Staged uniportal video-assisted thoracoscopic bilateral lower lobectomy for bilateral intralobar pulmonary sequestration complicated by Aspergillus infection: a case report

Background Bilateral pulmonary sequestration (BPS) is an exceptionally rare congenital bronchopulmonary and vascular anomaly. Its complex anatomy and aberrant systemic arterial supply make diagnosis and treatment difficult, especially when severe fungal infection is present. Case presentation A 28-year-old woman presented with a 1-year history of cough and hemoptysis and bilateral lower-lung masses. CT with 3D reconstruction showed bilateral intralobar pulmonary sequestration linked by an anomalous fistulous tract across the posterior mediastinum and supplied by multiple arteries from the descending aorta. Sputum culture and bronchoalveolar lavage next-generation sequencing confirmed Aspergillus infection. Because systemic antifungal therapy was ineffective, surgery was performed. Guided by 3D reconstruction, staged uniportal video-assisted thoracoscopic bilateral lower lobectomy was chosen to maximize safety and preserve function. The more severely infected left lower lobe was resected first, followed by pulmonary rehabilitation. Six months later, the right lower lobectomy and careful division of the communicating tract were completed successfully. Histopathology confirmed bilateral intralobar pulmonary sequestration and Aspergillus hyphae in the bronchial lumen. One year after surgery, lung expansion and cardiopulmonary function were well preserved, with no major postoperative complications and an excellent overall recovery. Conclusion This case delineates the clinical presentation of an extremely rare bilateral ILS connected via a posterior mediastinal fistulous tract and complicated by aspergilloma. Staged uniportal VATS, augmented by preoperative 3D reconstruction and interval pulmonary rehabilitation, represents an optimal, safe, and effective strategy for managing such intricate congenital malformations while maximizing functional preservation.