Right Middle Lobe Syndrome Workup

  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD   more...
 
Updated: Aug 3, 2011
 

Laboratory Studies

The following studies may be indicated in right middle lobe syndrome (RMLS):

  • Purified protein derivative (tuberculin) skin test
  • CBC count and differential
  • Westergren sedimentation rate
  • Fungal serology by complement fixation and immune diffusion
  • Quantitative immunoglobulins panel
Next

Imaging Studies

Chest radiography with anteroposterior (AP) and lateral views

  • The classic finding of right middle lobe syndrome is a blurred right heart border and a loss of volume in the right middle lobe (see the image below). Posteroanterior chest radiograph demonstrating rigPosteroanterior chest radiograph demonstrating right middle lobe collapse and infiltrate. Note blurred right heart border.
  • A wedge-shaped density extending from the hilum anteriorly and inferiorly is best visualized on a lateral view (see the image below). Lateral view chest radiograph showing a wedge-shapLateral view chest radiograph showing a wedge-shaped density extending from the hilum anteriorly and inferiorly.
  • Consolidation and infiltration are less commonly observed.
  • Acute pneumonia should clear radiologically in 6-8 weeks.

CT scanning

  • If bronchiectasis is suspected, confirm diagnosis by performing high-resolution chest CT scanning (see the image below), which carries less risk to younger patients or patients with asthma than the seldom-used traditional bronchography. Chest CT scan showing extensive bronchiectasis of Chest CT scan showing extensive bronchiectasis of both medial and lateral segments of the right middle lobe.
  • High-resolution chest CT imaging is also helpful for follow-up medical therapy.
Previous
Next

Other Tests

  • Pulmonary function tests (PFTs) can be used to establish a previously unidentified asthmatic component.
  • Although findings on a baseline forced expiratory volume in one second (FEV1) may be normal, a prebronchodilator and postbronchodilator study with 10-15% changes in FEV1 is diagnostic for asthma.
Previous
Next

Procedures

The value of bronchoscopy is 2-fold, as follows:

  • It is immediately therapeutic in removing mucus and clearing the airway and can be curative in some cases.
  • It allows visualization of the airway and the ability to determine patency of the right middle lobe bronchus and to discern whether endobronchial obstruction is the cause.

Bronchoalveolar lavage can be concurrently performed to determine cellular elements in the right middle lobe. It can also be used to assess the presence of infections by culturing and staining for bacterial, fungal, viral, and mycobacterial pathogens.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Nemr S Eid, MD, FAAP, FCCP  Professor of Pediatrics, University of Louisville School of Medicine; Director of Pediatric Pulmonary Medicine, Director of The Childhood Asthma Care and Education Center and the Cystic Fibrosis Center, Medical Director of Pediatric Respiratory Therapy, Kosair Children's Hospital

Nemr S Eid, MD, FAAP, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Kentucky Medical Association, and Kentucky Pediatric Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Eckerle  University of Louisville School of Medicine

Michelle Eckerle is a member of the following medical societies: Kentucky Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas Scanlin, MD  Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Heidi Connolly, MD  Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

References

  1. Springer C, Avital A, Noviski N, et al. Role of infection in the middle lobe syndrome in asthma. Arch Dis Child. May 1992;67(5):592-4. [Medline].

  2. [Guideline] Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of asthma. Jan 2008;[Full Text].

  3. Priftis KN, Mermiri D, Papadopoulou A, et al. The role of timely intervention in middle lobe syndrome in children. Chest. Oct 2005;128(4):2504-10. [Medline].

  4. [Best Evidence] Halliday HL, Ehrenkranz RA, Doyle LW. Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev. Jan 21 2009;CD001146. [Medline].

  5. American Journal of Medicine. Right middle lobe syndrome progressing to death in a 77-year-old woman. Am J Med. Mar 1987;82(3):471-80. [Medline].

  6. Ayed AK. Resection of the right middle lobe and lingula in children for middle lobe/lingula syndrome. Chest. Jan 2004;125(1):38-42. [Medline]. [Full Text].

  7. Brown M, Lemen R. Bronchiectasis. In: Kendig's Disorders of the Respiratory Tract in Children. Philadelphia, Pa: WB Saunders Co; 1998:150-2.

  8. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 19-1984. A 57-year-old woman with recurrent pneumonia. N Engl J Med. May 10 1984;310(19):1245-52. [Medline].

  9. De Boeck K, Willems T, Van Gysel D, et al. Outcome after right middle lobe syndrome. Chest. Jul 1995;108(1):150-2. [Medline]. [Full Text].

  10. Dees SC, Spock A. Right middle lobe syndrome in children. JAMA. Jul 4 1966;197(1):8-14. [Medline].

  11. Eggleston PA, Ward BH, Pierson WE, Bierman CW. Radiographic abnormalities in acute asthma in children. Pediatrics. Oct 1974;54(4):442-9. [Medline].

  12. Gudmundsson G, Gross TJ. Middle lobe syndrome. Am Fam Physician. Jun 1996;53(8):2547-50. [Medline].

  13. Kinzy JD, Powers WP, Baddour LM. Case report: Blastomyces dermatitidis as a cause of middle lobe syndrome. Am J Med Sci. Oct 1996;312(4):191-3. [Medline].

  14. Kwon KY, Myers JL, Swensen SJ, Colby TV. Middle lobe syndrome: a clinicopathological study of 21 patients. Hum Pathol. Mar 1995;26(3):302-7. [Medline].

  15. Lambert GW, Baddour LM. Right middle lobe syndrome caused by Mycobacterium fortuitum in a patient with human immunodeficiency virus infection. South Med J. Jul 1992;85(7):767-9. [Medline].

  16. Livingston GL, Holinger LD, Luck SR. Right middle lobe syndrome in children. Int J Pediatr Otorhinolaryngol. Jun 1987;13(1):11-23. [Medline].

  17. Priftis KN, Anthracopoulos MB, Mermiri D, et al. Bronchial hyperresponsiveness, atopy, and bronchoalveolar lavage eosinophils in persistent middle lobe syndrome. Pediatr Pulmonol. Sep 2006;41(9):805-11. [Medline].

  18. Rock MJ. The diagnostic utility of bronchoalveolar lavage in immunocompetent children with unexplained infiltrates on chest radiograph. Pediatrics. Mar 1995;95(3):373-7. [Medline].

  19. Saha SP, Mayo P, Long GA, McElvein RB. Middle lobe syndrome: diagnosis and management. Ann Thorac Surg. Jan 1982;33(1):28-31. [Medline].

  20. Shah A, Bhagat R, Panchal N, et al. Allergic bronchopulmonary aspergillosis with middle lobe syndrome and allergic Aspergillus sinusitis. Eur Respir J. Jun 1993;6(6):917-8. [Medline].

  21. Thacher H, Kaplan A. Middle lobe syndrome in asthmatic children. J Maine Med Assoc. Mar 1972;63(3):46-8 passim. [Medline].

  22. Torkian B, Kanthan R, Burbridge B. Diagnostic pitfalls in fine needle aspiration of solitary pulmonary nodules: two cases with radio-cyto-histological correlation. BMC Pulm Med. Sep 8 2003;3(1):2. [Medline]. [Full Text].

  23. Wagner RB, Johnston MR. Middle lobe syndrome. Ann Thorac Surg. Jun 1983;35(6):679-86. [Medline].

 
Previous
Next
 
Posteroanterior chest radiograph demonstrating right middle lobe collapse and infiltrate. Note blurred right heart border.
Lateral view chest radiograph showing a wedge-shaped density extending from the hilum anteriorly and inferiorly.
Chest CT scan showing extensive bronchiectasis of both medial and lateral segments of the right middle lobe.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.