A Rare Complication in a Child Undergoing Resection of a Huge Thoracic Lipoma

The parents of a 19-month-old, 11-kg, 86-cm girl brought their otherwise healthy daughter to their primary care physician for evaluation of a persistent dry cough of three weeks duration. They reported that the child's cough seemed to be worse at night, but it did not prevent her from sleeping comfortably on her back. The parents denied that she had a fever, chills, malaise, weight loss, night sweats, dyspnea at rest or on exertion, orthopnea, paroxysmal nocturnal dyspnea, or a change in appetite. Her development and level of activity were appropriate for her age. The physical examination was notable for minimal breath sounds over the left chest. A chest radiograph was obtained in the clinic that showed a large mass filling the left superior hemithorax, with pronounced tracheal and cardiac deviation (Fig 1). The patient was transferred immediately to the authors’ institution for further evaluation and definitive treatment. The thoracic computed tomography confirmed the presence of a 10.4 × 8.6 × 7.4-cm mass occupying the majority of the left hemithorax (Fig 2). A biopsy showed that the mass was a benign lipoma. The child was taken to the operating room for resection of the mass. One-lung ventilation was achieved using selective right endobronchial intubation. The mass was resected in its entirety. The endobronchial tube was withdrawn into the trachea, and the compressed left lung gradually was re-expanded, but the patient immediately developed profound hypotension concomitant with hypoxemia, markedly elevated peak inspiratory pressures, and the appearance of pink froth in the endotracheal tube. A chest radiograph was obtained (Fig 3). What is the diagnosis? Fig 2A coronal computed tomography with angiographic contrast showing a large mass in the left superior hemithorax and with marked distortion of the left pulmonary artery and displacement of the heart. View Large Image Figure Viewer Download Hi-res image Fig 3A chest radiograph showing acute pulmonary edema. View Large Image Figure Viewer Download Hi-res image