Stunning Visuals - Click of a Wrong Button

Abstract

INTRODUCTION: The tracheo-bronchial anatomy is supplied by the superior thyroid and bronchial-pulmonary arterial and venous system which is typically a low pressure system on the venous side. Typical bronchoscopy reveals pink mucosa without visible veins in the sub-mucosal level. CASE PRESENTATION: This case report describes a rare bronchoscopic appearance of the upper and lower respiratory tract of a 43-year-old caucasian male admitted with chest pain and hemoptysis. He had a large necrotic lung abscess in the left lower lobe on chest CT scan. Bronchoscopy was pursued to obtain lavage samples in order to determine the etiology. Incidentally, bronchoscopy revealed bluish mucosal blood vessels from the pharynx and epiglottis down through the glottis, trachea, and the segmental and visualized subsegmental bronchi. At the tracheal level, they were bundled along the intercartilage spaces. The vessels were thin, flushed to the surface, non- variceal and with no evidence of congestion. This phenomenon was separate from the black soot-like material seen in the sub-segmental bronchi from exposure to cigarette smoke and occupational exposure to asbestos and coal. Lavage and brush specimens were negtive for AFB, positive for alpha hemolytic streptococci in culture, and cytology was negative for malignancy. DISCUSSION: MEDLINE search for 'bronchoscopy musical vessels' revealed no similar pictorial or written literature explaining this appearance. After reviewing slides with multiple bronchoscopy specialists in the university, the diagnosis was finally revealed as not a pathology, but an appearance due to a specific bronchoscopic viewing mode called NBI- Narrow Band Imaging. Unnecessary concern was raised as to whether the patient had a fulminant disease from smoke and asbestos exposure. It appears at least from our experience that this mode of visualization was not known to 9 out of 10 pulmonology professors and bronch-lab technicians. The reason may be that it is being used only by gastroenterologists and pulmonologists specializing in lung cancer. CONCLUSIONS: It is very essential that all bronchoscopy specialists be educated about the NBI mode and be alert in using the appropriate mode while performing the procedure. The reason is that truly discolored lesions like melanoma of the lung, vascular malformations, soot from smoking etc. cannot be differentiated in this mode and bronchoscopy has to be repeated under normal imaging mode to ensure normal architecture.