Non-Anastomotic Bronchial Stenosis Leading to Dual Lobar Collapse and Ex Vacuo Pleural Effusion: A Case Report

Bronchial stenosis is a common airway complication following lung transplantation. Complete obstruction may result in "vanishing bronchus syndrome," a rare occurrence that typically affects the bronchus intermedius and causes the collapse of the right middle and lower lobes. While the condition predominantly involves the right lung, it can affect any bronchopulmonary segment. We present a case where bronchial stenosis led to the subsequent collapse of 2 independent lobes - the right upper and middle lobes. The volume loss resulted in ex vacuo pleural effusion.

A 61-year-old male underwent a bilateral sequential lung transplant for rheumatoid arthritis-induced interstitial lung disease. A month later, he was hospitalized with shortness of breath. Imaging revealed bilateral pleural effusion for which he underwent decortication and pleurodesis. Follow-up surveillance bronchoscopies identified narrowing of the right upper and middle lobe bronchi, necessitating balloon dilation and lobar stent placement. During the subsequent 5-year period, the patient underwent several balloon dilations and stent replacements, which were complicated by the distal migration of the stents. This eventually led to the collapse of the right upper and middle lobes, as well as the development of ex vacuo pleural effusion.

This case demonstrates an unusual anatomic pattern of vanishing bronchus affecting 2 independent lobes despite treatment of early acute rejection. Although aggressive multimodal bronchoscopic management, including balloon dilation and stenting, failed to prevent complete lobar collapse complicated by stent migration and ex vacuo pleural effusion, the patient has achieved 87-month survival with FEV1 maintained at 79% predicted, demonstrating that acceptable long-term outcomes remain possible.