A brain Stimulating Case

Clinical History

A 74 year old male being treated for M. Parkinson presented with worsening shortness of breath. No asbestos exposure and negative tests for TB.

Imaging Findings

A 74 year old male patient, who had been diagnosed with Parkinson’s disease 16 years ago, presented to a respiratory clinic with progressively worsening shortness of breath over the preceding year. He had no history of weight loss, increased temperature or haemoptysis. He was an ex-smoker, who had given up 20 years ago. The man had no previous exposure to asbestos or tuberculosis (mantoux test negative). There was no past surgical or other medical history of note. Medications included: Sinemet plus 125mg q.i.d. (active ingredients levodopa and carbidopa); Pergolide 3 mg o.d.; Madopar 125mg b.d. (active ingredients levodopa, benserazide hydrochloride); Dothiepin 75mg o.d.; Apomorphine; and oxibutynin 2.5mg b.d.
On examination his oxygen saturations were 95% SpO2, with all of his other vitals being within normal limits. On examination his chest was clear to auscultation; there was no evidence of cardiac failure, no palpable lymph nodes, and no clubbing, the only finding being an incidental metallic object which was palpated superficially over his anterior chest wall. Neurological examination revealed a bad tremor, some rigidity, slowed movements, and a shuffling gait. His baseline blood tests were normal. A chest radiograph (Fig 1) was ordered from the clinic. The respiratory team reviewed his chest radiograph in the clinic, saw a right hilar mass and so undertook a bronchoscopy, which was normal. This was followed by a CT chest (Fig 2-4), and a CT guided percutaneous biopsy of the easily accessible right upper lobe mass. This biopsy showed normal lung tissue.

Discussion

This is a case of pergolide lung, a condition of rounded atelectasis induced by pergolide, which is a drug used to treat the patients Parkinson’s disease. The chest radiograph (Fig 1) shows a deep brain stimulator device which obscures some of the lung field in the left mid zone; note that the leads of this device are directed cranially. There is a rounded shadow overlying the right hilar region. In the CT thorax (Fig 2-4) there are bilateral upper lobe masses anteriorly, both of which have “comet tail” converging bronchovascular markings adjacent to thickened pleurae, which are typical features of rounded atelectasis. Note is again made of the neurostimulator device in the soft tissue of the anterior chest wall.
Rounded atelectasis is an area of non-segmental peripheral pulmonary collapse, which often mimics a primary lung tumour. It was first described by Blesovsky in 1966 [1], which is why it is also called Blesovsky’s syndrome. Other names include folded lung, atelectatic pseudo tumour, shrinking pleuritis, pulmonary pseudotumour, helical atelectasis, and pleuroma [2-6]. Its aetiology is an inflammatory reaction at the visceral pleura leading to fibrosis. As the scar then matures it causes the pleural to “fold” into the lung. Another theory suggested that in the presence of a pleural effusion, the lung is folded into a cleft that formed in a focal area of volume loss. This cleft then became fibrosed maintaining the volume loss and the effusion later resolves [7]. It can affect any lobe, but most commonly the lingula followed by the, middle, upper and lower lobes. On the chest radiograph there may be several fibrous bands close to the area of atelectasis, which give the appearance of “crow’s feet”. The classical triad of CT findings is a rounded mass abutting the pleura, converging curving bronchovascular markings (“comet tail sign”), and thickening of the pleura adjacent to the mass [5,8]. The other CT findings are that the mass is densest at its periphery, has associated air bronchograms, forms an acute angle with the pleura, and has a blurred centrally directed edge [9]. All these findings are demonstrated in figures 2-4. Various causes have been reported including asbestos exposure (associated with calcified pleural plaques), tuberculosis, trauma, pulmonary infarction, cardiac failure, uraemia, Dressler’s syndrome, aortopulmonary bypass surgery, therapeutic pneumothorax, mesothelioma, and pergolide drug treatment [10-14].
Pergolide is an ergot alkaloid, a long acting dopamine receptor agonist. Some documented side effects of pergolide include retroperitoneal, pulmonary and pleural fibrosis, which occurs in 5% of patients [12, 15]. The effect when it does occur appears to be dose related [13]. The hypothesis is that the fibrotic changes are due to increased serotonin levels, which causes an increase in fibroblastic activity [14].
The deep brain stimulator is a device used to treat the debilitating symptoms of Parkinson’s disease and is used in patients whose symptoms are not adequately controlled by medication. It is important to realise that not all battery operated devices in the chest are cardiac pacemakers.

Differential Diagnosis List

Final Diagnosis

Pergolide from parkinsons treatment causing rounded atelectasis

URL:	https://www.eurorad.org/case/7903
DOI:	10.1594/EURORAD/CASE.7903
ISSN:	1563-4086