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Right Middle Lobe Syndrome Workup

  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Apr 17, 2015
 

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
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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 rig Posteroanterior 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-shap Lateral 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.

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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.

A study evaluating the usefulness of lung ultrasonography for the diagnosis of neonatal pulmonary atelectasis (NPA) concluded that lung ultrasonography is an accurate and reliable method for diagnosing NPA. This was a study solely in infants. The authors also concluded that lung ultrasonography can find occult lung atelectasis in neonates that could not be detected on chest X-ray.[2]

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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.

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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: Kentucky Chapter of The American Academy of Pediatrics, Kentucky Pediatric Society, American College of Chest Physicians, American Thoracic Society, Kentucky Medical Association

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

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.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

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

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; 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.

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

  2. Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis of neonatal pulmonary atelectasis using lung ultrasonography. Chest. 2015 Apr 1. 147(4):1013-9. [Medline].

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

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

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

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

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

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

  9. 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. 2003 Sep 8. 3(1):2. [Medline]. [Full Text].

 
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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.
 
 
 
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