A male Patient Mr.M, 51 years old who underwent a renal transplant one and a half years back. He was presented with complaints of hemoptysis 2-3 episodes in 2 weeks. He was evaluated elsewhere and his X-Ray showed a homogenous mass and was referred to Sri Ramakrishna hospital for further treatment. He was evaluated under Pulmonologist Dr. Loganathan and Nephrologist Dr. Madhu Shankar. After being examined, CT Pulmonary angio showed a giant aneurysm of the right pulmonary artery involving the interlobar branch and located within the middle lobe of the right lung. The patient was referred to cardiothoracic surgeons and was planned for early surgical treatment of removing the entire lung (PNEUMONECTOMY) .

Surgical challenges faced :

Patient was positioned for standard posterolateral thoracotomy and after entering the pleural cavity the aneurysm was found to be huge and pulsatile. It was not able to reach the hilar structures and could not find access to the right pulmonary artery. To prevent sudden flooding due to bleeding into both lungs, a decision was taken to do cardio pulmonary bypass. The patient was repositioned after covering the thorocotomy with steridrapes. Since the transplanted kidney is on the right side left femoral cannulation (arterial and venous) was done, in order to prevent malperfusion of the transplanted kidney.Once the patient was placed in heart lung machine, the patient was again positioned laterally for the main surgery. The Bronchial stump was secured first to protect the opposite lung if there is any inadvertent rupture of aneurysm. Then pneumonectomy was completed in step wise fashion and patient was weaned off Cardiopulmonary bypass.

Post Operative Course

Patient was extubated from ventilator on the first post operative day. He needed BIPAP support for a few days. Renal parameters gradually settled. The biopsy report came as inflammatory changes with isolation of MUCOR species (Fungus). Hence, patient was started on Liposomal Amphotericin B. Patient improved well and discharged with minimal home oxygen therapy.

Conclusion

Isolated Giant pulmonary artery aneurysm with fungal etiology in a post renal transplant patient within one and half a year post transplant is extremely rare and has never been reported in literature and managed surgically with Cardio pulmonary bypass support. We were able to achieve it because of multimodality team work.