Incidental Finding of Bronchial Atresia in an Asymptomatic 35-Year-Old Male

Dear Editor, A 35-year-old male with no significant past medical history presented for a medical fitness evaluation. The patient denied any history of smoking, alcohol consumption, or significant illnesses. On physical examination, he was afebrile with a pulse of 70/min and a blood pressure of 122/78 mmHg. Oxygen saturation was 99% on room air, and respiratory rate was 14/min. His clinical examination was unremarkable. Chest X-ray showed left upper lobar consolidation. A subsequent contrast-enhanced computed tomography (CT) scan of the chest was performed, which suggested a left-sided horizontal fissure separating the lingular segments from the rest of the upper left lobe and some fibrotic opacities with surrounding architectural distortion in the apicoposterior segment of the left upper lobe as seen in. It also showed dilatation of the apical-posterior segment bronchus, filled with branching hypodensities such as a “Finger-in-glove” appearance suggestive of a mucocele, as shown in Figure 1. Fibreoptic bronchoscopy revealed normal airway anatomy with no evidence of obstruction.Figure 1: Finger-in-glove appearance with dilatation of the apicoposterior segment bronchusDespite the lack of clinical symptoms and normal bronchoscopic findings, the CT scan raised suspicion for bronchial atresia. After a multidisciplinary discussion, considering the patient’s asymptomatic status and normal bronchoscopy, it was decided to discharge the patient with a recommendation for outpatient follow-up and repeat imaging if symptoms arise. On three monthly and six monthly follow-ups, the patient remains asymptomatic. This case highlights the diagnostic challenge of incidental radiologic findings in asymptomatic patients. Bronchial atresia is a rare congenital condition characterized by the obliteration or discontinuation of a bronchus, which may lead to segmental pulmonary overinflation and mucus impaction. Bronchial atresia, while typically presenting in infancy, can remain asymptomatic until adulthood and be detected incidentally.[1] The obstruction is primarily proximal, while the distal bronchi and alveoli remain intact. Mucus accumulation in the atretic bronchus leads to the formation of a mucocele, and distal lung hyperinflation occurs due to collateral air drift. Most patients are asymptomatic, with some presenting with cough, dyspnea, and recurrent chest infections. CT thorax is the gold standard and shows the finger in glove sign,[2] whereas bronchoscopy is essentially normal. The differential diagnosis of bronchial atresia includes bronchiectasis, congenital lobar emphysema, pulmonary sequestration, and postinfectious fibrosis, all of which can present with overlapping radiological and clinical features.[3] Careful evaluation using imaging modalities such as CT scans and bronchoscopy is essential to distinguish these conditions. There is no consensus on therapies for minimally symptomatic patients, but those experiencing recurrent infections, progressive airway obstruction, or significant bronchiectasis are often referred for surgical intervention, such as lobectomy or segmentectomy, to prevent complications.[4] A conservative approach with vigilant follow-up may be appropriate in asymptomatic individuals with inconclusive diagnostic findings, as unnecessary interventions can be avoided while ensuring timely detection of any disease progression. Regular monitoring through imaging and clinical assessment helps track potential complications such as recurrent pulmonary infections, localized pulmonary hyperinflation, and, in rare cases, respiratory failure. Long-term surveillance is essential to prevent complications and determine the need for future intervention.[5] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.