it is comprised of nonfunctioning primitive lung tissue , having no communication with the tracheobronchial tree , and contains a systemic arterial supply .
pulmonary sequestration has been found to be associated with other congenital anomalies like congenital diaphragmatic hernia , congenital heart diseases , and gastrointestinal malformations .
vomiting and repeated chest infections in patients of cerebral palsy ( cp ) are usually attributed to the reflux and aspiration of the secretions in these patients .
rarely , other causes of vomiting and repeated chest infections are found in these patients .
we report a patient of cp who presented with vomiting and repeated chest infections , having causes other than cp for vomiting and repeated chest infections .
an 18-month - old male baby was presented to the medical emergency department of our institution with complaints of fever , cough , respiratory distress , and vomiting for 10 days .
the baby was a patient of cp and did not achieve developmental milestones with respect to the age .
he was febrile with a temperature of 100f ; pulse , 110/min ; respiratory rate , 40/min ; and bp within normal limits . at inspection of the respiratory system
on auscultation of the chest , there were course crepts on the left side along with reduced air entry on the same side .
there was a bronchial breathing on the lower zone of the left half of the chest .
the baby was admitted in the medical emergency as a case of aspiration pneumonia and empirical antibiotics along with nebulization and chest physiotherapy instituted .
a chest x - ray was requested , which revealed an impression of some cystic lesion in front of cardiac shadow , along with pneumonic patch , on left side of the chest [ figure 1 ] .
his cbc report revealed mild anemia ( hb,9g / dl ) and raised tlc indicating acute infection
. a computed tomography ( ct ) scan of chest was requested to delineate the cystic shadow in the chest .
a call was sent to the surgical unit for management of hiatus hernia . at the end of treatment for the bronchopneumonia , patient
was shifted to our department and an exploratory laparotomy was planned to treat the hiatus hernia . after optimizing the patient for surgery ,
following were the operative findings : chest x - ray showing left - sided bronchopneumonia and a shadow of cystic mass overlapping the cardiac location 
 on opening the peritoneal cavity , cecum and appendix ( loaded with fecalith ) were present in the epigastrium with a band of ladd running toward the duodenum.there was widened hiatus , and stomach was present in the chest.after delivering stomach back into the abdominal cavity , a cystic mass was present in the chest . that mass was not having any communication with the normal tracheobronchial tree and had its own pleural covering .
the blood supply was identified to come from thoracic aorta [ figure 2].a meckel 's diverticulum with a thickened base was found as a coincidental anomaly . 
 
on opening the peritoneal cavity , cecum and appendix ( loaded with fecalith ) were present in the epigastrium with a band of ladd running toward the duodenum .
there was widened hiatus , and stomach was present in the chest . after delivering stomach back into the abdominal cavity ,
a cystic mass was present in the chest . that mass was not having any communication with the normal tracheobronchial tree and had its own pleural covering .
note that the stomach ( s ) had been taken down from the hiatus and liver ( l ) was present on the opposite side we identified the cystic mass as pulmonary sequestration cyst and sent for histopathology after surgical resection .
hiatus hernia was repaired and meckel 's diverticulectomy performed in view of having heterotrophic mucosa in it . at the end
the histopathology of the submitted tissue revealed a pulmonary sequestration cyst enclosed in a pleural covering .
the patient was on regular follow up and showed a remarkable improvement in episodes of repeated chest infections .
there are two types of pulmonary sequestrations , identified on the basis of its anatomical location , intrapulmonary sequestration , and extrapulmonary sequestration .
intrapulmonary sequestrations are surrounded by normal lung parenchyma without separate pleura , whereas extrapulmonary sequestration is enclosed completely in its own pleural sac . in our case ,
the sequestration was lying outside the main pleural cavity and had its own pleural investment .
there are two commonly accepted schools of thought regarding the etiology of the pulmonary sequestrations . according to one theory ( the accessory lung bud theory )
, there developed an accessory lung bud from the ventral aspects of the primitive foregut .
the accessory lung bud received its blood supply from vessels that connect to the aorta and that cover the primitive gut .
if the event of accessory lung bud development occurred early in the course of embryogenesis , it would give intrapulmonary variant ; on the contrary , later development of the accessory lung bud would result in the extrapulmonary type . according the other school of thought
, the necrotizing pneumonia causes obliteration of lower zone bronchi that may lead to the development of sequestration .
we favor the first theory because the second theory can not explain the systemic arterial supply of the sequestration , which can only be acquired during developmental phase of life .
both of the varieties differ in location , venous supply , and age of presentation .
the venous drainage of intrapulmonary variety is pulmonic , whereas that of extrapulmonary variety is systemic .
intrapulmonary sequestration presents in adulthood ; on the other hand , most of the cases of extrapulmonary sequestration present in the initial few years of life.[124 ] the presentation of pulmonary sequestration is mostly as an incidental anomaly in patients operated for some other surgical disease .
the main presentation is that of repeated chest infections.[14 ] in our case , the patient was a diagnosed case of cp and had been admitted multiple times for repeated chest infections and vomiting .
vomiting and repeated chest infections in these patients are usually considered the sequel of the cp itself , but in our case , vomiting and repeated chest infections were due to the hiatus hernia and pulmonary sequestration cyst .
ct scan can identify such lesions , but as in our case , overlapping of stomach and sequestration might preclude the radiologist in delineating the sequestration cyst .
we had the suspicion of some other associated anomaly in this patient due to a cystic shadow on the chest radiograph .
extrapulmonary sequestration is found to be associated with congenital diaphragmatic hernia in about 30% cases .
the extrapulmonary sequestration was present along with with hiatus hernia , malrotation of intestine , meckel 's diverticulum , hypospadias , and hydrocele .
the most common approach for surgical resection is left posterolateral thoracotomy ; however , vats ( video - assisted thoracoscopy ) has also been advocated by some authors . during the operation ,
phrenic nerve should be carefully identified and saved ; otherwise , a diaphragmatic palsy might occur .
, there developed a diaphragmatic eventration after excision of pulmonary sequestration ; and patient had another operation for the iatrogenic eventration of diaphragm.[47 ] we excised the sequestration cyst successfully through the transhiatal route .
to conclude , the association of other anomalies like hiatus hernia and pulmonary sequestration as a cause of vomiting and recurrent chest infections in a patient of cp is very rare and a high index of suspicion is required to diagnose it .
vomiting and repeated chest infections are not always the characteristics of the cp itself , other causes like pulmonary sequestration should also be considered in these patients .
 pulmonary sequestration cyst is a rare entity in pediatric patients . 
 most of the time , it is diagnosed as an incidental finding . 
 it is associated with other congenital anomalies , especially congenital diaphragmatic hernia . 
 we report a patient of cerebral palsy presented with vomiting and recurrent chest infections . 
 he was diagnosed to have hiatal hernia on computed tomography scan of chest . at operation , a pulmonary sequestration cyst along with hiatal hernia , malrotation , and meckel 's diverticulum was encountered . 
 the sequestration cyst was managed through transhiatal approach . 
INTRODUCTION
CASE REPORT
DISCUSSION