This patient is a 67 year old female who had a chronic right pleural effusion. A thoracentesis in March did not reveal a cause. She presented in May to HH with a pain in her left chest and increased sputum production for 2 weeks. A CT scan was done. What do you think was responsible for the air in the pleural space?
May 28, 2008 at 1:48 am
It looks intraparenchymal and I think its an air-fluid level in an existing bulla. It is either infected or a “parapneumonic” type of situation.
May 29, 2008 at 3:05 pm
This patient developed a bronchopulmonary fistula. Usually, when a patient develops a bronchopleural fistula, there is complete collapse of the lung and even a tension pneumothorax. This can occur with any indolent purulent infection that is not adequately treated. The CT scan image does show evidence of the bronchopleural fistula connection. In this case, I suspect the patient had already a pleurodesesis from chronic inflammation in the upper lobes so the lung could not collapse. On the other hand, she did start to drain through the bronchopleural fistula and this accounted for the two weeks of increased sputum production and the finding on the CT scan of air in the pleural space.
She was treated first with a pigtail catheter and did have air to confirm the diagnosis of bronchopleural fistula. Then, she underwent a surgical procedure with a flap to seal the fistula.