Thoracic radiography showed focal infiltration of the left cranial lung lobe and widening of the cranial mediastinum. Subsequent computed tomography revealed torsion of the caudal segment of the left cranial lung lobe, which was confirmed by exploratory thoracotomy. There was no apparent underlying etiology for the condition. To the authors’ knowledge, this is the first report of lung lobe torsion in this breed and the first detailed CT imaging report for segmental lung lobe torsion.     

Lung lobe torsion associated with chest wall defects in a dog

An 8-year-old, spayed, female poodle presented with exercise intolerance, lethargy, respiratory distress, retching, hyporexia and diarrhoea. Thoracic radiographs revealed increased opacity in the left cranial thoracic region. The fifth and sixth ribs appeared to be bulging cranially to caudally, and CT and surgical exploration confirmed the presence of a thoracic wall defect in that area. CT showed abrupt occlusion of the bronchus that branches into the left cranial lobe and consolidation of the caudal segment of left cranial lung lobe, which led to the diagnosis of lung lobe torsion. A thoracotomy was performed, the twisted lung lobe was surgically excised, and the defect in the thoracic wall was repaired. Respiratory distress gradually improved after the surgery, and there were no identified complications within the 2-year period following the procedure. Based on our literature search, this is the first reported case of lung lobe torsion caused by a thoracic wall defect in a dog.     

COMPUTED TOMOGRAPHIC FEATURES OF LUNG LOBE TORSION

The imaging features of lung lobe torsion in 10 dogs (nine complete, one partial torsion) acquired with a helical single‐slice computed tomography (CT) unit are described. Attenuation values of normal, rotated, and adjacent collapsed lung lobes before and after intravenous contrast medium administration were compared. Affected lung lobes were: left cranial (5), right middle (3), right cranial (1), and left caudal (1). CT findings in nine dogs with complete lung lobe torsion included pleural effusion and an abruptly ending bronchus. In eight of these dogs, enlargement, consolidation, emphysema of the affected lung lobe, and mediastinal shift to the contralateral side were present. Rotated lung lobes did not enhance, whereas adjacent collapsed and aerated lung lobes did (P<0.05). Apnea induced with hyperventilation or breath‐hold is essential to reduce motion artefacts and obtain a diagnostic study.     

Bronchial cartilage dysplasia with multifocal lobar bullous emphysema and lung torsions in a pup.

Bronchial cartilage dysplasia is believed to have caused lobar bullous emphysema in a 5-month-old Chow Chow that had exercise intolerance, progressive dyspnea, and episodic cough. Radiography of the thorax revealed hyperlucency of the left hemithorax, displacement of the mediastinum and heart to the right, and flattening of the diaphragm. The pup died shortly after the radiographs were obtained. Necropsy revealed massive hyperinflation with 180 degrees torsion of the cranial portion of the left cranial lung lobe, and hyperinflation with less than 180 degrees torsion of the right accessory lung lobe. Histologic examination of the affected lung lobes revealed a lack of bronchial cartilage, loss and displacement of alveolar walls, and bulla formation that resembled congenital (infantile) lobar emphysema of human beings. In this pup, lung lobe torsions may have been predisposed by bronchial cartilage dysplasia.     

Segmental lung lobe torsion in a 7-week-old Pug

Case summary: A 7‐week‐old, intact female Pug was referred with an acute history of expiratory dyspnea, tachypnea, and pyrexia. Radiologic evaluation revealed bilateral pleural effusion and a poorly demarcated area of soft tissue opacity cranial to the heart. The presence of air bronchograms in the cranial lung lobes suggested alveolar parenchymal pathology consistent with pulmonary edema, congestion, or cellular infiltration. Exploratory thoracotomy revealed a segmental torsion of the left cranial lung lobe. The affected lobe was removed and the puppy recovered uneventfully. Unique information: Lung lobe torsion tends to occur more frequently in mature large breed dogs at a mean age of 3 years. The age, breed, and segmental nature of the torsion in the reported case are contrary to most of the previously documented cases of lung lobe torsion. To the authors' knowledge, this is the first report of lung lobe torsion in a 7‐week‐old dog.     

Torsion of a lung lobe in the dog

A 3-year-old Whippet in severe respiratory distress was found to have an extensive pleural effusion associated with a 180^o torsion of the cardiac lobe of the right lung. The possible cause of torsion and diagnostic indications of this lesion are discussed.     

RADIOGRAPHIC DIAGNOSIS OF LUNG LOBE TORSION

Clinical data, thoracic radiographs, ultrasonographic exams, and histopathologic reports in 13 dogs and two cats with confirmed lung lobe torsion were reviewed. Age of dogs ranged from 4 months to 11.5 years, (mean of 6.4 years) and several breeds of large and small dogs were represented. Right middle lobe torsion was predominant in large dogs (five of eight large breed dogs) and left cranial lobe torsion was more commonly seen in small dogs (three of five small-breed dogs). Two domestic short-hair cats, 10 and 14 years of age, had right cranial and right middle lobe torsion, respectively. Underlying thoracic disease was found in only five of 15 patients. On thoracic radiographs, increased lobar opacity and pleural effusion were found in all patients (100%). Small dispersed air bubbles were found within the affected lobe of 13 patients (87%). This pattern, which was the result of vesicular emphysema, was variably extensive, and became more evident on follow-up radiographs in five of six dogs. The lobar bronchi could be seen in only eight of 15 patients (54%), and appeared irregular, focally narrowed or blunted in six of the eight patients, and displaced in five of the eight. Other common radiographic findings included mediastinal shift (nine), curved and dorsally displaced trachea (seven), and axial rotation of the carina (seven). Ultrasonography was used in seven patients and considered generally useful, although variable signs were observed.     

Radiography, computed tomography and virtual bronchoscopy in four dogs and two cats with lung lobe torsion

This report describes the imaging features of radiography, computed tomography and virtual bronchoscopy in dogs and cats with lung lobe torsions. The medical records, thoracic radiographs and computed tomography images of four dogs and two cats with confirmed lung lobe torsions were retrospectively reviewed. Computed tomography with virtual bronchoscopy showed bronchial narrowing, collapse or occlusion in all six animals, while this was only appreciated on one radiographic examination. A tapering terminating angle of the air-filled bronchus proximal or distal to the collapsed region was seen only on computed tomography and virtual bronchoscopy in all six animals. The vesicular emphysema pattern typical of lung lobe torsion was seen on three computed tomographies but only on one radiographic examination. The lung lobe torsion-specific findings of vesicular emphysema and a proximally narrowed or occluded bronchus were more easily recognised on computed tomography and virtual bronchoscopy than with radiographs. Computed tomography slices acquired through the bronchus and lung lobe of interest in a cat or dog with possible lung lobe torsion can be reformatted into virtual bronchoscopic images that can be utilised along with computed tomography to help make a more definitive preoperative diagnosis.     

Complications and management of a long-term pleural access port in a dog with chronic chylothorax associated with lung lobe torsion

A 2-year-old neutered male 35-kg golden retriever mixed breed dog was presented because of a 3-day history of increased respiratory effort. The patient was subsequently diagnosed with a lung lobe torsion and underwent lung lobectomy. Chylothorax developed after surgery and persisted for 3.5 y. Pleural access port (PAP) placement was used for long-term medical management. Several complications were encountered, including 2 episodes of PAP occlusion that were successfully treated with unfractionated heparin. The dog had a surgical site seroma and 2 episodes of pleuritis; euthanasia was elected after the second episode.Key clinical message:This case demonstrates successful long-term management of chylothorax with a pleural access port and management of 3 complications. Instead of the less accessible and more expensive tissue plasminogen activator, unfractionated heparin was used as an effective treatment for PAP occlusions.     

Spontaneous midlobar lung lobe torsion in a 2-year-old Newfoundland

A 2-year-old, intact male Newfoundland was presented for evaluation of a 1- to 2-day history of coughing, retching, and progressive lethargy. Thoracic radiographs demonstrated right-sided pleural effusion and lobar vesicular emphysema. An exploratory thoracotomy revealed midlobar torsion of the right caudal lung lobe. A partial lung lobectomy was performed, and following surgery, the dog recovered without complications. Lung lobe torsions in dogs typically occur at the hilus of the affected lung lobe. This report documents that midlobar lung lobe torsions occur in dogs and should be considered as a differential diagnosis in cases of lobar vesicular emphysema and pleural effusion.     

Recurrent pneumothorax associated with a pulmonary emphysematous bulla in a dog: surgical correction and proposed pathogenesis

A three year old dog was affected with recurrent dyspnea for two months, due to a recurrent pneumothorax. This followed an episode of mild blunt trauma to the thorax and transient strangulation. Conservative therapy of aspiration of air by repeated thoracentesis gave only temporary relief. Thoracic radiographs indicated the presence of a bulla in the right middle lung lobe. An exploratory thoracotomy confirmed the diagnosis, and a lobectomy was successfully performed. The pathogenesis of acquired pulmonary bullae is postulated. Reasons for the predisposition of the right middle lung lobe are outlined. These are related to the anatomy of the right middle bronchus, and include its position between the right pulmonary artery and vein, its oval shape, and the absence of cartilagenous support at its origin.     

Subcutaneous emphysema, pneumomediastinum, and pulmonary emphysema in a young schipperke

A 4-month-old, intact female schipperke was presented for evaluation and treatment of subcutaneous (SC) emphysema. Radiographs revealed pneumomediastinum and SC emphysema. Sequential radiographs confirmed a worsening of the SC emphysema. Extensive, nonsurgical evaluation failed to reveal the source of the air within the mediastinum. Exploratory thoracotomy revealed an emphysematous right middle lung lobe. Lobectomy of the right middle lung lobe resolved both the pneumomediastinum and SC emphysema. Histopathological evaluation confirmed pulmonary emphysema. A variation of congenital pulmonary emphysema was considered in this case.